Delayed Diagnosis of Endophthalmitis Following Cataract Surgery
Digest, Winter, 1994
ALLEGATION Insured ophthalmologist allegedly delayed diagnosis of endophthalmitis following cataract surgery.
DISPOSITION Case was settled for $50,000.
Background
Claims against ophthalmologists frequently arise from cataract treatment. Improper performance of surgery is the most common allegation related to the treatment of cataracts followed by failure to recognize and treat a complication of surgery. Careful postoperative evaluation and documentation is crucial for successful defense of these claims.
Case Summary
The patient was an elderly male who presented to the insured’s office for decreased vision in the right eye. V.A. was 20/80 OD with correction. The patient was scheduled for a cataract extraction OD with insertion of a posterior chamber IOL. Surgery proceeded without complication although toward the end of the procedure the ophthalmologist noticed a rent in the inferior posterior capsule. Maxitrol and Pilocarpine drops were instilled.
The patient was doing well on the first day post-op. The record for this visit noted that the vitreous had moved forward to occupy 3/4 of the anterior chamber. The patient was continued on Maxitrol TID and scheduled for another visit in six days. There was no record of visual acuity or a fundus examination on this date. On the third day post-op, the patient called the insured’s office complaining of a very severe sharp pain in the right eye. No record was made of the call. The following day, the patient came to the office complaining of increased discomfort and decreased vision. V.A. was 20/200 OD. 2+ cells and a cloudy vitreous were noted. No fundus examination was documented. The patient was scheduled for another exam the next day by which time the cells had increased to 3+ and were described as being deposited on the posterior cornea. The insured documented a “faint red reflex.” No visual acuity or fundus examination was recorded. When the patient was seen on the sixth day, the record noted that a vitreous tap had been scheduled for the following day. But again, there was no description of an examination or findings to explain why the tap had been scheduled. The insured attempted the vitreous tap but was unable to aspirate despite trying several size needles. Findings in the record noted substantial membranes within the vitreous cavity.
Eight days after the initial surgery, the patient was referred to a retinal-vitreal specialist who diagnosed an endophthalmitis that already had created permanent and extensive damage to the retina.
A culture indicated a bacterial strain sensitive to multiple antibiotics. Although the retinal specialist was able to preserve the eye’s structure, the infection had caused functional loss of the retina. One year after the cataract surgery, the patient’s vision was count fingers at two feet OD.
Outcome
This case presented documentation issues that made it difficult to defend. The insured’s medical record was replete with questionably substandard examinations, inconsistencies and incomplete descriptions of findings. Notes were in the form of computer billing printouts and did not follow chronologically. The insured was criticized by defense experts for not doing a more thorough examination when he noticed the vitreous had moved to occupy 3/4 of the anterior chamber, and in the presence of cloudy vitreous and a “faint red reflex.” Furthermore, the ophthalmologist failed to record visual acuities and to explain why he decided to “proceed with vitreous tap.” When the vitreous tap was unsuccessful, the insured was criticized for not referring the patient immediately to a retinal specialist and for not administering a proper dose of antibiotics in the meantime. Another 24 hours elapsed before the patient was seen by the retinal specialist. Earlier intervention with antibiotic therapy may have saved the eye.
Risk Management Principlesand Commentary
When a claim arises related to a post-op complication, the experts reviewing the case have only the patient’s record to assist them in evaluating whether treatment of the patient was reasonable. An ophthalmologist often will be given the benefit of the doubt by a reviewer if there has been documentation of the reasoning behind certain judgments at critical decision points. Careful documentation alone may not be enough to overcome claims of a delayed diagnosis; however, patently inadequate documentation is likely to raise doubts about whether the treatment met the applicable standard of care.
Wrong Power IOL Inserted During Cataract Surgery
By Randy Morris, JD
OMIC Claims Associate
Digest, Summer 2000
Allegation
Wrong power IOL insertion led to complicated lens exchange surgery.
Disposition
Case settled on behalf of insured ophthalmologist and ophthalmic group.
Case Summary
A 59-year-old female patient presented to the insured with complaints of glare and significant decrease in her visual acuity OS. Corrected VA was 20/20 OD, 20/25 OS. Glare testing showed decreased VA of 20/80 OD and 20/100 OS. After a discussion with the patient, the insured performed what he thought was an uncomplicated cataract surgery OS. One day post-op, VA with pinhole was 20/150. Anterior chamber showed 2+ cells. The patient was started on Tobradex four times daily and told to return in one week. Later that day, the operating room nurse informed the insured that the wrong IOL had been delivered into the field. The insured had inserted a 17.0 diopter lens instead of a 20.5. The insured contacted the patient to explain what happened and suggested a lens exchange.
