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Ethics of Surgical Service 

Does the Academy’s Ethics Committee address the following scenario? Some ophthalmologists receive a surgical patient from an optometrist and never examine the patient. The patient first meets the surgeon just before surgery and is never examined after surgery.

Robert W. Ridley, MD
Tullahoma, Tenn.

The following is a response from the Academy’s Ethics Committee.

The practice of seeing patients exclusively for surgical services may be problematic under several rules of the Academy Code of Ethics:

Rule 6 requires an ophthalmologist to assess the need for surgery. Absent any preoperative visit, it is difficult to see how this requirement is met.

Rule 7 requires that an ophthalmologist refrains from delegating aspects of care within their “unique competence.” Arguably, the decision to operate is the exclusive competence of a surgeon and cannot be delegated to a nonsurgeon.

Rule 8 requires that the surgeon takes primary responsibility for postoperative care, with circumstances for delegation as described: the proposed postoperative arrangements must be disclosed preoperatively and consent obtained. Failure to do so would be problematic regarding informed consent under Rule 2.

Rule 9 requires that an ophthalmologist does not perform services that may not be in the patient’s interest. Without a preoperative exam, it is difficult to see how that determination is made.

Rules 11 and 15 address the possibility that this scenario is primarily for economic benefit to the surgeon and the referring ODs, but would very much depend on specific facts and circumstances.

Moreover, if an ophthalmologist becomes merely a surgical technician, the relationship between the physician and the patientmay be incompletely established. If something goes wrong, the risk of litigation against the relatively anonymous surgeon seems very high.

For more information, go to www.aao.org/about, click “Ethics” and select “Code of Ethics.”

Charles M. Zacks, MD
Chairman, Academy’s Ethics Committee

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Orbital Pain: A General View 

The article “Pain in the Eye” (Feature, October) describes the “four major culprits” in orbital pain not originating in the eye. Unfortunately, the story does not reflect the experience of the general ophthalmologist.

We rarely see the exotica described in your article but instead deal with a steady stream of women with greater occipital neuralgia. Over the past eight to 10 years, I have seen at least 200 of these initially unhappy patients who have had either multiple imaging sessions or narcotics administered during their pain episodes. David L. Knox, MD, cowrote the classic article on this condition back in the ’70s.1 His beautifully written account is absolutely on the mark.

You will be amazed at how quickly a diagnosis of orbital pain can be made with simple digital pressure in the suboccipital area.

David T. Casey, MD
Pensacola, Fla.


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1 Knox, D. L. and E. Mustonen. Trans Sect Ophthalmol Am Acad Ophthalmol Otolaryngol 1975;79:513–519.

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Correction 

The Nov. 9 edition of Academy Live contained an error in the reporting of Dr. Harvey V. Fineberg’s Keynote Address. Dr. Fineberg noted that in the last 15 years the number of ophthalmology practices that employ optometrists has increased from fewer than one in four to about one in two. The article incorrectly attributed this increase to the number of ophthalmology practices that comanage with optometrists, instead of employ optometrists. He then went on to state, “You’ve been cohabitating, you might as well declare a marriage.”

To clarify, H. Dunbar Hoskins Jr., MD, Academy executive vice president, said, “I want to emphasize that Dr. Fine berg’s comments in no way imply that the Academy will soften its approach in state legislatures. The Academy is committed to ensuring high-quality eye care for patients. Dr. Fineberg provided the statistics to bolster his argument that ophthalmology should be talking about cooperation not just with optometrists but the whole range of paraprofessionals to ensure the efficient delivery of eye care.”

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