• Letters

    Thoughts From Your Colleagues

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    On Stem Cells and Ethics

    After reading the article “Stem Cell Studies Show Safety and More” (News in Review) in EyeNet’s January issue, I felt saddened and dismayed. Our profession has breached an ethical absolute by its use of human embryonic stem cells. There is no justification for the destruction of human life, even at its embryonic stage.

    Marjorie F. DeBenedictis, MD
    Tamuning, Guam

    Paying for Generic Drugs

    The type of article published in January’s EyeNet (“The State of Generic Drugs,” feature) must become commonplace. The health care industry must find a way to “fairly” pay manufacturers for continuance of these old, well-established drugs, preferably from more than one company. The capitalistic drive to maximize profit and the complexities of regulatory issues keep this simple solution from being mandated by policymakers on high (government, FDA, etc.).

    New rules will likely be required to find a fair balance between the manufacturing industry, providers, and patients. We need empathy and compassion to play a larger role in this situation, as high profit is currently the major engine in this industry.

    Roderick A. Morgan, MD
    Edmonton, Canada

    Postoperative Endophthalmitis: Some Suggestions

    As a cataract surgeon with a strong interest in using simple methods to reduce the risk of postoperative endophthalmitis following cataract surgery, I read your article on intravitreal (IVT) injection guidelines (May 2015) with interest. Following are my added suggestions to those doing IVT injections:

    1. Give the Betadine time—it takes several minutes for it to effectively kill bacteria.
    2. Allow several minutes between installation of the topical anesthetic and the Betadine so they do not dilute each other.
    3. Choose the option that everyone in the room, including the patient, wears a mask. I tried the “no talking rule,” but many patients didn’t seem to listen. (We cannot mask the patient in the OR during cataract surgery prepping because anesthesia needs access to the patient’s mouth and nose.)
    4. Use a drape to seclude every single eyelash completely out of the surgical field. My theory is that you cannot sterilize an eyelash without putting it into an autoclave. And yes, do use a lid speculum if possible.
    5. If the patient has an allergy to radiopaque iodine, such as IVP dye, or shellfish, use Betadine; if the patient is allergic to Betadine, still use Betadine and send the patient home with a prescription for a steroid ointment for the lids and conjunctiva postop. It is an old wives’ tale that IVP dye allergy or shellfish allergy means a patient is also allergic to Betadine. Betadine allergy is almost always a delayed cellular sensitivity reaction occurring 48 hours postop. I explain this to the patient and end by saying, “I would much rather deal with a rash on your eyelids than a postoperative infection.”

    I hope this additional information helps to round out a very good article.

    David M. Shepherd, MD
    Novi, Mich.

    When Diagnosing Merkel Cell Carcinoma

    Drs. Huang and Silkiss are commended for their interesting and clinically relevant article “Diagnosis and Management of Merkel Cell Carcinoma of the Eyelid” (Pearls, January). With regard to the differential diagnosis, ocular oncology experts alert clinicians that when they encounter progressively enlarging, deep red, solid adnexal masses, they should include Merkel cell, metastatic thyroid cancer (a bit more orange), and Kaposi sarcoma in the diagnosis. Biopsy and thoughtful use of immunohistochemistry assays will confirm the diagnosis.

    Additionally, do not be timid with tissue sampling when investigating an unusual tumor. There should be sufficient biopsy material for formalin-fixed histopathology, as well as molecular pathology studies, ultrastructural imaging, and fresh freezing for archival purposes. Best practices include preoperative consultation with the ocular pathologist to facilitate an expeditious and accurate diagnosis.

    William C. Lloyd III, MD, FACS
    Sacramento, Calif.