Volume 5, Number 33
Monday, August 22, 2005



In this issue: (click heading to view article)
Editorial: Barbarians at the Gate
Body Mass Index and Age-Related Cataract
Baseline Factors in Three-Year Myopia Progression and Axial Elongation in COMET
Increased Nuclear Cataract Risk in Airline Pilots
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Editorial: Barbarians at the Gate

Well, it has happened again. A jury in New York City awarded a patient in a LASIK-associated malpractice claim an excessive award of $7.25 million. As you’re aware, the previous record was set in the Post case in Arizona--a $4 reward. The New York City judgment will likely be appealed.

I know the defendants in each of these cases quite well, and they have my highest respect as physicians and as individuals. They are considered experts in their respective specialties and they’ve contributed greatly to the field of ophthalmology. Certainly, this supports the fact that malpractice claims and judgments do not reflect the quality of the physician in any way.

There has been a great deal of discussion about the New York City case, given the fact that it clearly exceeded the malpractice coverage for the physician involved. The finding strikes fear in all of us. Could an excessive claim wipe out all our savings? How would we survive? Clearly, physicians must assume a more proactive role in preparing for the likelihood that such excessive awards will continue. None of us are exempt, and certainly refractive surgeons will not hold a monopoly on that market. To date, we’ve attempted to work through AAO and ASCRS, as well as with our legislators, to enact reforms that will limit our exposure and keep our malpractice premiums in line. I’m not convinced we have had significant success in our pursuits, however, and until we do so (if that’s ever possible), the time may have come to consider ways to limit our exposure, protect our assets and control the premiums for our professional liability insurance.

Not every lawyer wants to file lawsuits against physicians. Some actually want to help us use the legal system to our advantage, as plaintiffs often do. To that end, aggressive legal tactics of asset protection may be worth considering. There are a variety of ways to do this. Captive insurance may also make sense for larger groups that need to reduce expenses. The goal of these actions would be to make one much less attractive to a trial attorney who seeks an outrageous "payday," so that he or she is forced to move on to another case.

A word of caution: choose your counsel carefully, because not all attorneys are well-versed in this type of litigation and asset protection. We need to protect not our hard-earned dollars so that with our families, we can reap the benefits of our years of dedication.

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

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Body Mass Index and Age-Related Cataract

Body mass index (BMI) may be an independent risk factor for nuclear and cortical opacities, according to a Taiwanese study of an Asian elderly population.

The population-based, cross-sectional study included 1,361 subjects aged 65 years or older living in the metropolitan area of Shihpai, Taipei. Of these, 806 were diagnosed with age-related cataract, defined as any type of lens opacity (nuclear, cortical and posterior subcapsular opacity) with a Lens Opacities Classification System III grade of higher than 2 in one or both eyes. BMI was calculated as weight in kilograms divided by the square of height in meters. The patients’ weight and height were measured by extensively trained interviewers.

With a BMI of less than 21.3 as a reference point (odds ratio, 1.00), investigators discovered a U-shaped graph relationship between BMI and nuclear opacity, and a reverse U-shaped relationship for cortical opacity. In the final multiple logistic regression models, BMI and BMI(2) were significantly related to nuclear opacity and cortical opacity, but neither BMI nor BMI(2) was related to posterior subcapsular opacity.

SOURCE: Kuang TM, Tsai SY, Hsu WM, et al. Body mass index and age-related cataract: the Shihpai eye study. Arch Ophthalmol 2005;123(8):1109-14.
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Baseline Factors in Three-Year Myopia Progression and Axial Elongation in COMET

Researchers at New York’s Stony Brook University conducted a study aimed at identifying the baseline factors independently related to three-year myopia progression and axial elongation in the correction of myopia evaluation trial (COMET).

A total of 469 children were enrolled in the trial and randomly assigned to progressive addition lenses with a +2.00D add or to single vision lenses. All were observed for three years. Eligible children were 6 to 11 years, with spherical equivalent myopia of -1.25D to -4.50D bilaterally. Investigators annually measured the primary and secondary outcomes, myopia progression by cycloplegic autorefraction and axial elongation by A-scan ultrasonography. They used multiple linear regression to adjust for covariates, including treatment.

At the younger baseline age (6 to 7 years vs. 11 years, 8 vs. 11 years, 9 vs. 11 years and 10 vs. 11 years), female gender and each ethnic group compared with African Americans (Asian, Hispanic, mixed and white) were independently associated with faster three-year progression. Children aged 6 to 7 years had the fastest progression of all age groups, progressing by a mean (+/- SD) of 1.31D +/- 0.13 more than children aged 11 years. Girls progressed 0.16D more than boys. Children of mixed, Hispanic, Asian and white ethnicity progressed more than African-American children by 0.49D +/- 0.16, 0.33D +/- 0.11, 0.32D +/- 0.13 and 0.27D +/- 0.08, respectively. Age and ethnicity, but not sex, were independently associated with axial elongation. Among these myopic children, a 0.5 mm increase in axial length was associated with 1.00D of myopia progression.

