It appeared that the nucleus was resting on the optic nerve. However, when there was a claim related to retained lens fragments, this study found that the age and gender of the physician did not affect the legal outcomes. Another study found that 7.4% of all physicians had a malpractice claim each year, with 1.6% having a claim leading to a payment.5 The proportion of physicians facing a claim each year ranged from 2.6% in psychiatry to 19.1% in neurosurgery. This may reflect bias in reporting surgical cases in the literature related to this complication or tendency toward legal actions when the patient feels not enough was done with observation alone. Distribution of closed claims related to retained lens fragments by region in the United States. Half of all claims in this study were referred within 1 week of cataract surgery or the same day as detection of the retinal detachment. The number of ophthalmologists being insured by OMIC grew steadily from 1,027 in 1989 to 4,107 in 2009 (Figure 1). What helps? 5.3k views Reviewed >2 years ago. Sufficient and legible documentations, including visual acuity, intraocular pressure, status of the cornea, IOL position, and dilated fundus examination, are essential for risk management purposes. There were also cases where the defense experts felt that the case was less defensible due to poor office visit documentations that did not include or had illegible notations regarding visual acuity, intraocular pressure, or dilated fundus examination in the setting of declined visual acuity. Ways to reduce significant vision loss, including improved management of corneal edema and IOP, and timely referral to a subspecialist should be considered. Seven hundred medicolegal cases in ophthalmology. government site. Male physicians may have a higher likelihood of being sued because male physicians are historically concentrated in the specialties with the highest levels of claim incidence, such as surgery, and female physicians in those with the lowest incidences, such as pediatrics. One month after the cataract surgery, the patient called and reported that the vision in the right side of the left eye was gone. He was seen on the same day and found to have visual acuity of 20/400 with a superotemporal retinal detachment. WebAllegation Wrong power IOL insertion led to complicated lens exchange surgery. Therefore, it would be interesting to continue to monitor closed claim incidence trends of this complication. In 10 cases, the tear of posterior capsule was not recognized by the cataract surgeon or was not indicated in the operative note and only became apparent during the investigation of the case. Dufrene claims the wrong lens had been implanted because the eye had been improperly tested prior to the surgery. Careers. If you and your attorney manage to navigate the many procedural requirements, find an expert witness and demonstrate to the other side that you probably have a winning case, the final wrangling in the case will be over just what kind of damages resulted from your ophthalmologist's negligence, i.e. If these cases are excluded, there was a mean of 1.5 return visits to the operating room among 94 patients who had additional surgical procedures. Ho and colleagues37 recommended that cataract surgeons refer patients with retained lens fragments to a retina specialist within 7 days for consideration of a pars plana vitrectomy to decrease the risk of developing secondary glaucoma. A recent study recommended that the cataract surgeon perform an anterior vitrectomy and place a posterior chamber IOL if possible, prior to referral to a subspecialist in order to achieve better visual outcome.37 Based on the current study findings, it is recommended that the cataract surgeons avoid aggressive intraoperative manipulations to remove retained lens fragment in order to minimize the risk of retinal detachment. Posterior-assisted levitation in cataract surgery. Poorly documented cases were deemed more difficult to defend, whereas claims with aggressive intraocular manipulation by the cataract surgeon resulting in retinal detachment were more likely to result in poor final visual acuity and were more likely to go to a trial or settle. Finally, the patient must have suffered actual damage or injury as a result of negligence. You will probably need to find a medical expert witness who has adequate knowledge of (or experience with) performing cataract surgeries (usually a practicing ophthalmologist) to testify as to what the proper standard of care was, and then to show that not only did your ophthalmologist fall short of that standard, but that you were also injured because of that sub-standard care. Management of dislocated lens fragments after phacoemulsification surgery. CLAIMS WITH A DOCUMENTATION OF INTRAOPERATIVE MANIPULATION BY THE CATARACT SURGEON DURING MANAGEMENT OF POSTERIOR DISLOCATION OF LENS FRAGMENTS. In one additional case, observation was recommended without further surgery because the retina specialist felt that the retinal detachment was inoperable. Management of retained lens fragments after cataract surgery with and without pars plana vitrectomy. After performing an anterior vitrectomy, the cataract surgeon may consider putting in an IOL at the time of complicated cataract surgery but should have the correct type and power of IOL available in order to avoid poor visual outcome and subsequent allegations. Continuous irrigation was performed, but the nuclear fragment could not be elevated. However, the cataract surgeon did not document having made this call and the case was settled. Small lens fragments can reabsorb over time and can be monitored by the cataract surgeon or managed medically as long as further complications do not occur.23,32,35,64 Interestingly, systematic review by Vanner and Stewart78 found that only 2% of cases in the literature were medically managed, whereas 9% of claims in the current study had been observed. Other potential associated factors that were identified in univariate analysis but fell out in multivariate analysis for a trial or resulting in an indemnity payment included the duration between complicated cataract surgery and referral to a specialist, and development of elevated intraocular pressure. With OMIC having 40% of the ophthalmology market share in 2010, OMIC policyholders compare favorably with current demographics of ophthalmologists.17 Because it is a single-specialty insurer with the ability to collect and analyze data on a large number of professional liability claims related to ophthalmology, gathering of information on malpractice claims related to a specific ophthalmic procedure is possible. In vitreous specimens of eyes with a history of retained lens fragments, the amount of inflammation increased starting 3 days after the retained lens fragments and increased substantially in eyes with delayed