Review of Ophthalmology

The Role of PAs, and a Post-PRK Drug Issue

Staff
4/5/2012

To the Editor,
... and how softly, on what faint dainty paws, does the death of a profession arrive?

Not a good day, today, in the Florida news. First I read how the Florida Medical Association has elected to align itself with the Florida Optometric Association, in direct opposition to the Florida Society of Ophthalmology, to expand the scope of optometric practice to include oral medications. An expansion that has been combatted with a united front by Medicine for the past 30 years as a professional wrong is now at once reversed and supported.

Certainly there has been no expansion of optometric training, expertise, or professional abilities in the last year ... so what changed?

Money.

Money changes everything. Optometric PACs raised $600,000 this year vs. $48,000 from ophthalmology. Money speaks, the legislature listens, and the world spins on its axis.

Secondly, a judge ruled in favor of St. Luke’s Cataract & Laser Institute in Tarpon Springs, Fla. He agreed that it was within medical standards for a PA to perform some of the surgical steps of cataract surgery. What motive could drive a surgeon to piece out a surgery that probably takes 10 minutes to perform? A surgery for which the time it takes to scrub and gown between cases probably exceeds the time saved by letting the PA perform the surgical steps? 

I don’t know the answer, but might one of the motives be ... money? 

So, today a judge ruled a PA under supervision could perform cataract surgery. I wonder if the Florida Optometric Association has taken notice? If a PA can perform surgery, could an optometrist?

... and how cheaply we are sold. And how cheaply we sell ourselves. And how cheaply our profession is lost.
Mark Johnson MD, FACS
                       Venice, Fla.


Reply:
Thank you for the opportunity to respond to Dr. Johnson’s February 17th letter. Only after casting aspersions on the surgical practices at St. Luke’s, and raising questions about the motives for these practices, does Dr. Johnson acknowledge that “I don’t know the answer.” This acknowledgement of his ignorance is the only thing he got right.

The court case to which Dr. Johnson alludes rejected a bogus challenge to Medicare billing where the services provided included support by a physician assistant. The medically sound role of physician assistants, operating with proper supervision, has been recognized throughout the country and encouraged by state legislatures and licensing Boards. The success of the PAs at St. Luke’s has been validated in tens of thousands of successful cataract surgeries, where PAs assist the surgeon, allowing him to focus his attention and skills where they are most critical and leaving more routine steps to others. There is no hand-off of responsibility; licensed and credentialed PAs are extensively trained and appropriately supervised by the surgeons. The approach is so superior that Dr. Gills relied on the same PA involvement for the surgery to address his own cataracts and those of his wife. The surgical outcomes at St. Luke’s speak for themselves.

St. Luke’s cataract surgical practice has been recognized within the profession for repeated innovations and improvements that have benefitted its patients, the practice and the profession with increases in efficiency, safety and outcome. The use of PAs is but one example.

For most of his career, Dr. Johnson has been a prolific author of uninformed critiques of ophthalmological practices, and for reasons only he knows has elected to persist in taking unfounded potshots at St. Luke’s. We hope that, in the future, he will modify his standard “unburdened by facts approach” before engaging in uninformed speculation to impugn an accomplished colleague who has contributed much to his profession. 
J. Bradley Houser, Administrator 
St. Luke’s Cataract and Laser Institute
Tarpon Springs, Fla.



To the Editor,
Recently we have noted many instances of prolonged re-epithelialization after PRK.

In reviewing our supplies and medical regimen, the only change noted was the recent substitution of besifloxicin for gatifloxicin. The commercial compound, Besivance, is manufactured with the DuraSite viscous delivery system, so that the drop remains in place longer than standard preparation, enhancing absorption.

In our series, we have noted six patients who were incompletely healed up to 18 days postoperatively. These patients were young, compliant, non-diabetic, without anterior basement membrane dystrophy, and displayed no evidence of dry eye or tear film abnormality preoperatively. In all cases, the defect was approximately 2 mm in diameter, oval, located at the corneal apex and involved the visual axis.

We found this pattern similar to contact-lens-induced hypoxia, and posit that the delivery vehicle in Besivance creates a barrier to oxygen transmission through the bandage soft contact lens, and likewise limits horizontal flow of tears and oxygen beneath the lens. Alternatively, this could represent a toxic response, but we feel this mechanism is unlikely, given that we have not seen this in any LASIK or cataract patient postoperatively who has been treated with an identical dosing regimen.

Since reinstituting gatifloxicin, we have not seen a delay in re-epithelialization in any patient.
Lance S. Ferguson, MD
Lexington, Ky.


Editor’s note: As this letter raised an issue regarding a specific product, we offered the manufacturer, Bausch + Lomb, the opportunity to reply. At the company’s request, the physicians below, who consult with B + L, responded:


Dear Dr. Ferguson,
Thank you for bringing your concerns to the attention of the ophthalmic community. As this issue goes to press, the Bausch + Lomb medical director and his team are in contact with your office to explore the possible causes of your six cases of prolonged re-epithelialization after PRK.

Since the FDA approval of topical besifloxacin, no cases of delayed re-epithelialization after PRK have been reported to the company, and Zhang’s animal study supports its safety in PRK as well.1

In our practices, besifloxacin suspension has been applied q.i.d. to thousands of eyes with large epithelial defects and bandage contact lenses, including abrasions, PRKs, PTKs, stromal punctures, lamellar keratectomies, as well as thousands of eyes with large epithelial defects without bandage contact lenses, including penetrating keratoplasties, DSAEKs and pterygium removals, without any delay in re-epithelialization. Perhaps there is an as yet unidentified cause for these recent cases of delayed re-epithelialization: excessive MMC exposure;2 apical rub from the bandage contact lens;3 or concomitant medication use. Nevertheless, your report is unique and requires careful investigation of the solutions, bandage lenses and surgical techniques employed. We will write a follow-up letter to the Review of Ophthalmology medical editor, Mark Blecher, MD, when the investigation is completed.

Thank you again for your vigilance, Dr. Ferguson.

Sincerely,
Eric Donnenfeld, MD, Edward Holland, MD,
Stephen Lane, MD, Richard Lindstrom, MD,
Marguerite McDonald, MD, and John Sheppard, MD.



1. Zhang JZ, Krenzer KL, Lopez FJ, Ward KW. Comparative effects of besifloxacin and other fluoroquinolones on corneal reepithelialization in the rabbit. J Cataract Refract Surg. 2010; 36: 1049-50.
2. Kremer I, Ehrenberg M, Levinger S. Delayed epithelial healing following photorefractive keratectomy with mitomycin C treatment. Acta Ophthalmologica 2010 April 23:1-6.
3. Kim JS, Na KS, Joo CK. Base curves of therapeutic lenses and their effects on post Epi-LASIK vision and pain: A prospective randomized clinical trial. Jpn J Ophthalmol 2009; 53(4): 368-73


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