Dislocated Lens Fragments Should Be Referred to a Specialist

By Arthur W. Allen, MD

Argus, June, 1993

Phacoemulsification is becoming increasingly popular in the United States. Techniques such as scleral tunnel “self sealing” incisions, small central continuous curvilinear capsulorrhexis, hydrodissection, hydrodelineation and nuclear fracturing have helped speed recovery after surgery. While such techniques have allowed the phaco surgeon to remove harder nuclei more safely, they also have increased the learning curve for surgeons performing this procedure.

These factors contribute to an increasing number of cataract patients who develop rents in the posterior capsule with loss of nuclear fragments into the vitreous cavity. It is well documented that loss of such fragments often leads to secondary glaucoma, uveitis, corneal edema, retinal detachment, discomfort and decreased vision. Anterior segment surgeons risk serious complications by attempting to remove these fragments with various maneuvers such as irrigation or grasping with a cryoprobe or other instruments. A complication that leads to a protracted, painful postoperative course and a poor visual result is a good recipe for a malpractice suit.

Recently, OMIC defended a case in which the posterior capsule broke, resulting in loss of nuclear fragments into the vitreous cavity. The ophthalmologist had previous retinal training but was primarily an anterior segment surgeon. He attempted a vitrectomy to remove the nuclear fragments, but encountered difficulty with a hard nucleus. At that point, he called in a vitreoretinal colleague who took over the case and removed the fragments. Unfortunately, retinal damage had occurred, resulting in poor vision and an unhappy patient who sued the cataract surgeon.

The case ultimately went to trial with a verdict for the plaintiff, primarily because the jury thought the anterior segment surgeon did not have enough practical experience in removing lens fragments to have made such an attempt. In the jury’s opinion, only an experienced vitreoretinal surgeon should have removed the fragments, and the anterior segment surgeon made an error in judgment in attempting to do so himself. The jury’s message was clear: The anterior segment surgeon had no business trying to retrieve lens fragments from the back of the eye even though he had additional retinal training.

How does an ophthalmologist avoid or at least minimize the likelihood of a successful lawsuit if lens fragments are lost during phaco?

Prior to surgery, discuss with the patient all possible complications of phacoemulsification, including rents in the posterior capsule and loss of nuclear fragments into the vitreous cavity, that may possibly lead to secondary complications and the need for further surgery. Sharing this information with the patient prior to surgery may help decrease the patient’s shock or surprise if such an untoward event occurs. Documenting that this conversation took place may be used as evidence that the patient made an informed decision to go ahead with the procedure. The patient also should understand that there are procedures to remedy most complications.

Several articles in the literature have documented the highly successful removal of retained lens fragments, using a three-port vitrectomy approach by experienced vitreoretinal surgeons. Because these lens fragments always come to rest at the posterior aspect of the eye, either on the macula or in the area of the optic nerve, it can be hazardous for an inexperienced surgeon to try and remove these hard fragments from the surface of the retina. The experienced surgeon, however, is usually able to perform the vitrectomy, aspirate the lens fragments, and retract them to the midvitreous cavity where they can be emulsified.

The legal issue that arises when lens fragments fall into the posterior aspect of the eye is this: should the anterior segment surgeon attempt to retrieve them or refer the patient to an experienced vitreoretinal surgeon? When prevailing professional standards require that particular services be performed by a specialist, the general ophthalmologist who fails to seek the aid of a specialist and undertakes to perform those services will not automatically be held liable for every untoward result; rather, he or she will be subject to the standard of care that the law imposes on specialists. In effect, the duty recognized in many jurisdictions may be a duty either to seek the assistance of a specialist or to have and exercise the same degree of knowledge and skill that is required of a specialist. In the case discussed above, the jury apparently was not persuaded that the anterior segment surgeon had either the same degree of knowledge or skill as a vitreoretinal surgeon and/or exercised such skill.

