Managed Care Malfeasance?
VSP’s agreement with Costco and its foray into online optical sales (“VSP Looks Into Online Optical,” January 2011) brings into question VSP’s commitment to professional optometry. There is also a question of whether other VSP’s actions are lawful.

VSP now offers priority listing on its online doctor directory in exchange for practices selling VSP frames to a specified number of VSP patients. This appears to be an unlawful inducement under federal anti-kickback law and a violation of federal anti-competitive law.

Certain managed vision care industry practices are unfair or dishonest­—others may be unlawful. It is time for Review of Optometry to publish a monthly column where examples of malfeasance by the managed vision care industry can be submitted and posted. It is time to shine a light on questionable practices and hold the managed vision care industry accountable.

As health care providers continue to be taken advantage of and treated unfairly by managed care organizations and state Medicaid programs, perhaps it is time to demand legislative protections and rights. Like the people of Egypt and the state workers in Wisconsin, if health care providers are willing to protest and shut down the health care system on a state-by-state basis, the balance of power can be shifted.

—(Name withheld),
New York

‘Faux’ Board Certifications
The American Board of Certification in Medical Optometry (ABCMO) offers certification in the specialty of medical optometry that requires completion of an ACOE accredited post-graduate residency in medical optometry, passage of the National Board of Examiners in Optometry written examination, “Advanced Competence in Medical Optometry,” and active practice of medical optometry.

Health care credentialing bodies recognize board certification as the attainment of specialist status resulting from residency training and passage of a written specialty examination testing advanced competency and require it of specialists.

Optometrists without specialty residency training are general practitioners and not required to be board certified at accredited health care facilities. And, “any licensed provider” rules, insurance panels and the 2010 Health Care Act do not require board certification of general practice optometrists, or of other defined-license practitioners such as dentists, because their degrees and licenses fully qualify them for general practice.

Two groups now offer voluntary “board certification in optometry” to “certify continuing competence in general practice.” But continuing competence in general practice is solely the legal responsibility of state optometry boards and their maintenance of license programs (MOL) required for license renewals. No evidence shows general practice optometrists are inadequately maintaining their competence, so the need for additional programs has not been established. Creditable professions do not use voluntary continuing competence programs, and the recognized purpose of board certification is not to ensure competence of general practitioners but to denote specialist status.

Nevertheless, these groups offer “board certification in optometry,” although neither requires residency training; one tests competence only at the level of general practice while the other requires no examination.

Similarly misleading board certifications in non-recognized medical specialties are rejected by credentialing bodies at accredited health facilities, and state medical boards are challenging their public use. In like manner, several state optometry boards have stated these “board certifications in optometry” may not be cited to the public and do not denote advanced competence. (See “Faux Certifications” at www.abcmo.org.)

State medical boards ( www.fsmb.org) are studying their MOL programs and may strengthen them. A study of whether optometry MOL programs adequately insure competence of general practitioners may be advisable. Offering voluntary programs misleadingly named board certification prior to a study is inappropriate and will not be accepted as board certification at accredited health care facilities.

—Kenneth J. Myers, Ph.D., O.D.
ABCMO President
Big Rapids, Mich.

This O.D. Has a Point
The study cited in your article “Acupuncture as Amblyopia Therapy” (January 2011) failed to include a sham acupuncture control. Sham acupuncture involves using needles that retract like stage knives, giving the patient the impression he has been stuck when he hasn’t. Studies show where sham acupuncture has been employed as a control it works as well as real acupuncture. Moreover, needle location in acupuncture treatment is immaterial. Outcomes are the same, regardless of “acupoints” stimulated.

If sham acupuncture works as well as real acupuncture and needle location is immaterial, it seems reasonable to conclude that perceived benefit from acupuncture therapy is purely placebo induced.

In addition to their failure to use a sham acupuncture control in the cited study, the authors patented their needle placement. Does this mean that other researchers must pay a fee to stimulate those “acupoints?” Will stimulating other points be sufficient reason to dismiss future researchers’ failure to duplicate the results of this study? Is there any precedent in medical history in which a researcher has patented body parts for proprietary stimulation?

How this study passed a peer review committee is a mystery to me.

—Jim Metheny, O.D.
Springdale, Ark.

Toxo: Take Two
We found the “Tips to Treat Toxoplasmosis” (December 2010) article interesting. It represents a nice primer. But the authors appear to have overlooked three relevant recent references.

In the first, the ingestion of shellfish (specifically oysters, clams and mussels), working in the meat processing industry, and having three or more kittens have been identified recently as additional risks for contracting T. gondii infection.¹

The second is a comprehensive review of the literature. It reiterates the guideline for making a treatment recommendation, specifically involvement of the posterior pole.²

The third demonstrates by OCT the almost exclusive inner retinal involvement of the inflammation secondary to T. gondii infection.³

Perhaps reactivation of the lesion was beyond the scope of the article, but readers may be interested to know that the longer patients go with an interval free from reactivation, the less the chances of that occurring. That optimism, however, is somewhat counterbalanced by increasing risk of reactivation with increasing age.⁴

With respect to management, as the authors’ case suggests, a contemporary treatment of choice is Bactrim (sulfamethoxazole and trimethoprim, AR Scientific, Inc.).

Yet controversy remains regarding the balance of efficacy, ease of dosing and cost.⁵

Finally, intravitreal injection of clindamycin plus dexamethasone may emerge as the optimal treatment strategy.⁶

—Leo Semes, O.D., Birmingham, Ala.
Larry J. Alexander, O.D., McKinney, Tex.

1. Jones JL, et al. Risk factors for T. gondii infection in the United States. Clin Infect Dis. 2009 Sep 15;49(6):878-84.
2. Commodaro AG, Belfort RN, Rizzo LV, et al. Ocular toxoplasmosis: an update and review of the literature. Mem Inst Oswaldo Cruz. 2009;104:345-50.
3. Monnet D, Averous K, Delair E, Brézin AP. Optical coherence tomography in ocular toxoplasmosis. Int J Med Sci. 2009;6:137-8.
4. Holland GN, Crespi CM, ten Dam-van Loon N, et al. Analysis of recurrence patterns associated with toxoplasmic retinochoroiditis. Am J Ophthalmol. 2008;145(6):1007-13.
5. Soheilian M, Sadoughi MM, Ghajarnia M, et al. Prospective randomized trial of trimethoprim/sulfamethoxazole versus pyrimethamine and sulfadiazine in the treatment of ocular toxoplasmosis. Ophthalmology. 2005;112:1876-82.
6. Soheilian M, Ramezani A, Azimzadeh A, et al. Randomized trial of intravitreal clindamycin and dexamethasone versus pyrimethamine, sulfadiazine, and prednisolone in treatment of ocular toxoplasmosis. Ophthalmology. 2011 Jan;118(1):134-41.