During the lens exchange surgery, the iris was caught in the scissors when the implant was being cut in the anterior chamber. A slight cut to the iris was noted at 12:00. The next day, VA OS was LP with marked corneal edema. Over the course of approximately two months, the patient’s VA improved to 20/150. The insured referred the patient to a corneal specialist, who performed a corneal transplant. The patient eventually had a VA with refraction of 20/25 OS, although she continued to complain of residual cloudiness due to posterior capsule haze.
Analysis
The insured maintained that responsibility for the incorrect lens insertion lay primarily with the nurse because the insured had performed the correct tests, specified the correct lens in his records, and inserted the lens properly. However, under the “captain of the ship” doctrine, the surgeon is deemed to be the person in charge in the operating room and is ultimately the one held responsible for any complications of surgery, even those caused by the actions of others. While the use of this doctrine is on the decline in many jurisdictions, plaintiff attorneys are still able to use it occasionally in situations such as this. Furthermore, the plaintiff could argue that it is the surgeon’s responsibility to verify that the correct lens is being inserted at the time of surgery. In light of this, the defense team and the insured agreed to settle the case on behalf of the insured ophthalmologist, the ophthalmic group, and the nurse codefendant.
Risk Management Principles
Fortunately, this kind of error does not occur frequently and can be avoided with due diligence and efficient sign-off procedures. Effective communications among surgical personnel, augmented by a system of checks and double checks, can go a long way toward preventing mix-ups. Many surgery centers require that the lens power be checked against the medical record and signed off by two people prior to surgery, then verified again visually and verbally by the assistant and the surgeon when the lens is handed to the surgeon for insertion. While such redundancy may sound inefficient or unnecessary, this attention to detail may well help prevent the captain from going down with the ship.
Disclosures of Risks, Complications, and Adverse Outcomes
By Anne M. Menke, RN, PhD OMIC Risk Manager
Allegation
Loss of vision following cataract surgery.
Disposition
Defense verdict on behalf of insured oph- thalmologist.
Case Summary
A 77-year-old female presented to the insured ophthalmologist with com- plaints of being unable to read, drive, or watch television and vision in the left eye of light and dark sensation only. Visual acuity was 20/25 OD and 20/80 with refraction OS. Past ocular history included peripheral iridectomies OU for intermittent angle closure glaucoma and pseudophakia OD. Medical history was significant for atrial fibrillation treated with aspirin, COPD, and hypertension. The patient had a dense cataract, grade 3-4+. The ophthal- mologist recommended phacoemulsification with IOL placement under topical anesthesia and a clear corneal incision. After removing the extremely dense cataract, the insured detected a large rent in the posterior capsule and per- formed an anterior vitrectomy with removal of the remaining cortex. He attempted to place the IOL in the sulcus but resorted to anterior chamber placement due to instability. No bleeding was noted.
The patient’s postoperative course was com- plicated by the development of a full eight-ball hyphema with loss of vision on day 3; treat- ment consisted of bed rest in a recliner at 30 degrees and 1% ophthalmic Atropine. The ophthalmologist later testified that he recom- mended but the patient refused hospitalization; he did not document this or any pre- or postop discussions regarding the possible effects of the patient’s aspirin therapy. IOP, slightly elevated at 28 on postop day 1 and treated with topical agents, rose to 62 on day 4 when the patient experienced a rebleed, prompting an anterior chamber paracentesis and hospitalization. An anterior chamber washout was needed the next day to control the pressures. Blood staining of the cornea and IOP of 30 was noted on day 13. The retina specialist to whom the patient was referred performed another anterior chamber paracentesis and found no posterior bleeding on B scan. The patient requested a second opin- ion; the consultant explained the treatment options but told the patient there was little chance for visual improvement.
Analysis
The plaintiff’s expert was critical of the insured on several accounts. First, the insured should have considered the impact of aspirin therapy on the development of the hyphema or rebleed and advised the patient to discontinue taking aspirin once bleeding developed. Second, the insured did not recognize the early readings as falsely low in the face of edema and hyphema. Third, had systemic agents been used to control the patient’s elevated pressure, optic nerve damage and the resulting loss of vision might have been prevented. Fourth, the hyphema should have been washed out earlier with care taken to remove the clot.
