To the Editor,
As a member of the Pennsylvania Department of Transportation’s Medical Advisory Board, I am compelled to offer a few corrections to the article recently published by Dr. Miller-Ellis ( Glaucoma Management, November 2011).

Penn DOT’s visual field standard is 120 degrees (in extent) along the horizontal axis rather than the cited 110 degrees. The Esterman VF test is a good screening test since it continues along the horizontal axis at its extremes (as contrasted, to say, the full field 120 degree screening). The Esterman tests a total field extent that approximates 145 degrees rather than “extends to 160 degrees temporally on both sides.” The Esterman tests (both binocular and monocular) use the same stimulus intensity as the other Humphrey screening tests, which would obviously differ from a threshold test.

Two plausible reasons why an individual would perform better on a binocular Esterman test would be: 1) The binocular test does not monitor fixation, which would allow a savvy patient to search for the stimuli; and 2) The Esterman tests have a longer stimulus duration—500 msec as opposed to 250 msec. Once again, this would afford a greater “search” time opportunity. Finally, although the “low vision” waiver (20/70 to 20/100) limits the driving privilege to “roads other than freeways,” it is not linked to an “under 45 mph” restriction.

Aside from these clarifications, this is certainly a timely topic that all clinicians should consider—particularly, with Pennsylvania’s mandated physician reporting.
Robert Owens, OD, FAAO

To the Editor,
I would like to comment on the quote: “We hope that this month’s features leave you feeling a little better about your profession,” included in the Editor's Page, in the December issue.

I am very enthusiastic about my profession and I always begin every new year with new projects and goals that I personally have to meet in order to reach and maintain my work at the highest possible level. The main goal of this behavior is to benefit my patients with the most advanced knowledge in the field of ophthalmology.

Paying careful attention, this letter has a lot of paragraphs that reveal prejudices related to the patients, to the ophthalmologists, to the industry … and is politically incorrect to mix profession with religion.

I am proud to be an ophthalmologist, to have the opportunity to offer to my patients the cutting edge in technology that for sure will change and improve the quality of their lives.

I am not selling my soul, and I consider myself a highly qualified expert in cataract and refractive surgery, and for that reason I am committed to offer the best to my patients, and I give to them the opportunity of choice.

I would like to advise Dr. Johnson to take a basic course on ethics, on advanced technology IOLs, and to remember that from now on, in cataract surgery (the most frequent surgery in the world, over 3.5 million in the United States) those patients who decide to implant an advance technology IOL must pay for it. This is a personal option of the patient. The doctor has the obligation to educate and help the patient to make the right option …, even being “ not the smartest… but ordinary enough” … “Mid-westerners put great faith in their physicians” … “these simple people.”

Finally, I would like to say that the money I get with advanced technology IOLs, I invest in new technology and knowledge to help my patients and make them and myself less unhappy.

To buy a Ferrari is for those who sell their soul.

Virgilio Centurion, MD
São Paolo, Brazil

To the Editor,
Regarding the Editorial in the January issue (“ Don’t Be Driven To iDistraction”), I like the way you left the physician-reader with the challenge to evaluate their usage of technology as it pertains to their patient care. I frequently witness both “good use” and “abuse” of technology by many physicians. These well-intentioned parties are “new-school” progressionists, but can lead to two different outcomes in terms of genuine patient care value.

Unfortunately, it is almost always the case that the physician believes his use of technology is helping his patient, when in fact, the patient’s personal interaction time with the doctor is suffering. I have observed that, amongst technology-embracing physicians, a common trait is that one’s technical savvy and clinical implementation of such, often gets in the way of, if not replaces, good old-fashioned patient face time. And consequently, “care-giving” (the root of practicing medicine) suffers as a result.

I’m waiting for these medical technology companies to recognize this fact and create a practical tool that will narrow this gap between too much technology and traditional patient CARE. The challenge to these developers will be adorning the new methods with window dressing that can compete with the hyper-marketed, half-useful applications that are spilling into our field on a daily basis.

In my “non-physician” opinion, the new drug-delivery modalities are a wonderful example of new technology that will actually provide a tangible value to the practically forgotten entity whose existence is why we’re all doing this—the patient. Online vision testing, the Cloud, iPad medical apps … these are all impressive uses of ophthalmology practice, but I’d personally rather see my ophthalmologist get excited about sub-retinal biofactories or extended drug-release implants. “Your latest newsletter was very impressive doctor, but I had to see you 10 times last year—what are you doing to reduce the frequency of injections I must get into my eye?”

I think some of the problem is a growing crop of young physicians who are so stimulated by the information-availability explosion that they are mentally divided between new ideas and opportunities, and genuine patient care. The fact that the huge majority of the ophthalmologists I know seem to have their hands in non-clinical-related entrepreneurial endeavors doesn’t help narrow this divide at all.

I’ve been on the front line, giving care to patients for 23 years. I can tell you unequivocally, the physician who is most endearing to the patient is the one who sits face-to-face and personally explains the impressions, plans and prognosis for that patient’s condition. The quickly-forgotten physician is the high-tech performer who replaces his care-giving opportunity with the newest EMR system, website with cool animations or tablet-based Amsler grid.

Where I work, my physician bosses allow ME (their staff) to be concerned about keeping the practice technologically up-to-date, while they focus on patient care. My vitreo-retina specialist now engages his high-tech gadgets in between seeing patients, out in the hallway, then puts them aside and enters an exam room environment that is equipped with a good balance of technology and personal patient care. I think this method is the best approach for a modern ophthalmology clinic.

As you mentioned, the development and availability of ophthalmology apps and other technologies is rising exponentially. Much like the American lifestyle, I believe its own success could be its downfall.

Mark Erickson, CRA, COT
Trinity, Fla.