Barry D. Kels

Ocular melanomas and melanocytic lesions of the eye

This article describes several melanocytic lesions of the eye. Benign and malignant lesions will be discussed as well as a review of the dysplastic nevus syndrome and its proposed association with ocular melanoma. Ocular melanomas arise from the same embryologically derived melanocytes as their cutaneous counterparts. However, ocular and cutaneous melanomas differ in many respects. The diagnosis and management of these ocular tumors rely heavily on the ophthalmologist. However, knowledge of melanocytic lesions will aid the dermatologist in detection and in proper referral of these patients.

Continuous wave argon laser iridectomy in angle-closure glaucoma.

By using a continuous wave argon laser in a multiburn fashion, successful iridectomies were achieved in 42 out of 45 phakic eyes with either acute or chronic angle-closure glaucoma. Five of the successful procedures required multiple sittings on different days or abandonment of the primary treatment site in favor of an alternate site, or both, to attain patency. Within the immediate postoperative period, ten eyes needed retreatment to eliminate moderate pigment proliferation at the perforation site. The procedure was performed on an outpatient basis under topical anesthesia, usually required less than one-half hour for completion, and resulted in only minimal complications. Therefore, continuous wave argon laser iridectomy appears to present a viable alternative to surgical iridectomy for the definitive treatment of angle-closure glaucoma, although long-term evaluation of this modality of therapy is presently unavailable.

Human ocular anatomy

We review the normal anatomy of the human globe, eyelids, and lacrimal system. This contribution explores both the form and function of numerous anatomic features of the human ocular system, which are vital to a comprehensive understanding of the pathophysiology of many oculocutaneous diseases. The review concludes with a reference glossary of selective ophthalmologic terms that are relevant to a thorough understanding of many oculocutaneous disease processes.

The spectrum of medical errors: when patients sue

Inarguably medical errors constitute a serious, dangerous, and expensive problem for the twenty-first-century US health care system. This review examines the incidence, nature, and complexity of alleged medical negligence and medical malpractice. The authors hope this will constitute a road map to medical providers so that they can better understand the present climate and hopefully avoid the “Scylla and Charybdis” of medical errors and medical malpractice. Despite some documented success in reducing medical errors, adverse events and medical errors continue to represent an indelible stain upon the practice, reputation, and success of the US health care industry. In that regard, what may be required to successfully attack the unacceptably high severity and volume of medical errors is a locally directed and organized initiative sponsored by individual health care organizations that is coordinated, supported, and guided by state and federal governmental and nongovernmental agencies.

The alcoholic bus driver and the dermatology consultation: Legal, moral, and ethical considerations

An adult female school bus driver presented to the dermatology clinic with her husband. After discussing the patient’s history of illness, review of symptoms and social history revealed that she consumed large amounts of alcohol every night. Upon further discussion the patient stated she remained sober during the day and took regular breathalyzer tests, but it was unclear who monitored the tests. The dermatologist was very concerned as the patient’s job involved driving children. On physical examination the patient appeared anxious and tremulous, and her breath smelled of alcohol. The patient denied needing help even after the dermatologist advised her to seek assistance and stop drinking. The dermatologist was hesitant to intervene as he did not want the patient to lose her job as she was supporting a son and her spouse was unemployed. The patient’s husband agreed with the physician and wanted his wife to seek assistance.

Joseph Plenck (1735–1807): Amalgam of dermatology and ophthalmology

In todays world of specialization, many of our current major contributors to the medical literature tend to work in only their specialty area. Historically, that was not the case. Great physicians were great observers and often contributed to many areas of medicine. The best example of this type of physician was Joseph Plenck who, although trained as a surgeon, had major impacts on many fields of medicine including both dermatology and ophthalmology.

Sunlight is the best disinfectant: legal and ethical analysis of a Mohs referral gone awry.

Dr Medderm (hereinafter referred to as Dr M for brevity) routinely refers cases needing Mohs micrographic surgery to her friend and colleague, Dr Idomohs (Dr IDM). Although Dr IDM is not fellowship trained he has been doing Mohs micrographic surgery in the community for many years and has completed several short preceptorships and courses to augment his skills. Dr M has a good personal and working relationship with Dr IDM, having first worked with him when he was her senior resident. There is also a fellowship-trained Mohs surgeon in town, Dr Collegefellow (Dr CF), whom Dr M does not like because he has a reputation among other physicians and patients of being arrogant as well as more costly than most Mohs surgeons. Unfortunately, one of Dr M’s patients has sustained what she regards as a suboptimal and unexpected, in her opinion, unsightly scar after surgery performed by Dr IDM, and is furious to learn that she was referred to a surgeonwith less training than Dr CF, about whom she was not even informed. The patient, Ms Plaintiff (Ms P) sues Dr M for alleged negligence, having failed to inform her that the surgeon to whom she referred her was not formally fellowship trained in Mohs micrographic surgery and that there was another Mohs surgeon in the community with formal Mohs fellowship training.

Defining the Gray Zone: Client Billing and Contractual Joint Ventures

Client billing is a practice in which the referring clinician pays the dermatopathology laboratory a fixed amount for both the technical and professional fees to prepare and interpret the biopsy, and then the clinician bills the Please provide affiliation details for all authors.patient or insurer. Although not inherently illegal or unethical, the practice becomes ethically suspect when a clinician takes advantage of client billing to secure personal profit, or fails to act in the patient’s best interest by not selecting the highest quality laboratory to interpret the patient’s biopsies. Contractual joint ventures are practice models which allow groups of clinicians to bill for work done by independently contracted (‘pod” model) or employed pathologists (“vertically integrated” model), practices that otherwise would not be permitted under Medicare reassignment rules. This chapter presents ethical arguments for and against these practices using illustrative case scenarios.

Electronic health record donations by laboratories: Is legal necessarily ethical?

Megapath Laboratories* is offering some of its new and established dermatopathology clients a popular electronic health record (EHR) system with an advertised price of

The unsolicited ominous diagnosis: legal, moral, and ethical considerations.

50,000 per provider for 15% of its cost. Dr Jones and his associates currently send their biopsy specimens to a local academic medical center dermatopathology laboratory, University Dermpath.* However, they are being wooed with the EHR offer by Megapath and are seriously considering switching. The academic dermatopathology laboratory is part of a university health system that cannot match the offer.