Like many of you, I subscribe to KeraNet and the ASCRS list serv. These forums are excellent resources for enhancing our knowledge and promoting better patient care. From time to time, they can also bring to light how some matters in our profession may not be as clearly understood as we might wish. Recently, a somewhat lengthy thread appeared regarding the occurrence of ectasia following laser refractive surgery. Let’s face it: we do not know all that we would like to know to help identify factors that would help us properly select appropriate patients for such procedures and exclude those at possible risk for ectasia. We still argue about whether going back to the surface and wiping out Bowman’s is better than creating a thin flap that preserves Bowman’s. Also, we look to technology that allows us to view the posterior cornea elevation but not really allowing us to determine the true accuracy and significance of the data. Clearly, this technology has helped many patients, but there are still those subtle cases that are lurking out there--and that might come back to bite us in a future medical liability claim.

Ophthalmologists need to press for an exacting definition of the "standard of care." Understandably, we reserve the right to modify these standards to enhance patient care as our knowledge expands. In addition, these standards must be clearly communicated to rank-and-file ophthalmologists and must have as much science behind them as possible. I believe that if the "standard" is too ill-defined, mistakes are bound to occur, and eventually we may be forced into a situation in which a plaintiff’s expert witness will define that standard for us. To the credit of Drs. Perry Binder, Doyle Stulting, Bill Trattler and others, we are gaining knowledge about ectasia after LASIK. But if a crystal-clear standard exists for screening topography of the corneas of potential LASIK patients, I must have missed it.

Ophthalmology is blessed with some of the brightest minds in medicine so let’s put those minds to work at defining those standards and promote better patient care, a clearer understanding of risk factors among practitioners and a legal foundation upon which we can rely in the event of a medical malpractice claim.

This can be an exciting time for ophthalmology. Our technology continues to improve, and we are accomplishing some amazing things with lasers and lenses. At the same time, the margin for error seems to be ever shrinking, so we must be well-equipped with the knowledge and tools to deliver a rewarding and safe visual outcome.

Stephen E. Pascucci, MD Medical Editor [email protected]

Molecular testing can confirm a clinical diagnosis, identify carrier status and confirm or rule out the presence of a familial mutation in nonsymptomatic at-risk relatives. Because causative mutations cannot be identified in all patients with retinal diseases, say the authors of this University of Michigan study, it is essential that patients are counseled before testing regarding the benefits and limitations of this emerging diagnostic tool.

Researchers conducted mutation analysis of eight retinal genes by dideoxy sequencing and offered pre-test and post-test genetic counseling to patients. The laboratory reports listed results and provided individualized interpretation. A total of 350 tests were performed; the molecular basis of disease was determined in 133 of 266 diagnostic tests and the disease-causing mutations were not identified in the remaining 133 diagnostic tests. Predictive tests were requested for nine non-symptomatic patients with known familial mutations, and carrier tests were requested for 75 non-symptomatic patients with known familial mutations.

The authors stress that the molecular definition of the genetic basis of disease provides a unique adjunct to the clinical care of patients with hereditary retinal degenerations.