Intraoperative Floppy Iris Syndrome
A syndrome named intraoperative floppy iris syndrome or IFIS has been linkedto a medication called Flomax, which is prescribed for men with prostatic hypertrophyand women with urinary retention.
See AAO article by Dr.David F. Chang below.
Managing Intraoperative Floppy Iris Syndrome
Endophthalmitis malpractice claims
Endophthalmitis malpractice claims provides data from a review of OMIC claims from 2006 to 2017, and provides recommendations on how to decrease the likelihood of these claims.
Cataract Surgery Interval
Ophthalmologists are at times asked by patients who live far from the hospital or surgery center, or those with significant medical co-morbidities, to perform cataract surgery on the same or consecutive days.
See OMIC’s risk management recommendation guide below.
Cataract Interval Recommendations
Debunking the Exploding Cataract: Why You Shouldn’t Sell Surgery
By Michael R. Redmond, MD
[Argus, March, 1992]
A patient presents to the ophthalmologist’s office with a cataract and 20/40 Snellen visual acuity. Visual acuity with medium glare is recorded as 20/100. Cataract surgery is performed and goes well, but the patient develops a retinal detachment soon after surgery. Complications ensue and the final visual acuity is light perception. The patient sues the cataract surgeon on the basis that the surgery was unnecessary in the first place.
A young father, himself postop twice for strabismus surgery, has his son in the pediatric ophthalmologist’s office for the child’s strabismus follow-up. Allegedly, the ophthalmologist initiates a discussion and tells the father that he, the father, needs additional strabismus surgery and that it can be done simply and without problems. Postoperative restrictions develop, corneal exposure with keratitis ensues and the father endures additional surgeries without total relief. He sues the ophthalmologist alleging, among other things, lack of informed consent.
Were the surgeries marketed too vigorously? Expectations set too high? Were the surgeries themselves trivialized, potential complications minimized or not even discussed? Were the patients “solicited” for surgery?
In today’s medical milieu, the ophthalmologist must avoid any hint of pressure on the patient or the family to undergo an elective procedure. Physicians are required to inform patients about the therapeutic (surgical) alternatives available and the urgency or elective nature of a procedure, but they must avoid “selling” their services. If a patient is pressured to undergo an elective procedure and a less than satisfactory result occurs, the patient is much more likely to become angry and initiate a malpractice action. Under these circumstances, the patient is unlikely to admit to recalling discussions of risks and alternatives, but will likely remember assurances, trivializations and encouragement to undergo surgery.
Documentation and informed consent are two cornerstones of risk prevention and management. An ophthalmologist can never do too much in these areas but can easily, all too often, do too little. Because what an ophthalmologist does every day may become routine, the multiple complaints the patient expresses (e.g., headlight glare, inability to read, people not knowing whether or not the strabismus patient is looking at them) are not always recorded adequately in the chart. If the records do not substantiate the ophthalmologist’s claims, a jury is likely to doubt his or her credibility and may begin to suspect a lapse not only in charting but also in professional judgment and/or ethics. The ophthalmologist should also record anything of importance, i.e., test results, consultations and family members present.
Informed consent must include an understanding between the patient and the physician, not simply discussion and signing a piece of paper. The proper relationship and rapport between patient and physician can thus be established.
Ethically, an ophthalmologist should never pressure or cajole a patient to have an elective procedure. Such pressure could turn into a malpractice liability. Communicate, document and inform but never “sell.” After all, cataracts really do not explode.
PAM Testing Before Cataract Surgery
Anne M. Menke, RN, PhD, OMIC Risk Manager
Digest, Summer 2003
A policyholder called OMIC to ask if PAM (Potential Acuity Meter) testing is required before cataract surgery in patients with coexisting eye disease, such as macular degeneration or glaucoma. This question raises important risk management issues about elective surgery. A medical malpractice claim focuses on the following aspects of care: indications for surgery (preoperative evaluation and diagnosis); type of procedure planned (choice of procedure, technique, implant); candidacy for surgery (coexisting ocular and medical conditions, known risk factors for complications and poor outcomes); informed consent (disclosure and documentation of risks, benefits, alternatives); performance of the procedure (technique, recognition, management, disclosure of complications); and postoperative care (discharge condition and instructions, postop visits and telephone calls, recognition and management of complications and poor outcomes). This article focuses on indications and informed consent. The next Risk Management Hotline will address risk reduction when performing elective surgery on a patient with serious medical comorbidities.
Q What are the indications for cataract surgery in the adult?
A The American Academy of Ophthalmology’s Preferred Practice Pattern (PPP), “Cataract in the Adult Eye,” states that surgery is indicated if visual function does not meet the patient’s need and there is a reasonable likelihood of improvement with surgery. The ophthalmologist would, therefore, need to determine, disclose, and document that the cataract is responsible for the vision loss and verify and document that the cataract-induced vision loss has led to an inability to function. The PPP points out that patients with ocular comorbidities such as glaucoma or macular degeneration tend to have poorer outcomes after surgery. The ophthalmologist should determine, disclose, and document the impact of cataract-related vision impairment on these preexisting ocular comorbidities in order to carefully manage the patient’s expectations about the likely benefits of surgery.
Q Is PAM testing required?
A Some evaluation of potential visual acuity is needed. The PPP discusses various types of subjective (such as PAM) and objective potential acuity tests and concludes that there “is no significant evidence that demonstrates that these tests predict the outcome of cataract surgery more reliably than clinical examination.” The actual type of potential acuity evaluation is less important than doing one and informing patients that the predicted results may not match the actual outcome. A PAM may or may not be helpful. Corneal topography, ultrasound, hard lens over refraction, and clinical examination all play an important role, as does evaluation of the patient’s distance and near vision, and consideration of such issues as glare.
Q How should I handle the discussion if the patient is at high risk for complications or a poor outcome?
A First, personally obtain the patient’s informed consent. This legal duty cannot be delegated. During the discussion and documentation process, it is crucial to explain the effect of ocular and medical comorbidities and other known risk factors on the likelihood of complications during and after the procedure and on the final outcome. Use a procedure-specific consent form. Circle or underline the appropriate section of the consent and write in the reasons for the increased risk (e.g., hemorrhage if anticoagulants cannot be stopped for medical reasons; rupture of the posterior capsule with dense cataracts). See Closed Claim Study on opposite page.
Explain that conditions such as glaucoma, diabetes, and macular degeneration can impact visual acuity and functionality. Inform the patient that while the acuity evaluation indicates that he/she is likely to benefit from surgery, potential acuity testing may not accurately predict the results. Even though you recommend surgery, no guarantee can be made that visual acuity will improve.
Q How can I verify that the patient understands the risks and the likely outcome?
A Patients are understandably anxious and fearful during these discussions and may only hear portions of what you say. Have the patient sign a procedure-specific consent form. Keep the original document in the patient’s record and give the patient a copy. Ask the patient to review the document at home with family members and to call your office if there are questions. Your staff can play a valuable role in verification, either when the form is signed or the surgery is scheduled, by asking patients what procedure will be done and why. If the patient does not appear to understand, you can discuss the procedure again and clear up any confusion. You or your staff can document the repeat discussion and the fact that the patient now understands and consents.
