Risk Management

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.