Color coding medications: Reply

Ophthalmology Volume 106, Number 1, January 1999 from the pitcher’s perspective (or for that matter from any other player on the field besides the catcher), it becomes clear that right-handed hitters bat from the right side of home plate, and vice versa for left-handed hitters. Additionally, if one uses the catcher’s perspective, then we must assign a right-handed pitcher as throwing from the left! This certainly is not the case, and besides the classic assignment of left and right field based on the hitter’s view, almost all other designations are made based on the view from the field toward home plate. We adopted this standard, as set by Major League Baseball (specifically that used in the annual media guide published by the Los Angeles Dodgers), which intuitively assigns a right-handed hitter as batting from the right side of home plate and a left-handed hitter as batting from the left side of home plate. As the majority of your readers are aware, the term switch hitter is used to indicate a player who is capable of both batting from the left side or from the right side of home plate. This capability is often an advantage and is used by the manager as a strategic asset in the game. In an effort to keep our analysis as pure as possible, we assigned switch hitters (and all batters as well) to the left or right side based on which side of home plate they had more at-bats. Although this does not take into account switch hitters in particular, it did allow us to compare a player’s batting average based on his usual or most frequent batting position. Following receipt of Dr. Romano’s letter we returned to our original data and reconsidered the impact of switch hitters on our conclusions. We found a total of eight switch hitters in our study cohort (three major league players and five minor league players). After separating each player’s batting average into left- and right-sided appearances, we found no difference between the two groups. Specifically, switch hitters who batted with a crossed hand– eye dominance pattern had an average batting average of 0.296 (range, 0.264 to 0.321), while those with same hand– eye dominance patterns had an average batting average of 0.293 (range, 0.248 to 0.360). Thus, our data do not appear to support Dr. Romano’s finding that crossed hand– eye dominance leads to a “significantly” higher batting average.4,5 Once again, we would like to thank Dr. Romano for his thoughtful comments, and we look forward to further interest in ocular dominance and future works in the area of ocular dominance determination and its effect on athletic performance. DANIEL M. LABY, MD Karkur, Israel DAVID G. KIRSCHEN, OD, PHD Brea, California ARTHUR L. ROSENBAUM, MD Los Angeles, California MICHAEL F. MELLMAN, MD Los Angeles, California References 1. Fink WH. The dominant eye: its clinical significance. Arch Ophthalmol 1938;19:555– 82. 2. Walls GL: A theory of ocular dominance. Arch Ophthalmol 1951;45:387– 412.

8

3. Laby DM, Kirschen DK, Mellman MF, Rosenbaum AL. Pointing towards ocular dominance: Is it right, left or central? Proceedings of the American Association for Pediatric Ophthalmology and Strabismus: 1998 April; Palm Springs (CA). 4. Portal JM, Romano PE. Patterns of eye-hand dominance in baseball players. [letter]. N Engl J Med 1988;319(1):655– 6. 5. Portal JM, Romano PE. Ocular sighting dominance: a review and a study of athletic proficiency and eye-hand dominance in a collegiate baseball team. Binocular Vision and Strabismus 1998;13:125–32.

Color Coding Medications Dear Editor: The accidental ocular administration of chemicals, such as super glues bottled in plastic bottles similar to eye medications, is well known. Recently, I had a patient who mistook a bottle of Mycocide NS for an ocular sulfa drop and sustained a mild chemical keratoconjunctivitis, which quickly healed. This Mycocide NS, made by Woodward Laboratories of California, was provided by a podiatrist to treat a fungal toe nail infection. Its active ingredient is 0.6% benzalkonium chloride. Its label carries a warning not to use in the eyes or ears. Interestingly, the most common eye medication preservative is benzalkonium chloride, usually in a concentration of 0.01%, and some as dilute as 0.004% to 0.005%. So this is a concentration at least 600 times stronger than in most eye drops. When the soft contact lens first became popular, they were often removed for an examination and put in a container with an eyewash solution containing a high concentration of benzalkonium chloride. When later the contact was replaced in the eye, epithelial damage and an unhappy patient resulted. We quickly learned not to use such eyewashes for temporary soft contact lens storage. The other point again demonstrated is that similarly appearing plastic bottles are used for eye medications, other topical medications, and for various chemicals of many uses. Once again, a patient makes an easy mistake and damages his eye. How can this hazard be lessened? Round bottles probably are the easiest to manufacture and function as a drop bottle best, but could a certain color be reserved only for eye medications and another only for otics, and other colors for various other chemicals? Eye medication tops would continue to be color coded for class of drug. JEMISON BOWERS, MD Chattanooga, Tennessee Reply Dear Editor: In researching stock bottles and caps, we realize that there is not a large selection of sizes and colors from which to choose. No matter what shape or color we proposed, we found other companies (including pool chemicals, testing laboratories, and pharmaceuticals) using the same combinations. We eventually selected packaging we felt more effective for our products, and have differentiated ourselves with a large blue “W” on the label. Our product is safe; however as cautioned, it is not intended to be used in the eye or the ears. If eye contact

Letters to the Editor accidentally occurs, irrigation with water is recommended. As related by Dr. Bower’s letter, we have never had any serious effects reported, and Dr. Bower’s experience of a mild chemical keratoconjunctivitis confirms that. I would venture to say that putting soap in one’s eye would also give you a mild keratoconjunctivitis. We advise all patients (and always have) regarding their handling of prescription bottles from the pharmacy. We recommend that all medicines be separated by location rather than by size or shape. With any type of product, this is obviously the purchaser’s responsibility for prudent use. Even medications which I take myself, upon receipt from the pharmacy, I label with large black writing on the bottom of the bottle for ease in visibility. As for Dr. Bowers’s suggestion to have certain colors reserved for eye medications, another one for otics, another one for various chemicals, our perspective is that we have no problem with that. If it were ever standardized that medications to be applied topically to the skin and nails would require a certain color cap, I am certain our company would be more than willing to comply. Unfortunately, many ocular medications have colorcoded tops, and as you might imagine there are only so many stock colors available. In the interest of public safety, however, we would like to assist you in any way possible and entertain suggestions from you as to how you think we may help prevent this situation from occurring in the future. Understand, as we represent only ourselves, that other manufacturers currently make similar products in similar bottles with variations in cap colors (I know of two other bottles that are white: one with a red cap and the other with a green cap), and we cannot obviously control anything that they do. In the meantime, all I can suggest is that as we advise and caution our patients to keep different medications in different areas so that confusion will not result. KENNETH B. GERENRAICH, DPM Los Alamitos, California

9