When I wrote my first editorial about the AOA/JBCPT proposal, I had hoped it would initiate open and collegial discussion about board certification. While I have no doubt that my efforts have shed light on this important issue, it also created a backwash that I have unfortunately been caught up in.

As of now, I have received over 200 e-mails with virtually all against the AOA/JBCPT proposal. This so-called "vocal minority" represents somewhere in the vicinity of 90% of our profession. A currently running survey on optcomlist is showing 93% of optometrists opposed. Far from being a small group of loudmouth malcontents, this increasingly engaged majority includes some of the profession's brightest and best. The e-mails have been thoughtful and intelligent and make me proud I am one of you.

Because many e-mails contained questions, I decided to create my own FAQ. Keep in mind that these answers represent my opinions. In some cases, I share ideas that come from colleagues who do not wish to be identified. Given the political climate, I don't blame them. Here we go:

Q – Several colleagues have shared that they have heard or been told that Art Epstein has an "agenda". So what's up with that?

A – I thought about this question for a long time. Honestly, no matter how hard I try, I can't come up a single way that I can benefit from taking a stand against the AOA/JBCPT proposal.

One brainiac suggested that I was against board certification because as a speaker, I would have to pay more in course submission fees. Hey genius, considering that faux-certification would likely double and in some states triple the demand for CE, I would be far better off if it passed.

The truth is that I've devoted many precious hours investigating and researching board certification — time that I could ill afford to squander. My inbox has been so jammed that I am weeks behind on responding. I already had more work than I need and I certainly didn't need this mess.

I came out squarely against the AOA political machine and placed myself opposite the side of many respected friends and colleagues. Even for someone used to speaking his mind, this has been difficult and unpleasant.

So why did I do it? Those who know me already know the answer. It was something that had to be done. And for those who are wondering, no, I am not running for the AOA Board of Trustees — not this year anyway.

Q – What do I have against the AOA?

A – Regular readers of this column know that I have been a long time, very vocal supporter of the AOA. For the most part, that has not changed. Not only have I written numerous editorials and given countless presentations extolling the AOA's success in PR, communications and legislative issues, but I have also been an AOA volunteer for more than a decade. I served as the editor of the Contact Lens Section's newsletter and oversaw its conversion to electronic media. I served on the AOA's Contact Lens & Cornea Section for many years and was Chair during the 2006 Fusarium outbreak. In addition to being the first to alert the AOA of the outbreak, I was also a primary architect of the AOA response and served as the AOA's spokesperson. I testified in Washington, DC, for the AOA. I've served on the communications committee for several years. I could go on.

One of the main reasons that I so strongly oppose the AOA/JBCPT proposal is that I believe strong and successful opposition may be the only way to save the AOA. Anti-AOA sentiment is rising to record levels, and many AOA members are pondering whether to cancel their membership. Bizarrely, and I think irresponsibly, the AOA is aware of this growing disaffection and is doing nothing about it. AOA President Pete Kehoe has publically acknowledged that the AOA is expecting to "lose a few good members". Pete, I am afraid that it may be more than just a few.

Let me make this clear: No question the AOA needs to change, but a weakened AOA would be a disaster for our profession. Please do not resign from the AOA — help to change it.

Q – Am I afraid of retribution?

A – Many well-known optometrists have contacted me, and a surprising number have requested anonymity. The words "dirty" and "politics" go together like peanut butter and jelly and that is just as true in St. Louis as in Washington, DC — perhaps even more so.

Personally, I have not been surprised. I received exactly what I expected, from disparaging comments made broadly behind my back to a letter sent March 20th informing me that my decade of volunteer service to the AOA has come to an end. My editorial "Examining the AOA/JBCPT Proposal" was e-mailed on March 14th. Coincidence? You tell me.

Q – How do I feel about the JBCPT and if the process is so bad, do I know why the other organizations are participating?

A – Many of the members of the team are individuals I have tremendous respect for. Several I consider good friends. Almost all have contributed greatly to our profession and all hold leadership roles in their respective organizations. It is easy to understand why organizations such as the AAO and ARBO were brought on board by the AOA. The AOA did not want to repeat the mistakes of ABOP. A veneer of credibility and cohesion was needed, and the JBCPT was created to serve that purpose.

