Risk Management

When Dissatisfied Patients Seek Second Opinions

By Jean H. Ellis, MD

Argus, June, 1996

 Fifteen percent of all OMIC closed cataract surgery-related cases involve an intraocular lens (IOL) problem: malpositioning, dislocation, wrong size or incorrect power. The majority of these cases are resolved without a payment to the plaintiff or with a relatively low indemnity payment of less than $50,000.

Patients who are symptomatic with IOL abnormalities need timely and proper medical and surgical intervention as well as openness and good communication about their particular problem. However, often the patient is asymptomatic and pleased with the surgical outcome following cataract surgery. In such cases, discussions about some lens implant abnormalities may be unnecessary and only serve to upset the patient or trigger a claim or lawsuit.

Most legal actions regarding implant abnormalities stem from a patient’s dissatisfaction with the results and/or a bad experience with the surgeon. Sometimes a patient may initiate a lawsuit in response to an evaluation by another ophthalmologist who may have criticized the implant, the eye’s appearance or the surgical technique.

In one OMIC case, a patient sued an insured ophthalmologist as a direct result of a colleague’s inadvertent critical comment about a lens implant. The patient had sought a second opinion from the other ophthalmologist regarding dry eye syndrome, a condition everyone admitted had pre-existed the cataract surgery. Before all the pertinent facts were identified, the second ophthalmologist informed the patient that the IOL was put in backwards. (The operating ophthalmologist was unaware that the lens was inverted.) The patient believed the inverted lens contributed to her eye irritation.

Despite a visual outcome of 20/25 in the operative eye, this case was settled with a small payment to the plaintiff. The plaintiff’s expert witness intended to testify that backward insertion of the lens increased the patient’s postoperative intraocular inflammation. The expert agreed that similar anterior chamber IOLs have been placed in the eye backwards by other surgeons, and that these patients achieved similar excellent visual recovery without irritation. However, it was felt that a jury might not understand that the malpositioned implant did not cause any harm.

Problems encountered with IOLs can also correlate to the surgical technique used, as with capsulorrhexis contracture syndrome. Surgeons now prefer using smaller IOL designs in an effort to reduce unwanted postoperative astigmatism. Smaller-sized optics can be associated with decreased patient tolerance in issues of lens centration. Understanding the surgical technique used is important when evaluating a cataract patient’s complaints.

When a dissatisfied patient seeks out a second opinion following cataract surgery, first collect all pertinent facts and data. This includes a thorough patient history, a comprehensive ocular examination, a review of the prior ophthalmologist’s medical and surgical records, and ideally, a discussion with the surgeon of possible etiologies for the patient’s symptomatic lens implant problems. Only after all this information has been gathered can the patient be properly diagnosed and informed. Often, sympathetic and careful management is enough to mitigate a patient’s dissatisfaction and avert unwarranted malpractice litigation.