In response to the October 2006 letter Stop the Shell Game, Dr. Michael Cohen is correct that some doctors are playing a shell game with doctor-exclusive lenses. It's important to realize, however, that GP lenses aren't all the same and that some custom-made lenses designed from corneal topography or for keratoconus need to remain dispensed by practitioners.

The legitimate health issues that practitioners are concerned about occur when patients are able to order a year's supply of lenses one month before the prescription expires, or when a contact lens seller refills a prescription by passive verification when the prescribing practitioner didn't have time to verify that prescription within the time limit. Both of these situations result in patients not having their eyes checked on a regular basis for adverse reactions to lens wear. It's these issues that have lead some practitioners to promote the doctor-exclusive lenses.

Steven Ohlbaum, OD

New Hartford, NY

I was just about to send a letter congratulating ophthalmologists and optometrists on one thing we can agree on - the necessity of supervision of contact lens wear - when I came across Dr. Cohen's letter Stop the Shell Game.

The truth is, we don't care if lenses come from our offices, 1-800 Contacts, another Internet or mail-order retailer or from outer space. I don't know any MD or OD who has a huge profit center based on selling contact lenses. What we do care about is the supervision of contact lens wear and the compliance of lens wearers to wear their lenses as advised.

1-800 Contacts doesn't see the bacterial corneal ulcers, fungal ulcers, Acanthamoeba, pannus, GPC and other complications that we eyecare practitioners see in our practices. When will the retailers understand that contact lenses are medical devices that are in constant contact with living tissue? Not just any living tissue, but that of the most important refractive interface of the eye?

I've seen contact lenses sold in Halloween costume shops, at swap meets, at clearance sales in shopping malls and, my favorite, by teens who trade contact lenses as if they were baseball cards. We need retailers to understand the reality of the abuse we see in our practices. If it will save just one eye, isn't it worth the direct supervision of contact lens distribution by ODs and MDs?

Geoffrey V. Davis, MD

Aiea, HI

Because he touched so many people in such gracious ways, here's another Neal Bailey story.

During my tenure at FDA, Neal never failed to be present at ophthalmic panel meetings. We always had opportunities to speak with each other, albeit briefly. He never failed to walk over, say hello and offer a bit of anecdotal contact lens history.

What struck me about Neal was his never diminishing spirit, as well as his need to learn about new technologies and then to report them in Contact Lens Spectrum (or whatever predicate journal he was editing). There he'd sit in the audience, front row center, with his note pad, pen and that ever present camera, ready to grab the next most important contact lens revelation. Neal never missed one meeting - because I never missed one meeting - in more than 11 years. No meeting was complete without his presence.

But the most striking thing about Neal was what he left with you after each meeting - his remarkable personage, gentle humility and those anecdotes. I can't think of anyone in this profession who had a better sense of contact lens history than Neal Bailey (except for Irv Borish, but that's another story) and a most unique way of telling those stories. I was proud to know him.

Richard E. Lippman, OD, FAAO

Rockville, MD

I never write letters about items I use, but for the Contact Lenses & Solutions Summary (CLASS) I need to make an exception. CLASS is great! Much more convenient than Tyler's Quarterly and Jobson's Review of Cornea and Contact Lenses.

I use CLASS all the time. Very simple format. Easy to find things. Less is indeed better in your case. Thanks for a very helpful and useful publication.

Ron Sheahan

Lewiston, ID

I am a contact lens manufacturer from Brazil (member of the CLMA) and I also run the IOSB (Instituto de Olhos Dr. Saul Bastos). We have a very advanced GP special design for keratoconus and pellucid marginal degeneration called Ultracone as well as another design for post-graft patients called Ultraflat.

The results we've obtained with these lenses in our clinical experience are very high. We're from the Joseph W. Soper school; Dr. Soper was a close friend of ours, and we both worked with him and learned much from him in the United States. We improved the Soper Keratoconus design and developed the Ultracone, which is a type of modified Soper design.

Our experience with the Ultracone lens indicates that its performance is as high as 99.5 percent for keratoconus cases. We also have a special Ultracone design called Ultracone Mini-Scleral, which can fit corneas with curves as high as 65.00D and even up to 75.00D. Corneal topography sometimes shows even steeper curves that we've succeeded in fitting with this design. Based on our experience in the United States and in the United Kingdom, I believe that the Ultracone design is excellent for keratoconus.

I also developed a consultory that I named Digital Consultory, in which practitioners can shoot images or even record a small movie of the fluorescein pattern during the final test with the best lens, and we can provide the doctor and his patient with a personalized design. This new philosophy has proven to be very effective because I analyze the video or picture myself, and I understand the contact lens manufacturing technology and process. I also know what makes a good cornea/lens fitting relationship and I can modify the lens during the manufacturing process and also after the final exam.

I would add that we just use corneal topography technology to study the corneal pathology. It gives us an idea of what diagnostic lens we will try first. Corneal topography is a great tool, but when dealing with an irregular corneal surface, the only way to achieve the best results is to observe the fluorescein pattern. I never use fluorescein dip, only strips so it won't overflow the tear film. Overflow can cause misjudgment of the tear film pattern. After observing the fluorescein pattern I decide if the lens/cornea relationship is reasonable and which modifications the lens needs to achieve the best performance possible.

Luciano Bastos

Porto Alegre, Brazil

I always enjoy the writings of William Townsend, OD, in Contact Lens Spectrum. Regarding his January 2007 Dry Eye Dx and Tx column titled Eyelid Transillumination, does he literally push into the lower lid to evert it?

As to documentation using CPT 92285, it seems to me that coding experts discount using this CPT for documentation purposes solely; that is, unless there's a treatment plan to ensue, I've been told that you can't bill for such procedures. Should I assume that Dr. Townsend would document as such with a treatment protocol in mind for ocular surface disease?

Jordan D. Rosen, OD

Richmond, VA

I first want to thank Dr. Rosen for his interest. Regarding the technique, it's easier to demonstrate than to describe. You place the transilluminator against the eyelid with the end close to the lid margin. While exerting gentle pressure and maintaining contact between the transilluminator and the lid, pull down on the lower lid. This rolls the margin out and allows you to change the location of the transilluminator as it shines though the lid.

Regarding the coding issue, I've asked Dr. John Rumpakis, a friend and lecturer on the subject of coding, to address this issue.

The answer is that it depends. If you feel in your medical opinion that the procedure is necessary to document a baseline condition and that taking the photo is necessary to benefit the patient (when not taking the photo would alter your medical decision making regarding your treatment protocol or the patient outcome), then document the medical necessity of the procedure, order the photo and bill for it. If you're taking the photo simply for documentation and patient education purposes, then most likely it wouldn't be appropriate to bill the carrier for it, but you could bill the patient.