So why did so many intelligent, respected colleagues go along with the charade? Loyalty to their organizations necessitated it. Put yourself in their position. If your local colleagues were planning something and asked if you wanted to be involved or remain blissfully unaware about something that could be game changing, what would you do? This doesn't temper my disappointment that none of these intelligent and responsible individuals has not spoken out (I suspect that some are as uncomfortable with the proposal as I am). Nevertheless, I still think of them as friends and hope they understand that this is not personal.

Q – Why am I so against board certification?

A – This is a perfect example of reading into things and hearsay. I am not against board certification. I am against the AOA/JBCPT proposal, which is, by any definition of the term, not board certification. The AOA/JBCPT proposal offers meaningless credentialing, which I believe will be viewed by both the public and insurers as purely self-serving while offering potent ammunition to our enemies. Even worse, it harms legitimate advanced competency and existing board certification processes such as those offered by the AAO Diplomate programs, the International Examination and Certification Board (IECB) of the College of Optometrists in Vision Development (COVD), NORA's Neuro-Optometric Rehabilitation Skill Building Program and the American Board of Medical Optometry (ABMO). I am in favor of legitimate specialty board certification.

Q – Are you against measures of continued competence or a maintenance of competency (MOC) process?

A – I am in favor of a legitimate MOC process. I will detail this at length in a subsequent editorial.

Q – Should non-AOA members be represented in this process?

A – As far as I am concerned, any optometrist, regardless of affiliation, has a right to express their opinion and be heard. That may be a bitter pill to those of us who have supported organized optometry for years while our non-participating colleagues rode our coat tails, but that does not change the issue. Anyone who will be economically impacted should have a right to participate in the decision-making process. This is America. Expect legal action if the proposal passes.

Q – I thought only my State Board had the right to judge me qualified to practice. Doesn't the AOA/JBCPT proposal interfere with State sovereignty and board authority?

A – In my opinion, yes it does. The North Carolina Board of Optometry has already taken this view and communicated their findings to the AOA and JBCPT.

Q – What happens if the AOA rejects the proposal — won't the other JBCPT members still go ahead and form the ABO?

A – When pigs fly. I understand that the NBEO and the AOSA have already been exited from the team. The other entities have too small a constituency and lack the financial wherewithal to pull this off. I also expect that with the AOA out of the picture, the other organizations will come to their senses and drop the proposal like a molten lead potato.

Q – I've been told that the government, the AARP, and major insurers will soon demand board certification and that without it, I will lose access to my patients. What will happen if I don't get certified?

A – No chicken little, the sky is not falling — regardless of what you are being told. We are in the midst of a rapidly changing healthcare landscape. No one, not the AOA or the AMA, have any clue of what things will look like in a year, let alone in 2 or 3 years. Yes, the AARP has been exploring ways to ensure that the needs of their constituents are met. They have never, nor will they ever, insist that a profession change its structure to meet needs that have not been adequately explored, let alone validated. Insurers and the government are primarily concerned with cost. There is no possible way they would or could force adoption of even a credible form of board certification if it increased the cost of care. I will discuss the cost of the AOA/JBCPT proposal in a future editorial. However, you don't need to be Einstein to realize that adding another layer of bureaucracy and doubling or tripling required education hours will come at significant cost — which will, of course, be passed through to patients.

Q – Hasn't the President and CEO of the American Board of Family Practice (ABFM) endorsed the JBCPT proposal for optometric board certification?

A – Here are the facts: The AOA/JBCPT has stated that their proposal was modeled after the ABFM mechanism for certification of continued competence. It is not modeled after the ABFM mechanism for board certification. The ABFM, as they state repeatedly on their web site, is a medical specialty and board certification requires completion of a three-year, post-graduate residency.

Arthur B. Epstein, OD, FAAO Chief Medical Editor artepstein@optometricphysician.com

Want to share your perspective? Write to Dr. Epstein at artepstein@optometricphysician.com. Comments received may be published on OP-Blog at the discretion of the editor without attribution. Please indicate if you would like your thoughts attributed to you. The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of the editorial board, Jobson Publishing or any other entities or individuals.

At the introduction of the fixed-combination of brimonidine/timolol in Germany in 2006, a non-interventional, multicenter, observational, open-label study was initiated to evaluate efficacy, tolerability and safety of this preparation in a broad patient population. The study population comprised patients with bilateral primary open-angle glaucoma or ocular hypertension with insufficient intraocular pressure (IOP) control who participating physicians determined required a change of medication, and who switched to exclusive use of the new fixed-combination brimonidine 0.2%/timolol 0.5%. Patient demographics and information on specific risk factors were collected. IOP readings were recorded for each eye at treated baseline (previous therapy), 4 to 6 weeks, and 12 weeks after changing to twice-daily brimonidine/timolol. Tolerability was measured using a four-step scale ranging from excellent to poor. All adverse events were recorded.

