• Convergence Exercise Therapy
I appreciate the “Phacoenvy” letter (October 2005) introducing a companionmania to my phenomenon of phacomania. I would like to go one step further and introduce phacoconscience.
The scenario is repeated. An about-to-retire senior ophthalmologist brings into the practice the younger physician fresh out of residency and a fellowship at a prestigious institution. The eager new doctor starts scheduling cataract surgeries at a dizzying pace. The techs in the office are having a hard time keeping up. The burden of communication between the doctor and patient has now shifted to the patient and technician.
I am absolutely amazed at how the new ophthalmologist can convince all these patients about the benefits of cataract surgery. Before the new associate entered the practice, the older doctor was doing about five cases a week. He listened carefully to patients, dutifully recorded the office visit findings and assured patients that surgery was not needed unless they felt significantly handicapped by their current level of vision. The decision was left up to the patients.
But now things have changed. The surgical volume has rapidly accelerated to about 15 cases per week. Phacomania has set in for good. There is no stopping the new associate. Indications for surgery have dropped enormously. The doctor now tells the patient that surgery is needed, and soon. Patients seem to accept the diagnosis but rarely ask questions because they have been turned over to the technician. The technician has now become the surrogate ophthalmologist.
With the availability of accommodating and multifocal IOLs, the decision of whether a patient will be best served by the new technology will become even more difficult. The conscientious ophthalmologist will need to be there to answer these questions. Patients cannot and should not be turned over to a technician.
Judson P. Smith, MD
Fort Worth, Texas
Convergence Exercise Therapy
In the May issue’s “Diagnosis and Treatment of Strabismus in Seniors” (Ophthalmic Pearls), I felt there was a glaring omission of convergence exercise therapy, especially since one of the authors is a certified orthoptist.
In my 35 years of practice with strabismus, convergence exercise therapy is always the first line of treatment for convergence insufficiency. The majority of patients can be made functionally comfortable by this approach. Base-in prism glasses can work, but they allow the eyes to relax into divergence and often lead to eating up prism or requiring increasing amounts over time with no benefit to patient control over the problem. Furthermore, convergence amplitude testing should be included in the examination for diagnosis and used to demonstrate improvement as the exercise regimen is carried out. This is more sensitive than the near point of convergence and the measurement of exotropia at near.
Maynard B. Wheeler, MD
One of the coauthors wrote the following response to Dr. Wheeler.
Eileen Schuler, CO, and I want to thank Dr. Wheeler for his insightful comments. Although exercises are a valuable tool, especially for mild cases, we have found exercises less effective in many seniors and those with severe convergence insufficiency (e.g., Parkinson’s disease). In our experience, base-in prisms often give these patients the ability to read again.
Mark L. Silverberg, MD
Santa Barbara, Calif.
The July/August Ophthalmic Pearls, “Diagnosis and Treatment of Neovascular Glaucoma,” stated that anticholinergics should be avoided in the treatment of elevated IOP. It should instead have said, “Cholinergic (pilocarpine) and anticholinesterase agents (Phospholine Iodide) should be avoided.” EyeNet regrets the error.
A coalition of associations is supporting the Visionary Benefit Campaign. June’s Academy Notebook incorrectly listed the American Academy of Pediatrics in that coalition.
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