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April 2009

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More DME Options 

I’d like to add another treatment option to those suggested in “On the Near Horizon: Better Treatments for Diabetic Macular Edema” (Feature, January).

For diabetic retinopathy, I have found that a trial of topical ketorolac tromethamine (Acular) and, to a lesser degree, flurbiprofen (Ocufen) and bromfenac (Xibrom) with or without steroids often ameliorates the macular edema. It oftentimes eliminates the need for photocoagulation or intravitreal treatment.

Heskel M. Haddad, MD
New York


Another Treatment Possibility 

EyeNet’s “Review of Capillary Hemangioma” (Ophthalmic Pearls, February) omitted a promising medical treatment: propranolol.

Pediatric oncologists have been using propranolol for a variety of vascular tumors. A report of infants successfully treated for severe capillary hemangiomas has recently been reported in the medical literature.1

Janet L. Roen, MD
New York


1 Léauté-Labrèze, C. et al. N Engl J Med 2008;358(24):2649–2651.


A Realistic Paradigm Shift? 

In his “A Call to Disenroll” (Letters, January), Dr. Dotson says that we should revert to a fee-for- service paradigm. I strongly agree in principle but think that’s unrealistic. Until a few years before my retirement, and well after Medicare, Medicaid, HMOs and PPOs appeared, I ran my practice on the same fee-for- service basis that my father did before me. Accounts owed were kept on note cards, very simply. My office staff consisted of a receptionist and a nurse/technician. My mother typed the bills at the end of the month. Overhead was minimal.

Our collection ratio was 95 percent. We relied on a combination of patient attitude and reduced charges for those who could not afford regular fees. If it appeared that a patient could not afford my cataract surgery fee, for example, we told them to look in their pocketbook and bank account and decide what they could afford. My receptionist would accept that amount as full payment of their account, no questions asked! At Christmas, we reviewed the long overdue accounts, considered what we knew of the patient and forgave the debt.

People back then were brought up to take pride in paying their just debts. They espoused dicta that said, “You get what you pay for,” and “What you get for nothing is worth nothing.”

What changed? Our politicians declared a crisis in medical care (they still do) and said that the government could do it better than doctors could. The best medical care for all was proclaimed a right, and the government would provide it free! Later, HMOs and PPOs decided they could do it even better and more efficiently than the government. As a result, paperwork abounded.

For many years, I didn’t buy in. Patients who wanted free care were referred to good colleagues. There was still a waiting list for my appointments. What began to hurt were the loyal patients, who, when they came to need cataract surgery, asked me to refer them to someone who would do it without cost to them. My office remained busy. However, my surgeries declined meaningfully.

In an environment where patients demand (or feel entitled to) free care, the traditional cost-for-services system will not work. It might work out for some sectors but not for doctors.

Eventually, like many of my colleagues, I retired. Unfortunately for those ophthalmologists still in practice, undoing this “entitlement” would require a major change in attitude. And this is very unlikely, barring a crisis that is not doctor-induced.

Robert C. Drews, MD
St. Louis



In the January EyeNet, the feature story, “On the Near Horizon: Better Treatments for Diabetic Macular Edema,” discussed two studies of ranibizumab (Lucentis) for the treatment of diabetic macular edema: and READ2. But it neglected to mention two other current studies: the RISE and RIDE trials. Both are in phase 3 and are recruiting patients.

For more information, interested physicians should go to and enter “DME” and “ranibizumab” in the search field.