Risk Management

Global Perforation and Vision Loss in High Myopic, Deaf Patient

By Paul Weber, JD

OMIC vice president of risk management

Digest, Summer/Fall 2004

ALLEGATION  Negligent choice of anesthesia and failure to communicate patient history to anesthesiologist, resulting in globe perforation and loss of vision.

DISPOSITION Settled with indemnity payments on behalf of the insured ophthalmologist and codefendant anesthesiologist.

Case Summary

A 36-year-old deaf male was referred to the insured for cataract surgery. He presented with cataracts OU and myopic degeneration. VA was 20/400 OD and 20/60 OS in a dark room and 20/100 OS with the lights turned up to normal. The patient elected to have cataract surgery on the left eye only because there would have been little to gain from surgery on the right eye. The risks and benefits of surgery were discussed using a sign language interpreter with the patient and his wife. They were informed of the risk of complete loss of vision and/or loss of the eye with surgery, including the significantly greater risk of retinal detachment (RD) due to high myopia. The insured maintains that prior to surgery he informed the anesthesiologist that the patient had the longest eye he had ever encountered and that special care needed to be taken with the peribulbar injection.

Delivery of the anesthesia and surgical procedure proceeded uneventfully. On the first day post-op, when a vitreous hemorrhage was noted by the insured, the patient was immediately referred to a retinal specialist. The diagnosis was a posterior perforation in a mid-equatorial staphyloma from the anesthetic injection, resulting in a posterior RD. The RD was repaired the following day, but the patient developed a hyphema, a vitreous and subretinal hemorrhage, and a recurrent detachment postoperatively. Although the second reattachment was successful, post-op VA was light perception only.

The patient claimed that loss of vision resulted in loss of independence. He asserted that prior to surgery he was self-sufficient and independent, but afterwards he could no longer leave the house by himself, ride his bike, or walk to work. As a result of his vision loss, the plaintiff claimed his marriage ended and he was forced to move in with and become completely dependent upon his mother.

Analysis

The medical records reflected appropriate informed consent and no deviation in the insured’s surgical decision-making or technique. The ophthalmologist maintained that the risks of general anesthesia outweighed the risks of local anesthesia because, regardless of the shape of the eye, there is always space to safely place a peribulbar injection without perforating the globe if the physician stays outside the muscle cone. Unfortunately, the anesthesiologist entered the papilomacular bundle during administration of the peribulbar block and pierced the globe.

Several issues made defense of this case difficult. The anesthesiologist alleged that the insured did not fully inform him about the extent of the patient’s eye abnormalities. If he had, the anesthesiologist claimed he would not have performed a peribulbar block. Defense experts argued that the patient should have been offered the option of general anesthesia given the extreme myopia of his eye and the fact that deafness is a relative contraindication to a peribulbar block. Additionally, the patient’s staphyloma was not documented in the medical record and there was a discrepancy between the axial length determined by the MRI (27mm) and the axial length determined by the ultra-sound (35mm). Furthermore, a PAM (Potential Acuity Meter) test was never performed, and there was no evidence that cataract surgery would have benefited this patient.

Risk Management Principles

Documentation of eye abnormalities must be meticulous; discrepancies between test results must be resolved before surgery; and diagnostic procedures must be thorough. The final determination as to what type of anesthetic to use should be made jointly by the anesthesiologist and the ophthalmologist, taking into consideration the patient’s medical sta- tus and any significant ocular abnormalities. Documentation should include the medical reasons for the choice of anesthesia. Discus- sions with a hearing and visually impaired patient regarding the risks and benefits of eye surgery and anesthesia options and the signing of consent forms should take place at least one day prior to surgery. On the day of surgery, the patient should again verify that he/she has made an informed decision.