method
employs a script that guides the ophthalmologist through "one-pass" system: the physician sees each patient once, not to return after leaving the room. To perfect the system, the consultant had monitored the doctor's performance\p=m-\athis side and with a stopwatch. In a high-performance eye care encounter, the ophthalmologist enters the examining room with a smile. He is followed by the ophthalmic assistant, who has taken a "history," deter¬ mined and written the prescription for new glasses, recorded the intraocular pressures, and dilated the pupils. Dr: "Good morning, Mrs R., I am Dr C., and it's nice to meet you." The ophthalmologist sits and makes eye contact. a
Dr: "Let me think about you, Mrs R." The ophthalmologist looks at the chart on which the above data are recorded. He paraphrases the chief complaint. Dr: "I see that you are having (eg) blurred vision. As the ophthalmologist examines the eyes with a slit-lamp microscope and ophthalmoscope (about 45 seconds during which the patient is not expected to talk), he dictates his observations to the assistant. Then he sits back and looks directly at the patient. Dr: "I have good news for you. Your eyes look perfectly normal and healthy. There are no signs of glaucoma or cata¬ ract. You just need a small change in your glasses. Here's your prescription and a card with the prescription and our telephone number for your wallet." (Variation: If he finds an abnormality, he deals with it quickly, for example, by referring the patient to another physician. Or, if additional expenses can be incurred, he calls his surgical nurse who, assisted by videotapes, explains and schedules surgery or laser treatments. Similarly, the assis¬ tant explains macular disease, glaucoma, use of eye drops, "
etc.)
To avoid the appearance of haste, the ophthalmologist just sits for 10 seconds and makes a personal and complimentary remark. Then he makes his closing remarks. Dr: "It was very nice meeting you. I suggest that you be reexamined in 2 years. Of course, if you have any problems, come in at any time. Do you have any questions?" The ophthalmologist transfers the patient's gaze from him¬ self to the assistant standing behind him and says, if neces¬ sary, before leaving the room: Dr: "My assistant will answer that for you." The practice consultant quickly perceived that I was a poor student, and I had to find another place to work. As far as I could tell, most patients appreciated the efficiency of the office. Carl Ellenberger, JR, MD Lebanon, Pa
Homologous vs Autogenous Fascial Grafts Buckling
for Scleral
To the Editor. \p=m-\Dresneret al1 describe a technique for dealing with exposed buckling elements in patients having had previous retinal surgery. They recommend using autogenous fascia grafts. I would like to point out that homologous fascia grafts would be just as useful and would eliminate the need to subject the patient to a second procedure. At the Ohio State University, Columbus, we have used homologous fascia lata strips for more than 30 years in retinal and plastic surgery.2 The fascia is harvested from postmortem donors and frozen in antibiotic solution. The fascia may be stored from months to years without apparent degradation of the integrity of the collagen structure. Neither infection nor host rejection has been encountered. I commend the authors on describing a technique to correct exposed buckling elements, thus eliminating the need to remove the hardware. I suggest that instead of using autogenous fascia they use homologous fascia lata, which would accomplish the same end without exposing the patient to a second procedure. Frederick H. Davidorf, MD Columbus, Ohio 1. Dresner SC, Boyer DS, Feinfield RE. Autogenous fascial grafts for exposed retinal buckles. Arch Ophthalmol. 1991;109:288-289. 2. Davidorf FH, Havener WH. Homologous fascia lata in retinal surgery: use offascia lata in scleral buckling procedures. Ophthalmic Surg. 1974;5:89-97.
In
Reply. \p=m-\Wethank Dr Davidorf for suggesting the use of homologous fascial grafts in patients with exposed buckles.
We agree that this is a viable alternative to autogenous fascial grafts; however, it would still not be our first choice of material. Crawford,1 who had much experience with both banked and autogenous fascia, preferred autogenous fascia because of the variability of the banked tissues in vivo. Banked fascia is also not always available in the community. It is also important to recognize that with even the remotest chance of acquiring viral conditions from homologous tissues, most patients would prefer autogenous grafts. The obtaining of autogenous fascial grafts is easy and quick and it has limited complications. We believe that the additional effort is well worthwhile. Steven C. Dresner, MD David S. Boyer, MD Robert E. Feinfield, MD Santa Monica, Calif 1. Crawford JS. Fascia lata: its nature and fate after implantation and its use in ophthalmic surgery. Trans Am Ophthalmol Soc. 1968;66:673-745.