Mean treated baseline IOP for all patients (N = 861) was 20.8 mmHg. Five hundred sixty-five patients switched from monotherapy, 138 patients switched from other fixed combinations, and 158 patients had been using non-fixed combinations of up to four different active agents. The brimonidine/timolol fixed combination provided an additional IOP decrease in most pretreatment subgroups, with an overall reduction to 16.9 mmHg after 4 to 6 weeks and to 16.5 mmHg after 12 weeks. Both of these values were significantly lower than baseline IOP. A target pressure of <18 mmHg was achieved in 79.5% of all eyes at week 12. Tolerability of fixed-combination brimonidine/timolol was rated excellent or good by the physicians for 97.1% of patients, and by 93.4% of the patients themselves. Few adverse events occurred during the treatment period.

Although this study was limited by its observational design, our results show that the fixed combination of brimonidine 0.2%/timolol 0.5% was effective, well tolerated and safe in a broad POAG patient population.

In this prospective, nonrandomized, clinical study, Descemet membrane endothelial keratoplasty (DMEK) was performed in a first group of 35 consecutive patients with either Fuchs endothelial dystrophy or bullous keratopathy to evaluate visual rehabilitation after DMEK. The Descemet membrane was stripped from the recipient posterior stroma with the anterior chamber completely filled with air. Using a 3.0-mm clear corneal incision, an organ-cultured donor Descemet roll 9 to 10 mm in diameter was inserted into the recipient anterior chamber, positioned on the posterior stroma, and secured by completely filling the anterior chamber with air for 45 to 60 minutes.

Ten eyes had preexisting ocular disease or an early graft detachment. In the remaining 25 DMEK-treated eyes, best-corrected visual acuity was 20/40 (Snellen notation, 0.5) or more in 18 eyes (72%) within 1 month. At 3 months, best-corrected visual acuity was 20/40 (0.5) or more in 23 of 25 eyes (92%) and 20/25 (0.8) or more in 15 of 25 eyes (60%).

In most cases, DMEK results in functional visual rehabilitation within 1 to 3 months. Overall, visual recovery after DMEK may be faster and more complete than with other techniques for (lamellar) keratoplasty for treatment of corneal endothelial disorders.

Pterygium is a common ocular surface disease characterized by fibrovascular invasion of the cornea and is sight-threatening due to astigmatism, tear film disturbance, or occlusion of the visual axis. However, the mechanisms for formation and post-surgical recurrence of pterygium are not understood, and a valid animal model does not exist. This study investigated the possible mechanisms of pterygium pathogenesis and recurrence. A genome wide expression analysis (human Affymetrix Genechip, >22000 genes) was performed with principal component analysis and clustering techniques, and validated expression of key molecules with PCR. The controls for this study were the un-involved conjunctival tissue of the same eye obtained during the surgical resection of the lesions. Interesting molecules were further investigated with immunohistochemistry, Western blots, and comparison with tear proteins from pterygium patients.

Principal component analysis in pterygium indicated a signature of matrix-related structural proteins, including fibronectin-1 (both splice-forms), collagen-1A2, keratin-12 and small proline rich protein-1. Immunofluorescence showed strong expression of keratin-6A in all layers, especially the superficial layers, of pterygium epithelium, but absent in the control, with up-regulation and nuclear accumulation of the cell adhesion molecule CD24 in the pterygium epithelium. Western blot shows increased protein expression of beta-microseminoprotein, a protein up-regulated in human cutaneous squamous cell carcinoma. Gene products of 22 up-regulated genes in pterygium have also been found by us in human tears using nano-electrospray-liquid chromatography/mass spectrometry after pterygium surgery. Recurrent disease was associated with up-regulation of sialophorin, a negative regulator of cell adhesion, and never in mitosis a-5, known to be involved in cell motility.

Aberrant wound healing is therefore a key process in this disease, and strategies in wound remodeling may be appropriate in halting pterygium or its recurrence. For patients demonstrating a profile of "recurrence," it may be necessary to manage as a poorer prognostic case and perhaps, more adjunctive treatment after resection of the primary lesion.