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The Proper Time for CTRs 

I’d like to comment on Dr. Howard Fine’s suggestion in “Capsular Tension Rings: Innovation and Debate” (Clinical Update, March) that the list of indications for a capsular tension ring (CTR) includes all cases of trauma.

I find this recommendation erroneous and dangerous. CTRs, by their very nature, put extra tension on the remaining zonules, transferring function onto them from zonules that were weakened or destroyed by the injury.

The problem is that the surgeon does not know how many intact zonules are left and what their true longterm condition is. I have had the misfortune of fishing “successfully implanted” CTRs out of the vitreous on several occasions, as well as dealing with eyes in which the entire IOL/capsular bag complex subsequently subluxed—only to find during reconstructive surgery that a CTR had been implanted. Of course, these cases are rarely managed by the original cataract surgeon who therefore remains convinced that his or her original decision to employ a CTR was correct.

CTRs do have a place in our armamentarium, but placing one into a contused eye with damaged zonules is akin to Russian roulette. The goal of surgery on these eyes, in fact on any eye, is to adapt your surgical approach to the actual situation and not vice versa. The aim is not to have the IOL placed in the bag at all cost but rather to have long-termstability.

A contused eye with a dislocated lens is best managed by a trauma expert who will look at the big picture and consider alternatives for IOL placement other than the “in the bag” option.

Ferenc P. Kuhn, MD, PhD
Birmingham, Ala.

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Entitled Youth 

I enjoyed Dr. Richard Mills’ “Entitlement: Do You Feel You Deserve It?” (Opinion, October).

I am fascinated as a pediatric ophthalmologist by how many of my young patients have similar attitudes.

Often at the end of an exam, I suggest that they might take their accompanying parent out for a treat (given the amount of time the parent has spent at an appointment for the child), that birthdays are when children give presents to their parents or that they should use money from a tooth fairy to buy a gift for a parent.

Kids look at me like I am crazy!

It starts early.

Susan H. Day, MD
San Francisco

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A Call to Disenroll 

After reading the Sept. 18 edition of the Academy’s “Washington Report” (e-newsletter, vol. 13, issue 9), I am compelled to send a comment.

We have surrendered our role as patient, friend and advocate to a cabal of powerhungry and greedy entities—Big Pharma, Big Medicine, Big Insurance and Big Government. Many of our most prestigious academicians have played a role in this insanity and have aided and abetted compromise with these forces to ensure the bottom line of an academic program or the enhance ment of their egos. Even scientific study has been subverted by researchers who benefit from funding by some specialinterest group. (No, a disclaimer in a journal article does not confer some special sign of impartiality!)

Sadly, our Academy has caved into these pressures and, consequently, is constantly fighting rearguard actions in battles that have been long lost in a war that is almost over. We can’t hope to avoid defeat if we continue to operate within the rules dictated by our adversaries.

Basically, the Academy leadership should stop groveling for ever-smaller fees from bureaucrats of a bankrupt nation and call for all members to disenroll from Medicare, Medicaid and all government and private medical schemes, and simply revert to a cash, fee-for-service paradigm. Within my practice, I would be able to immediately dispense with tremendous costs in overhead. My income would rise if I were just able to charge the Medicare fee schedule and collect it! More important, prices to patients could be reduced while charity care would become much more available and accessible.

Robert S. Dotson, MD
Oak Ridge, Tenn.


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