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Where Do Ancillary Services Fit? 

In 1979, ophthalmologists and otolaryngologists went their own way—for good reasons—by splitting their combined American Academy of Ophthalmology and Otolaryngology.

Now, I read with some amazement and alarm the article “A Look at Hearing Services in Eye M.D. Offices” (Clinical Update, June). The author describes the addition of higher-margin ancillary services—namely, audiology—to the ophthalmology practice because both serve older patients.  

Allow me to add some suggestions of my own. Maybe podiatry would be a good fit; after all, the same people who have difficulties with their vision and hearing also have trouble bending over to cut their toenails. Selling facial creams and lotions could also be profitable, but the dermatologists would not like it.

Thirty years ago, eyelid tattooing or “permanent eye makeup” became a popular and higher-margin sideline for many ophthalmologists before it left the ophthalmology world and moved to the makeup business. It would be quite easy to resuscitate this.

Indeed, why bother with the ophthalmology part at all? Why not concentrate on the ancillary services since they are less of a hassle and have a better bottom line?

All kidding aside, why did most of us go through training? I wanted to be an eye physician and surgeon and not an audiologist, makeup or tattoo artist, or a cosmetics salesperson—even if this might improve my financial bottom line.

Johan T. Zwaan, MD, PhD   
San Antonio   


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Preventing Ocular Injury in the Pugilist 

I read with interest the article “The Trouble With Having Fun: Eye and Head Trauma From Sports” ((Clinical Update, June)).

For nearly 10 years, I was the ophthalmologist assigned to the Keller Army Hospital at the U.S. Military Academy at West Point. At that time, the Military Academy was the only major college in the country where boxing was a mandatory course of instruction. Approximately 1,000 cadets per year participated in the instructional boxing program and over 300 cadets participated yearly in intramural boxing competition.

During that time period, there were numerous ocular injuries secondary to several sports, including retinal tears from participation in wrestling, rugby, soccer, tennis, racquetball and golf.

However, in spite of the large number of boxing participants, there were no diagnoses of retinal tears or retinal detachments related to boxing.

The single most important factor in the prevention of boxing-related ocular injuries at West Point was the exclusive use of thumbless gloves to prevent gouging of the thumb into the opponent’s eye, which accounts for most of the ocular injuries in boxers. The sudden compression of the globe and rapid equatorial expansion result in severe vitreous traction on the retina in the region of the vitreous base with a resultant retina tear or dialysis in this region.

The use of protective headgear was another significant factor in the absence of boxing-related eye injuries at West Point. This padded headgear was designed to be positioned just above the brow. Additional projections to the headgear extended down over the malar area and beneath the temporal aspect of the globe. This combination of the thumbless glove and protective headgear assured protection to the orbit to the extent it was nearly impossible to achieve impact with the eye.

The West Point experience demonstrated it is possible to have such a program without significant risk of ocular injury to the participants.

John E. Riffle, MD   
Augusta, Ga.   


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