Risk Management

Negligent Lid Surgery on a Graves’ Patient

By Stacey Meyer
OMIC Claims/Litigation Associate

Digest, Summer 1998

ALLEGATION 

Unnecessary panretinal photocoagulation for proliferative diabetic retinopathy.

DISPOSITION

Case settled on behalf of insured ophthalmologist.

Case Summary

A 52-year-old male presented with a history of severe thyroid disease, which eventually manifested itself through bulging eyes. He was seen by the insured for surgery to correct the proptosis. Prior to performing the surgery in question, the insured referred the patient to an internist for a second opinion. The internist concurred with the proposed surgery, although this was never documented. The insured then performed bilateral tarsorrhaphies and bilateral upper and lower lid blepharoplasties.

Postoperatively, the patient complained of incomplete lid closure, swelling and pain thought to be most likely a Graves’-related autoimmune inflammatory reaction. He was placed on steroid medication, which alleviated the symptoms temporarily. But as soon as the dosage was tapered, the inflammatory symptoms returned. The insured then referred the patient to the Mayo Clinic, where the postoperative inflammation was ultimately stabilized. Prior to stabilization, however, the patient went through a series of unsuccessful attempts to diminish his proptosis through the use of steroids, radiation therapy and two major orbital decompression surgeries, which triggered a severe autoimmune reaction.

The patient claimed he was not informed of the risk of an autoimmune reaction following this type of surgery and if the insured had not performed the original surgery, these subsequent complications would not have occurred.

Analysis

The underlying liability issue in this case was whether or not it was appropriate for the insured to perform lid surgery on this patient given the status of his Graves’ disease at the time. Oculoplastics experts were split in their opinions. Plaintiff experts set forth that the standard of care for Graves’ patients is to do nothing because of the danger that surgery may accelerate the disease. They argued that surgical intervention should not be undertaken unless visual acuity is imminently threatened. Furthermore, if surgical intervention is undertaken, the approach should be decompression or radiation therapy prior to lid adjustment surgery. Defense experts, on the other hand, opined that the patient’s Graves’ ophthalmopathy was stable, that his disease would have worsened with or without surgery, and that the procedures performed by the insured did not cause the disease to accelerate.

A related issue was alleged lack of informed consent regarding the possible complications and poor documentation of the risks of surgery for a patient with Graves’ disease. Causation also was disputed. Experts for the defense opined that the patient’s underlying Graves’ disease caused the claimed damages, whereas plaintiff experts alleged that the lid surgery initiated the long series of medical dominoes that befell the patient.

Riddled with conflicting views on every substantive medical question, the case turned out to be a battle of the experts. Defense counsel cautioned that the sympathetic appearance of the plaintiff, the lack of informed consent documentation regarding possible complications and risks, and a jury’s probable inability to sort through the complex medical facts would likely result in a plaintiff verdict. Because opinions varied so widely and testimony was not decisive on either side, each side would be able to present a plausible argument, leaving a confused jury to decide. It was counsel’s opinion that the jury would have a great deal of sympathy for the plain-tiff, who claimed to be uninformed of the possible consequences of surgery, and award him compensation.

Risk Management Principles

The insured showed good judgment by requesting a medical clearance for surgery from the internist, but by failing to document it, his credibility was called into question and he was left without any defense. After consulting with his private counsel, the insured made the decision to settle rather than be subjected to the ramifications of an excessive plaintiff verdict.