Risk Management

Second cataract surgery proceeds when CRVO goes undetected

RYAN BUCSI, OMIC Senior Litigation Analyst

Allegation

Negligent management of cataract patient resulting in bilateral blindness.

Disposition

Ophthalmologist was dismissed from case and a settlement of $930,600 was paid on behalf of the entity.

A 78-year-old patient presented to a young OMIC insured, who diagnosed bilateral cataracts. The patient paid in advance for the cataract surgeries with a credit card. The first surgery on the left eye was uncomplicated. Hours later, a staff member confirmed via telephone that the patient was doing well. On the postoperative day one examination, neither the patient nor the insured had any concerns. The patient was to return to clinic in one week, the day prior to surgery on the right eye. Although there was no written protocol, it was the insured’s understanding that patients who have eyes operated on one week apart are given a placeholder clinic appointment prior to the second eye surgery. The insured believed the patient was called the day before the second surgery and denied having any problems, so the appointment was cancelled. However, there was no documentation that such a call to the patient ever took place. The insured performed an uncomplicated cataract surgery on the right eye. On postoperative day one, the insured noted that vision in the left eye was virtually gone and diagnosed a central retinal vein occlusion (CRVO). A retina consult confirmed the diagnosis of CRVO and the left eye was injected with Avastin. One week later, the insured examined the patient, who complained of a rapid visual decrease in the right eye. Upon examining the right eye, the insured could actually see the retinal vein occlusion occurring. The insured immediately referred the patient back to the retina specialist, who confirmed the diagnosis of CRVO.

Analysis

The patient and his spouse testified during their depositions that they had reported reduced vision in the left eye to one or more of the intake persons at the surgery center. They were distressed that no one at the surgery center examined the left eye and contended that the surgery center, through its personnel and technicians, deviated from the standard of care by not communicating their complaints to the insured. If staff had relayed the complaint, the plaintiff argued that the insured would have examined the plaintiff’s left eye, diagnosed a developing CRVO, and cancelled the surgery on the right eye. The plaintiff’s argument gained credibility when the insured testified that, even though there was no protocol in place to do so, the patient was asked by multiple staff about the left eye, and had he been informed of any problem, he would have cancelled the surgery. Both the insured and surgery center staff testified that they were not informed of vision loss in the left eye. In order to rule in favor of the plaintiff, a jury would have to believe that an experienced staff failed to inquire about the left eye and pass on the patient’s complaint of visual loss to the ophthalmologist. However, this was a catastrophic injury that occurred in a notoriously plaintiff friendly venue where a jury was more likely to side with the sympathetic plaintiff’s story, so a settlement of $930,600 on behalf of the entity was negotiated.

Risk management principles

Only one postoperative examination occurred prior to proceeding with cataract surgery on the second eye. If another examination had taken place prior to the second surgery, it is possible that some vision loss may have been detected, thus leading to further exploration and cancellation of the second surgery. While the defense argued that the patient and his wife did not report any decrease in vision in the left eye, none of the surgery center employees documented that he was asked about his left eye or complained of decreased vision. The importance of documentation cannot be overstated. A lack of thorough documentation or no documentation negatively affects the defensibility of medical malpractice lawsuits. As mentioned earlier, the patient paid for the procedures using a credit card. After the poor result, the patient disputed the charges with the credit card company and refused to pay the bill. This was not brought to the insured’s attention and the billing department pressed forward with collection. This created even more ill will between the patient and the insured’s office and would have also made the surgery center look unsympathetic in front of a jury. Waiving a bill for services after a poor outcome is something that should be considered and discussed with our risk management or claims department. OMIC welcomes and encourages early reporting of poor outcomes prior to the initiation of litigation.