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Valuing Physician Services 

Dr. David Chang is to be commended for drawing attention to the issue of balance billing and shared patient responsibility for physician services as described in “Is It Time for Balance Billing?” (Feature, November/December).

What must not be lost in the discussion is this simple fact: Physician services do have a value that remains extraordinarily important to society despite the continual threat of lowered payments and new systems of payment designed to dramatically reduce physician revenue. This value is not determined by insurance companies or government but is defined by improvement in the health of patients—which thereby promotes their livelihoods and their quality of life.

As such, the economic value for these services must not be allowed to drop below a reasonable threshold. Otherwise, as Dr. Chang aptly points out, the system will contract and ultimately collapse as physicians will no longer take the risks and expend the resources necessary to provide services that are so poorly valued by insurance companies and government.

Steven Thomas Berger, MD   
Springfield, Mass.   


Help in an Emergency 

I have become aware of three relatively new developments in emergency ophthalmic care about which there is a scarcity of U.S. ophthalmological literature.

An informal survey of my ophthalmic colleagues reveals that knowledge of the following three options is limited at best. I think it is of the utmost importance (if just from a medicolegal standpoint) that ophthalmologists have a working knowledge of these agents.

  • Fomepizole in the treatment of acute ethylene glycol toxicity. There are only a few articles in the American literature on the use of this agent.1 We were traditionally taught in residencies that the treatment of this toxin is with IV alcohol. Fomepizole is a significant improvement over this antiquated therapy. Although it is significantly more expensive than IV alcohol, it offers a safer and more effective treatment for this usually blinding condition.
  • Tissue plasminogen activator in the treatment of central retinal artery occlusion. Although the use of this agent is now in the American literature, it is certainly not universally used and has the potential to be of substantial benefit in patients presenting within 6.5 hours of an acute central retinal artery occlusion. 2 I discussed tissue plasminogen activator at a recent meeting of our oncall ophthalmologists and found that the majority of them were unfamiliar with its use in central retinal artery occlusion.

    The logistics of administering this agent and providing proper care to the patient would need to be handled by the “stroke team” at most institutions. A conversation needs to be held with these individuals to get them on board with the option of using it in acute central retinal artery occlusion. This needs to be done in a proactive manner rather than when a patient presents acutely. 

  • Diphoterine in the treatment of acute alkali and acid injuries. This agent is a significant new development in the treatment of these injuries.3 There is almost no U.S. ophthalmological literature on diphoterine—and I have recently learned that it is currently unavailable in the United States—but it appears to be used to a significant degree in Europe. I am unsure of the process required to allow U.S. hospitals to have this irrigating compound in stock and available for emergency use, but perhaps readers may have some insight in this regard.

In all three of these entities, time is of the essence in providing effective care. Ophthalmologists need to be aware of these agents so they can consider offering them when presented with these relatively rare conditions.

Mitchell J. Wolin, MD   
Greenville, S.C.   


1 Velez, L. I. et al. J Med Toxicol 2007;3(3):125–128.
2 Hattenbach, L. O. et al. Am J Ophthalmol 2008;146(5):700–706.
3 Langefeld, S. et al. Der Ophthalmologe 2003;100(9):727–731.


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