SOURCE: Hyman L, Gwiazda J, Hussein M, et al. Relationship of age, sex, and ethnicity with myopia progression and axial elongation in the correction of myopia evaluation trial. Arch Ophthalmol 2005;123(7):977-87.
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Increased Nuclear Cataract Risk in Airline Pilots

Aviation involves exposure to ionizing radiation of cosmic origin. The association between lesions of the ocular lens and ionizing radiation is well-known. Investigators at the University of Iceland, Reykjavik, investigated whether employment as a commercial airline pilot and the resulting exposure to cosmic radiation is associated with lens opacification.

In a population-based case-control study of 445 men, researchers classified lens opacification into four types using the World Health Organization simplified grading system. These four types, serving as cases, included 71 individuals with nuclear cataracts, 102 with cortical lens opacification, 69 with central optical zone involvement and 32 with posterior subcapsular lens opacification. Control subjects had a different type of lens opacification or had no lens opacification. Researchers assessed exposure based on employment time as pilots, annual number of hours flown on each aircraft type, timetables, flight profiles and individual cumulative radiation doses (in millisieverts) calculated by a software program. Odds ratios were calculated using logistic regression.

The odds ratio for nuclear cataract risk among cases and controls was 3.02 (95 percent CI, 1.44 to 6.35) for pilots compared with non-pilots, adjusted for age, smoking status and sun exposure. The odds ratio for nuclear cataract associated with estimation of cumulative radiation dose (in millisieverts) to the age of 40 years was 1.06 (95 percent CI, 1.02 to 1.10), adjusted for age, smoking status and sun exposure. The results suggest that cosmic radiation may be a causative factor in nuclear cataracts among commercial airline pilots.

SOURCE: Rafnsson V, Olafsdottir E, Hrafnkelsson J, et al. Cosmic radiation increases the risk of nuclear cataract in airline pilots: a population-based case-control study. Arch Ophthalmol 2005;123(8):1102-5.
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BRIEFLY
  • LIFELONG MAINTENANCE THERAPY SAFE TO DISCONTINUE IN CMV RETINITIS PATIENTS WITH RESTORED IMMUNE FUNCTION. The incidence, visual morbidity and mortality of cytomegalovirus (CMV) retinitis and other HIV-associated retinopathies have decreased in the era of highly active antiretroviral therapy (HAART), and thus lifelong maintenance therapy may safely be discontinued in patients with restored immune function, according to a recent study by the Vitreous, Retina, Macula Consultants of New York. The study, which was published in Retina, reviewed the medical literature pertaining to HIV-associated retinopathies for differences in incidence, management strategies and complications of these conditions in the eras before and after the widespread use of HAART. In the pre-HAART era, CMV retinitis was the most common HIV-associated retinopathy, occurring in 20 to 40 percent of patients. Median time to progression was 47 to 104 days, mean survival after diagnosis was 6 to 10 months, and indefinite intravenous maintenance therapy was mandatory. Retinal detachment occurred in 24 to 50 percent of patients annually. In the HAART era, by contrast, the incidence of CMV retinitis has declined 80 percent and survival after diagnosis has increased to more than one year. The authors of the study point out, however, that patients with regressed CMV retinitis may still lose vision from epiretinal membrane, cystoid macular edema and cataract secondary to immune recovery uveitis, which may occur in up to 63 percent of patients with regressed CMV retinitis and elevated CD4 counts.
    SOURCE: Goldberg DE, Smithen LM, Angelilli A, Freeman WR. HIV-associated retinopathy in the HAART era. Retina 2005;25(5):633-49.
  • HEIDELBERG ENGINEERING LAUNCHES HRT3 FOR EARLY GLAUCOMA DIAGNOSIS. Heidelberg Engineering GmbH has introduced the Heidelberg Retina Tomograph 3 (HRT3), a newly enhanced version of its flagship product for assessing, diagnosing and managing glaucoma. New features include the Fast Check Glaucoma Probability Score, which is generated using an advanced form of artificial intelligence called a relevance vector machine. The analysis provides a statistical probability of glaucoma using ethnic-specific databases. The software eliminates the need to draw contour lines or use reference planes, and it provides real-time feedback to the operator for acquiring a quality image. The HRT3 is a portable, laptop-based system that can be stored in a compact carrying case. The company expects to begin shipping the HRT3 in the last quarter of 2005.
  • SECOND GENETIC MUTATION FOR AMD IDENTIFIED. Researchers at the University of Pittsburgh have identified a gene mutation that appears to significantly increase the risk of developing age-related macular degeneration (AMD). The finding follows the spring 2005 discovery of the first "susceptibility gene" for AMD. The newly discovered gene seems to be just as strongly associated with AMD as the one discovered earlier: it’s believed that it could increase by up to five times an individual’s risk of developing AMD. Based on a 15-year gene-mapping study of 612 families affected by AMD and another 323 unaffected individuals, the researchers discovered that an area of chromosome 10 containing the location of a gene called PLEKHA1 was strongly associated with the disease. The study also confirmed earlier findings that a variant of the gene for complement factor H (CFH) is strongly associated with AMD. CFH and PLEKHA1 are involved in cellular processes related to inflammation, a possible factor in AMD; thus the researchers believe that steroids or other anti-inflammatory agents may be used to treat the disease at early stages. They point out that perhaps three to five more major susceptibility genes remain to be identified before any type of genetic test for AMD is feasible.


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