While noting the insured’s lack of documen- tation regarding aspirin and recommended hospitalization, defense experts supported the accuracy of the IOP measurement and felt he had appropriately recognized and managed the intraoperative and postoperative complica- tions. The jury returned a verdict in favor of the insured ophthalmologist.
Risk Management Principles
The ophthalmologist disclosed the potential complications to the patient and responded each time to the patient’s complaints by promptly examining her, even on Christmas. This responsive care no doubt contributed to the jury’s defense verdict. Like many patients, the plaintiff was angry about experiencing two rare complications and about learning the permanent nature of her vision loss from a con- sultant she herself had asked to see. Had the ophthalmologist explained that she had two risk factors that might lead to rupture of the posterior capsule (the dense cataract and the fragile condition of the capsule), the patient might have been better prepared to deal with her poor outcome.
When anticoagulants are medically neces- sary for surgical patients, the surgeon should explain the need and risks to the patient and choose the most appropriate anesthesia and operative technique. Instructions to stop medications, especially anticoagulants, and recommendations for hospitalization must be documented. When there is significant loss of vision, the patient should be kept informed of treatment options and prognosis for recovery. If a poor outcome is final, the patient should be assisted in adapting to a low vision status.
Negligent Telephone Care of Postoperative Patient
By Anne M. Menke, RN, PhD OMIC Risk Manager
ALLEGATION Delay in diagnosis and treatment of retinal detachment following cataract surgery.
DISPOSITION Defense verdict at trial.
Case Summary
A 58-year-old female with lattice degeneration had uncomplicated cataract surgery. Three months post-operatively, the patient called the surgeon to report seeing branches and black spots of one day duration and was told to come in. She denied seeing flashing lights. BCVA was 20/25, and a dilated fundus with scleral depression examination of the right eye revealed vitreous hemorrhage and floaters. The macula and peripheral retina were flat without holes, tears, or evidence of retinal detachment. The ophthal- mologist prescribed bed rest (with the head of the bed elevated at 30 degrees) and advised the patient to follow up in 1 to 2 weeks or sooner if she developed increasing floaters, photopsia, or a veil/curtain formation.
The patient said she called the office four days later to report that she could barely see through a dark bubble. She claimed to have spoken to the receptionist, who consulted with the ophthalmologist, and was told not to worry. There was no documentation of the call. In deposition, the insured recalled being told only that the patient wanted to know when the floaters would resolve. She believed that she either asked the receptionist to call the patient back and verify the lack of new symptoms or that she called the patient herself. Five days later, the patient called again and said she was coming in. At the visit, she reported fluctuating vision and was noted to have a VA of CF, with both a horseshoe tear and a macula-on retinal detachment in the superotemporal quadrant. The insured spoke with a retinal specialist, who agreed to see the patient the next day; the call was not documented and the specialist had no recall of the conversation. When the patient was seen the next day, the detachment had progressed to macula-off. The patient had a scleral buckle, vitrectomy, air/fluid gas exchange, and endolaser surgery. At the time of trial eight months later, the retina was still attached, with vision pinholed to 20/60; the patient reported multiple visual problems.
Analysis
Plaintiff experts focused on the increased risk of retinal detachment in patients with lattice degeneration and cataract surgery. They doubted the ability to visualize the retina in the presence of vitreous hemorrhage and criticized the delay in referral to the retinal specialist then and when the detachment was diagnosed. Defense experts supported the insured’s examinations and treatment; more- over, they felt strongly that an experienced cataract surgeon, who had explicitly warned the patient about retinal detachment, would never ignore reports of a dark bubble. The lack of documentation, especially of the phone calls with the patient and the retinal specialist, became the focal point of the trial. Jurors who returned a defense verdict later explained that the plaintiff lost credibility when she refused to pursue the recommendations of a blind vocational rehabilitation expert. Nonetheless, they had sharp criticism for the insured’s call screening process and failure to document telephone care.