Interestingly, there seems to be no contraindication for continuing with surgery and placing an anterior or posterior chamber lens in an eye following a complication in which lens fragments have entered the vitreous cavity. Indeed, it has been shown that the final visual result is better in eyes in which an intraocular lens has been placed than in eyes in which one has not. Although immediate removal of the lens fragments is not necessary, the patient should be referred promptly to a specialist for evaluation and, if necessary, surgical removal of the fragments.

In summary, the fact that the capsule breaks and the nucleus is lost posteriorly does not inherently pose a risk for the retina or the eye. It is the maneuvers done by the cataract surgeon to retrieve these fragments that often lead to irreparable retinal damage or poor visual results.

As a general rule, anterior segment surgeons should not attempt to remove the nuclear material, but should simply clean up the anterior segment, put in an appropriate intraocular lens, and allow the fragments to be taken care of by a specialist in this field. Eyes handled by a three-port closed vitrectomy have an excellent chance of achieving good visual acuity. Patients who ultimately achieve good vision are less likely to be angry and sue than are patients who experience complications and a poor visual result.

Phacoemulsification: Use Careful Patient Selection

 By Reginald J. Stambaugh, MD

Argus, August, 1993

Surgical removal of a cataract, when performed under the right conditions and using the proper technique, can be extremely rewarding for the patient. If complications occur and patient expectations are not achieved, however, the result can be disastrous for both patient and surgeon. Therefore, proper preoperative evaluation by the operating ophthalmologist is critical.

Improvements in technique, equipment, instruments and implants have driven the number of cataract extractions up to unprecedented levels in recent years, resulting in closer public scrutiny of the procedure and those who perform it. Further, misleading advertising promises for “painless, instantaneous vision” have contributed to unrealistic expectations in many patients. The result is that it is imperative for the ophthalmologist, who may be held legally liable for the outcome, to carefully evaluate patients before performing surgery.

Preoperative evaluation by the surgeon should assess not only the physical findings of the patient, but also the realistic needs of the patient. These needs are determined by such factors as the patient’s occupation, age, overall health, lifestyle, recreational activities and family obligations. The surgeon must consider whether surgery will improve the patient’s vision and whether improved vision will meet the patient’s needs and improve the patient’s quality of life. If the answer is yes and there are no physical contraindications, the ophthalmologist may feel comfortable recommending surgery.

Phacoemulsification has become the procedure of choice for many cataract surgeons. Ophthalmologists who have made the transition to phaco know it is not a simple procedure nor one without complications, and they have developed a healthy respect for the learning curve involved in perfecting this technique. Once the surgeon’s skill is established, patient selection becomes the most important risk management consideration for the surgeon.

Visual acuity should always be the primary criterion in preoperative evaluation. Determination of the glare factor may or may not be significant. While inflammation, infection, corneal scars, macular or retinal deterioration, optic nerve disease, etc., are generally accepted contraindications to ocular surgery, there are other less decisive factors to consider such as corneal endothelium, anterior chamber depth, size of the dilated pupil, grade of the nucleus and posterior capsule status.

Corneal decompensation with poor results can be prevented in selected cases, but even with improvements in technique, the stage of the nucleus and integrity of the capsule continue to be important criteria in the selection of phaco candidates. When emulsifying the nucleus, problems with the endothelium and posterior capsules, both critical structures, can produce complications, as experienced surgeons know.

Age of the patient is an important factor. The procedure is quite different in young patients who have minimal nuclear changes and a stronger posterior capsule that can tolerate more manipulation before rupturing.

Having done phacoemulsification and intraocular lens implants since 1975, including 10 years of specular microscopy and endothelium study, I have become more conservative in my selection of surgical candidates. Although the success rate of phaco is high, poor results in a patient with unreasonable expectations can result in the filing of a malpractice claim, even if the procedure is done properly. Given our litigious society and the competitive marketplace in which we practice, legal disasters may be avoided only if ophthalmologists remember that they are entrusted with their patients’ care, and evaluate each one’s needs, physical findings and expectations with integrity.