Downloaded From: http://archopht.jamanetwork.com/ by a University of Pittsburgh User on 06/20/2015
employs a script that guides the ophthalmologist through "one-pass" system: the physician sees each patient once, not to return after leaving the room. To perfect the system, the consultant had monitored the doctor's performance\p=m-\athis side and with a stopwatch. In a high-performance eye care encounter, the ophthalmologist enters the examining room with a smile. He is followed by the ophthalmic assistant, who has taken a "history," deter¬ mined and written the prescription for new glasses, recorded the intraocular pressures, and dilated the pupils. Dr: "Good morning, Mrs R., I am Dr C., and it's nice to meet you." The ophthalmologist sits and makes eye contact. a
Dr: "Let me think about you, Mrs R." The ophthalmologist looks at the chart on which the above data are recorded. He paraphrases the chief complaint. Dr: "I see that you are having (eg) blurred vision. As the ophthalmologist examines the eyes with a slit-lamp microscope and ophthalmoscope (about 45 seconds during which the patient is not expected to talk), he dictates his observations to the assistant. Then he sits back and looks directly at the patient. Dr: "I have good news for you. Your eyes look perfectly normal and healthy. There are no signs of glaucoma or cata¬ ract. You just need a small change in your glasses. Here's your prescription and a card with the prescription and our telephone number for your wallet." (Variation: If he finds an abnormality, he deals with it quickly, for example, by referring the patient to another physician. Or, if additional expenses can be incurred, he calls his surgical nurse who, assisted by videotapes, explains and schedules surgery or laser treatments. Similarly, the assis¬ tant explains macular disease, glaucoma, use of eye drops, "
etc.)
To avoid the appearance of haste, the ophthalmologist just sits for 10 seconds and makes a personal and complimentary remark. Then he makes his closing remarks. Dr: "It was very nice meeting you. I suggest that you be reexamined in 2 years. Of course, if you have any problems, come in at any time. Do you have any questions?" The ophthalmologist transfers the patient's gaze from him¬ self to the assistant standing behind him and says, if neces¬ sary, before leaving the room: Dr: "My assistant will answer that for you." The practice consultant quickly perceived that I was a poor student, and I had to find another place to work. As far as I could tell, most patients appreciated the efficiency of the office. Carl Ellenberger, JR, MD Lebanon, Pa
Homologous vs Autogenous Fascial Grafts Buckling
for Scleral
To the Editor. \p=m-\Dresneret al1 describe a technique for dealing with exposed buckling elements in patients having had previous retinal surgery. They recommend using autogenous fascia grafts. I would like to point out that homologous fascia grafts would be just as useful and would eliminate the need to subject the patient to a second procedure. At the Ohio State University, Columbus, we have used homologous fascia lata strips for more than 30 years in retinal and plastic surgery.2 The fascia is harvested from postmortem donors and frozen in antibiotic solution. The fascia may be stored from months to years without apparent degradation of the integrity of the collagen structure. Neither infection nor host rejection has been encountered. I commend the authors on describing a technique to correct exposed buckling elements, thus eliminating the need to remove the hardware. I suggest that instead of using autogenous fascia they use homologous fascia lata, which would accomplish the same end without exposing the patient to a second procedure. Frederick H. Davidorf, MD Columbus, Ohio 1. Dresner SC, Boyer DS, Feinfield RE. Autogenous fascial grafts for exposed retinal buckles. Arch Ophthalmol. 1991;109:288-289. 2. Davidorf FH, Havener WH. Homologous fascia lata in retinal surgery: use offascia lata in scleral buckling procedures. Ophthalmic Surg. 1974;5:89-97.
In
Reply. \p=m-\Wethank Dr Davidorf for suggesting the use of homologous fascial grafts in patients with exposed buckles.
We agree that this is a viable alternative to autogenous fascial grafts; however, it would still not be our first choice of material. Crawford,1 who had much experience with both banked and autogenous fascia, preferred autogenous fascia because of the variability of the banked tissues in vivo. Banked fascia is also not always available in the community. It is also important to recognize that with even the remotest chance of acquiring viral conditions from homologous tissues, most patients would prefer autogenous grafts. The obtaining of autogenous fascial grafts is easy and quick and it has limited complications. We believe that the additional effort is well worthwhile. Steven C. Dresner, MD David S. Boyer, MD Robert E. Feinfield, MD Santa Monica, Calif 1. Crawford JS. Fascia lata: its nature and fate after implantation and its use in ophthalmic surgery. Trans Am Ophthalmol Soc. 1968;66:673-745.
Downloaded From: http://archopht.jamanetwork.com/ by a University of Pittsburgh User on 06/20/2015