Risk Management Principles
Telephone screening of eye complaints, especially in postoperative patients, is an extremely risky aspect of ophthalmic practice and a regular feature of malpractice lawsuits. Physicians need written protocols, including contact forms that prompt them and their staff to ask crucial questions and document the responses, as well as guidelines to determine when the patient needs to be seen. Such sample forms and protocols are available online and from OMIC’s Risk Management Department (see cover article). The physician’s screening process is intended to gather the information necessary to develop a differential diagnosis that includes the worst case scenario for the patient’s presentation. In this case, the ophthalmologist clearly identified the risk of retinal detachment, but she could have been more proactive in managing it by making an early referral to a retina specialist to verify her examination in the presence of hemorrhage and by scheduling frequent follow-up visits before the patient left her office.
Codefendant Nurse Anesthetist’s Insurance Carrier Builds a Case Against OMIC Insureds
Ryan Bucsi, OMIC Senior Claims Associate
Digest, Winter 2006
Allegation
(Against Insured A) Negligent supervision of nurse anesthetist during administration of a retrobulbar block. (Against Insured B) Negligent use of gas bubble injection to repair a retinal detachment. (Against Non- Insured Nurse Anesthetist) Improper administration of a retrobulbar block.
Disposition
Insured A was dismissed prior to trial while insured B received a defense verdict at trial. Jury verdict of $250,000 against non-OMIC insured codefendant nurse anesthetist.
Case Summary
An elderly male patient underwent a retrobulbar block by the codefendant nurse anesthetist, apparently without complication. Insured A then performed cataract surgery on the left eye. When the patient returned the following day, insured A diagnosed a submacular hemorrhage and referred the patient to insured B, a retinal specialist. Insured B performed a TPA/gas injection and two weeks later performed a pars plana vitrectomy. Subsequent procedures were performed by insured B because of a retinal detachment resulting from proliferative vitreous retraction. The patient ultimately lost all useful vision in his left eye. During their respective depositions, insured A and the nurse anesthetist both testified that the injury was a result of the retrobulbar block.
Analysis
The defense expert for insured A testified that since the nurse anesthetist had significant experience in administering anesthesia, there was no need for direct supervision of the anesthesia administration. The defense expert for insured B was fully supportive of the insured’s care and treatment of the patient, stating that TPA and gas injection was cutting edge and the least invasive approach. The defense expert for the nurse anesthetist testified that everyone except the nurse violated the standard of care. He testified that insured A breached the standard of care by performing cataract surgery on the patient in the first place and opined that a macular pucker, not a cataract, was the cause of the patient’s poor vision. The codefendant also retained an expert to testify against insured B. This expert opined that the decision to use a gas bubble injection, rather than a vitrectomy with membrane stripping, fell below the standard of care. This testimony prompted the plaintiff to amend the complaint to include insured B. As to the care provided by the nurse anesthetist, the plaintiff’s expert opined that the double perforations represented a considerable departure from the standard of care. An additional criticism was that the nurse failed to recognize this complication, thus delaying a referral to a retinal specialist.
The plaintiff did not retain an expert to testify against insured A or B. Insured A was dismissed from the case, but the group he was part of was not. The codefendant alleged the ostensible agency theory, essentially claiming that the group caused the plaintiff to believe the CRNA was an agent or employee of the group. Since insured A was dismissed and there remained only the allegation of vicarious liability against the group, OMIC attempted to tender the defense to the nurse anesthetist’s carrier. The carrier denied OMIC’s tender based on the theory that insured A was somehow independently negligent, even though insured A had been dismissed.
OMIC’s defense counsel estimated a 90% chance of a defense verdict, since the plaintiff’s expert was supportive of insured B, and the only critical testimony would be presented by an expert retained by the codefendant. The plaintiff’s demand was for $1 million.
The case was mediated prior to trial and the codefendant offered $100,000. No offer was made on behalf of any OMIC insured. The jury returned a defense verdict for OMIC insured B, found against the nurse anesthetist, and awarded the plaintiff $250,000. Since OMIC’s offer to tender the defense to the nurse anes- thetist’s carrier was rejected, it allowed OMIC to pursue a portion of the defense costs. Defense counsel filed a complaint for costs against the codefendant and OMIC received $22,250 reimbursement from the nurse anesthetist’s insurance carrier.
Risk Management Principles
As this case demonstrates, ophthalmologists who delegate retrobulbar injections to quali- fied anesthesia providers are not held liable for the alleged negligence of that provider. The surgeon does, however, need to carefully convey to the anesthetist any information that could impact the anesthetic choice, dosage, or technique, such as unusual anatomical features and co-morbid ocular or medical conditions.
