Risk Management

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.