We read with interest the excellent article  " Eavesdropping on Blepharitis" (October 2007, p.92). There are more questions than answers in regards to the clinical entity we call blepharitis.

Chronic blepharitis is one of the most common diseases of the eyelids, yet one of the least understood. Various organisms have been implicated in its causation including bacteria, yeasts, mites and viruses. It may also be associated with generalized skin conditions such as seborrheic dermatitis, atopic dermatitis or acne rosacea. 

"Cylindrical dandruff" and associated Demodex infestation is often a neglected entity.¹ Some suggest that Demodex is a direct pathogen in chronic palpebral conditions while others consider the saprophyte to be innocuous to skin. Studies show that the incidence of Demodex in patients with blepharitis is very high when compared with normal subjects, showing a possible association between blepharitis and Demodex infestation.²

Patients with blepharitis are likely to have normal skin bacteria on their lids but in greater quantities than nonblepharitis patients.³ Gram-positive as well as gram-negative bacteria have been shown to grow more often in patients with Demodex.⁴ This indicates that Demodex might be responsible for disrupting the symbiotic relationship of the bacteria with the host by acting as a vector for the bacteria, activating quorum sensing and contributing to blepharitis. 

Demodex infestation has been implicated in causing rosacea. A variety of corneal pathologic features, together with conjunctival inflammation and meibomian gland dysfunction commonly noted in rosacea, can be found in patients with Demodex infestation of the eyelids.⁵

These findings strongly suggest that ocular Demodex infestation might be pathogenic. When conventional treatment for blepharitis fails, one may consider lid scrubs with tea tree oil and shampoo to eradicate mites.⁶

 

I noted with interest the excellent article in October 2007, "Medical Malpractice Litigation: Ten Things They Didn't Tell You" by Daniel F. Ryan III, Esq. (p. 68), discussing ways to protect oneself from malpractice litigation. Having actively practiced for 39 years following a U.S. Army Medical Corps tour of duty, I would add that in addition to documenting medical charts well, not running an assembly line, doing all of your own follow-up, not farming postop care out to non-medical practitioners for financial quid pro quo, we have our own in-office "permit." After the patient sees my own self-made video tape reviewing the eye's anatomy and physiology, we then review the cataract surgery, including complications, with the patient in a non-threatening but lucid way. We then discuss this afterwards with the patient (and family, if present) documenting this on the chart, and have the patient sign our in-office permit. Among other things, it details "every complication known to man," stating that "problems listed can occur, but are not limited to the following …" and then listing every complication that could possibly occur!

We do tell the patient that most of these things, including death, are exceedingly rare, however, in the interest of full disclosure, we list everything that is possible. Virtually all patients understand and do sign. I feel that this signed sheet has been quite "immunizing."

Allentown, Pa.

 

I read your article " Update: Calculating Post-LASIK IOL Power" (November 2007, p. 33) with great interest. However, I was disappointed that you failed to mention two additional resources that have been available for some time: the OcularMD IOL Calculator and the ASCRS IOL Calculator.

The OcularMD IOL Calculator ( ocularmd.com) has been on-line since May 2006 and computes IOL power using up to 10 different compensatory methods and the SRK/T and Haigis IOL formulas. In addition, surgeons have the option of including their data in our database to help determine which of the methods are most accurate and under what circumstances.

The ASCRS IOL Calculator ( iol.ascrs.org) went online in late June 2006. While it is limited to calculations using only a few methods, it does include techniques for utilizing Pentacam and EyeSys data.