In the article "Seeking the Safer Clear Corneal Incision" in the April issue of Review of Ophthalmology, Ashley Behrens, MD, alludes to a technique I use called stromal hydration of a supra-incisional pocket.

I would like to make a few points about the technique. Unlike other stromal hydration methods in which the fluid is resorbed in an hour or two, the swelling in my technique lasts longer than 24 hours. This is important, as I have followed intraocular pressures in vivo in a series of my patients and found about 25 percent had pressures of 10 mmHg or less at the four to six hour post-surgery timeframe. This is perhaps when fluids off the surface of the conjunctiva are "sucked in." The supra-incisional swelling keeps the lips of the clear-cornea incision apposed despite the hypotony.

Further, by the time the endothelium begins to pump out the excess stromal fluid, it must have already "dried" the wound watertight in the same way that a LASIK flap is drawn securely in the first 24 hours postoperatively.
Best of all, this technique is free and takes only a few seconds to do.

Michael Y. Wong
Princeton, N.J.

I enjoyed your article in April's Review about optometric co-management. The type of candor from those interviewed clearly depicts many ophthalmologists' true sentiments in regard to optometry. I become annoyed with patronization, so I find these heartfelt thoughts to provide refreshing clarity.

Here is a painful part of co-management from another perspective. There exists a wide range of skill within ophthalmology, from superb to less than mediocre. The same is true in all professions. Ironically, optometrists are the only professionals outside of ophthalmology who have any ability to rank the skills of their local surgeons. We must all agree that MD's outside of the eye care arena couldn't tell the difference between a no-stitch phako and one with 10. We all know them, the fellows who prescribe sulfonamides or good old "gent" for gram-negative rods. Their referral patterns are much more apt to be based upon reputation, friendship or location than real objective evaluation of surgical outcome. Even an ophthalmologist might require a slit lamp to make that same determination.

Like it or not, I only send my patients to the best surgeons, who deliver the best outcomes. I only refer to the ones who I would allow to operate on my family. Understandably, this leaves most of ophthalmologists out of the running. It so happens that in Cincinnati, those very surgeons, who truly have first class international reputations in their respective fields and the best outcomes, employ OD's to perform postoperative follow-up and management. They also co-manage. Please understand that I expect that the excellent surgical management of my patients by these select surgeons includes scrupulous individualization of patient care. I expect nothing less. Patients are returned to my care based upon their recovery rather than any strict formulary or timetable. Indeed, because my co-managing surgeons are so good, with so few complications, their timetable tends to be remarkably dependable. One might argue that a clever way to hide one's embarrassing complications is to not co-manage.

As far as the litany of ophthalmologist's comments reported in your article, which clearly demean optometry and co-management relationships, I wonder how their tale might be mitigated if each practice like my own in their area suddenly started referring a few hundred procedures per year to their practices. As an optometrist, I do not take offense by the disparaging remarks made by these ophthalmologists. While, admittedly, they are annoying, my knowledge of human nature compels me to understand that these comments are merely reflective of intractable cases of pathological subrogated jealousy of those select and most highly skilled and experienced eye surgeons who enjoy the substantial ongoing benefits of optometric referrals and co-management. Optometrists have an endearing name for this pathology; we call it "short man's disease." 

Elliot M. Kirstein, OD, FAAO