vitrectomy for more than 30 days when compared to less than 30 days.72 Therefore, ancillary testing such as optical coherence tomography should be used to document absence of cystoid macular edema, which may result from persistent inflammation, and ultrasonography should be considered in the setting of significant inflammation with diminished view to the posterior segment to detect possible retinal detachment. However, there is no prospective randomized clinical trial to guide which cases should be referred for surgical management. Kim JE, Flynn HW, Jr, Smiddy WE, et al. Because the patient was receiving warfarin therapy, pneumatic retinopexy was performed. The patient claimed that the physician should have In addition to the original cataract surgery, patients underwent a mean of 1.3 additional surgeries (range, 04) where one or more combined procedures were performed. Kraushar MF, Robb JH. The number of Ophthalmic Mutual Insurance Company policyholders from years 1989 through -2009. As noted already, the majority of claims are dropped, dismissed, or closed without payment. The attorney listings on this site are paid attorney advertising. Closed claims data related to cataract surgeries complicated by retained lens fragments (1989 through 2009) from an ophthalmic insurance carrier were reviewed. Spicer J. The retina successfully reattached with a final visual acuity of 20/25. 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When intraocular pressure or inflammation cannot be managed adequately or cystoid macular edema is detected, the patient should be definitely referred to a specialist. The most common complications were elevated intraocular pressure requiring initiation of pressure-lowering medications and development of visual field damage due to elevated intraocular pressure. Standard of care is what a reasonable physician would do in similar circumstances. Most people may get benefited from an IOL transplant during surgery. Furthermore, these malpractice claims data can be used to identify ways to improve patient safety, develop risk management programs, and provide an excellent opportunity to enhance patient care related to an ophthalmic subspecialty or an ophthalmic procedure. In the multivariate analysis, only the amount of change between preoperative and final visual acuity ( logMAR visual acuity) was found to be statistically significant in predicting more severe legal outcome. An official website of the United States government. Also, settlement should not be considered admission of malpractice, since some physicians, patients, and insurance carriers may elect to settle in order to avoid prolonged litigation or stress or to minimize legal expenses. The needle impaled the lens and tore the lens capsule. The time between the date of cataract surgery and the date of evaluation by a specialist to further manage the complications of retained lens fragments was a median of 7 days (range, same day to 15 months) in this study. The last variable was not included in the predictive model because it is not a preclaim covariate, but rather a type of outcome. Mello MM, Chandra A, Gawande AA, Studdert DM. 23-gauge transconjunctival pars plana vitrectomy for removal of retained lens fragments. Murat Uyar O, Kapran Z, Akkan F, Cilsim S, Eltutar K. Vitreoretinal surgery for retained lens fragments after phacoemulsification. Of these cases, 11% went to trial, 28% settled, and 61% were dismissed. Regan JJ, Regan WM. A retinal surgeon who was called into the operating room was able to remove the nucleus using 3-port pars plana vitrectomy. Bovbjerg RR, Petronis KR. Cataracts cause foggy or blurred vision that makes it hard to do everything from reading to Additionally, there can be surprises in post-penetrating keratoplasty patients and in cases where the anterior segment of the eye is disproportionately sized compared to the overall length of the eye. The distribution of the number of closed claims related to the complication of retained lens fragments per year from 1989 through December 2009 is shown in Figure 2. Postoperatively, dilated fundus examination should be performed to detect possible retinal detachment, and patients should be promptly referred to a retina specialist when it occurs or if the fundus cannot be visualized well by indirect ophthalmoscopy.15,28,34,61 In this study, there were 3 claims that named the retinal surgeon as the defendant. Sloan FA, Mergenhagen PM, Burfield B, Bovbjerg RR, Hassan M. Medical malpractice experience of physicians: predictable or haphazard. Who sues their doctors? 0 likes, 62 replies Report / Delete New discussion Reply 62 Replies Since corneal edema is a common finding in eyes with retained lens fragments, close postoperative monitoring and appropriate treatment are advised.2022,27 Furthermore, the cataract surgeon should minimize significant trauma to the cornea intraoperatively during an effort to handle posterior dislocation of the lens material. WebUltrasound: The predominant technology for cataract removal is ultrasound. Copyright 2023 MH Sub I, LLC dba Nolo Self-help services may not be permitted in all states. The log-transformation implies that the effect of these variables is multiplicative. Among these, the patients sought a second opinion and referred themselves in 3 cases. In: Gonzalez ML, Zhang P, editors. The case was closed with an indemnity payment of $215,000. The trial verdict was for the plaintiff in the amount of $125,000, although the initial demand was for $450,000. Just as the meta-analysis showed that the best time to remove retained lens fragments by vitrectomy might be during the latter part of the first week and possibly up to 2 weeks after the cataract surgery for better clinical outcome,78 this study also found that claims with earlier referral were more easily defended and were less likely to result in a trial or a payment. Studdert DM, Mello MM, Gawande AA, et al. Furthermore, certain eyes are known to have an increased risk for developing this complication, including eyes with prior trauma, pseudoexfoliation, dense cataract, and history of having had prior vitrectomy surgery.42,49 Therefore, additional care should be taken during the cataract surgery in these eyes. Some studies found that there was a decreased incidence of retinal detachment, glaucoma, or cystoid macular edema in early vitrectomy group compared to delay of more than 1 week to 1 month.34,3740 Others found only a trend toward better visual acuity outcome with earlier vitrectomy.32,33,36 Yet others found that there was no difference in terms of the incidence of retinal detachment or glaucoma or visual acuity outcome with the timing of vitrectomy.2031,35, Furthermore, there is no clear evidence that all patients with retained lens fragments need to be referred or need surgical management. 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