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Opening the Septum 

There is a crucial detail absent from “Evaluation and Management of Orbital Hemorrhage” (Pearls, January). The authors describe performing a canthotomy and cantholysis in the setting of postseptal hemorrhage to “release entrapped orbital blood,” but they do not mention opening the septum. Releasing the canthal tendon and its crura will only allow the globe to prolapse anteriorly, resulting in expansion of the orbital volume and a decrease in ocular pressure secondary to reduced mechanical compression of the globe. The blood will remain behind the intact septum.

Unless the septum has been violated by a penetrating trauma, surgical incision in the “safe zone” between 4 and 5 o’clock in the patient's left eye and 7 and 8 o’clock in the right is required to release any compartmentalized blood and/or allow volume expansion of the orbital space secondary to fat prolapse.

John A. Burns, MD   
Craig N. Czyz, DO   
Columbus, Ohio   

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Revisiting Rationing 

We read “The SGR Fix Is Nowhere in Sight. What Alternatives Are Available?” (Outlook, November/December 2010) with dismay and concern. Academy Past President Randolph L. Johnston, MD, presented his personal views for health care rationing and against balance billing. We disagree with him on both issues.

He states at the outset that “all doctors and most politicians realize that health care in the United States must be rationed in some way” because the cost of advances in medical care “are beyond the country’s ability to pay.” The inescapable conclusion is that Dr. Johnston expects the federal government to pay for everyone’s health care. The country cannot do that now nor will it be able to do so anytime in the foreseeable future without engaging in a massive bureaucratic rationing system that has no chance to be successful.

We do not believe that health care should be rationed. And we seriously doubt that even a significant minority of the Academy membership agrees with Dr. Johnston. Moreover, polling of U.S. citizens and the extension of the public’s views vis-a-vis last November’s national election fly in the face of his opinion. Even the current director of CMS, Dr. Donald Berwick, has found it necessary to deny his prior recorded statements in favor of rationing.

Dr. Johnston says he regards balance billing as “worthy of discussion.” Yet he states that it deprives patients of coverage for the unexpected major expense. He prefers higher premiums for everyone, thus “maximizing the insurance effect.” Since when do higher premiums guarantee better health care? How about allowing individuals to purchase whatever amount of coverage they want and giving the patient rather than a private insurer or the federal government control of their health care? How about letting insurance companies design policies that are free of mandated benefit levels? If this was done, nationally chartered insurers would rush out cheap, high-deductible polices that actually make sense to those who don’t desire gold-plated coverage. The healthy cohort would then be covered for a rare major injury or illness, and the rest of us would not have to pick up their tab.

Balance billing represents a return to a free market system that has been terribly distorted by governmental interference.

In such a free market, patients have the ability to choose the level of technology and medical services they desire. The best possible care can be received by the greatest number of patients, while innovations in medical care are encouraged and rewarded based upon their value to those who benefit from them. This has long been the hallmark of American health care and can be guaranteed to virtually disappear in a socialized system.

Our health care system is the finest in the world. We should not accept the notion that if the federal government is not going to pay for it, then no one should be allowed to have it.

Richard J. Mackool, MD   
Astoria, N.Y.   
Paul S. Koch, MD   
Warwick, R.I.   
Eric D. Donnenfeld, MD   
Rockville Centre, N.Y.   
Stephen G. Slade, MD   
Houston, Texas   
Kerry D. Solomon, MD   
Charleston, S.C.   
John F. Doane, MD   
Kansas City, Mo.   
Richard L. Lindstrom, MD;  
Bloomington, Minn.   

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