Improper performance — cataract surgery

Presentation 
A 63-year-old man came to Ophthalmologist A complaining of visual changes to both eyes. He had a history of bilateral cataracts. Visual acuity with contact lens measured 20/25 in each eye, with spectacle correction of 20/30 OD and 20/40 OS. The diagnosis was visually significant cataracts with glare and near vision changes. The patient requested the ability to read without glasses. Ophthalmologist A recommended phacoemulsification with posterior capsule intraocular lens implant with some monovision in the left eye.
 

Physician action
One month later, Ophthalmologist A performed an uncomplicated cataract surgery in the left eye with implantation of a +18.5 intraocular lens.

Four days after the surgery, the patient returned to see Ophthalmologist A with complaints about the vision in his left eye. Visual acuity was measured without correction at 20/400. A-scan biometry was performed, revealing the wrong power lens was placed during the surgery. It was determined that a +23 diopter lens should have been used. This would have achieved the desired result, monovision.

The patient elected to proceed with another surgery to have the correct power lens placed. The surgery was performed three days later. During this surgery, a complication was encountered when the posterior capsule ruptured and there was loss of the vitreous. Ophthalmologist A confirmed the rupture and performed an anterior vitrectomy. The vitreous, which had prolapsed into the anterior chamber, was removed and the lens was placed into a new position.

The patient was seen the next day for follow up. The intraocular pressure in the left eye was measured at 46 mm Hg, which was highly elevated. The patient received immediate treatment that reduced the pressure by his next postoperative visit. Subsequently, cataract surgery was performed on the right eye, without complications, one month after the first surgery was performed on the left eye.

Two months later, the patient returned to Ophthalmologist A with complaints of a “star burst episode” that was limiting his vision in the left eye. Ophthalmologist A recommended a YAG laser capsulotomoy for the left eye. This was the patient’s last visit with Ophthalmologist A. The patient elected to seek another ophthalmologist’s opinion.

The patient was seen by Ophthalmologist B six months later. He was diagnosed with pseudophakia, with displacement of the left lens. One month later, Ophthalmologist B evaluated the patient and diagnosed a temporal displaced intraocular lens in the left eye, vitreous detachment, blepharitis, and pseudophakia.

Three weeks later, the patient came to Ophthalmologist C with complaints of seeing flashers and floaters in the left eye. The patient was diagnosed with vitreous detachment of the left eye and pseudophakia. He was advised to follow up for new or increased floaters, flashing lights, veils, or other visual field abnormalities that could indicate a retinal detachment or tear requiring immediate attention.

Nine months later, the patient was experiencing visual loss inferiorly and peripherally in the left eye with associated flashes and floaters. He was seen again by Ophthalmologist B who diagnosed superior retinal detachment with the macula on. Visual acuity was measured as counting fingers. The patient was seen later that day by a retina specialist, Ophthalmologist D. She confirmed the presence of a retinal detachment and determined the macula was “shallowly detached.”

The following day, Ophthalmologist D performed a pneumatic retinopexy to the left eye. Follow-up visits on postoperative day one and two revealed the retina was still detached. Five days later, the patient underwent a pars plana vitrectomy with the injection of silicone oil in the left eye. The patient continued to report having finger-counting vision in his left eye despite the fact his retina had been reattached.

Five months later, the patient was diagnosed as having sensory exotropia and an outward-turned left eye. He underwent surgery to correct the left eye appearance two months later, reportedly with good cosmetic results.


Allegations
A lawsuit was filed against Ophthalmologist A, alleging failure to properly perform an A-scan measurement before the first cataract surgery and improperly performing cataract surgery. The plaintiff alleged he sustained irreparable and permanent damage to the optic nerve and capsular sac during surgery.


Legal implications
Consultants who reviewed this case felt the loss of vitreous during the second surgery caused the subsequent retinal detachment and the patient’s permanent loss of vision. Since the second surgery became necessary only because the incorrect lens was placed in the first surgery, the failure of Ophthalmologist A to correctly and accurately measure the left eye and use the correct lens caused the patient’s permanent loss of vision.


Disposition 
This case was settled on behalf of Ophthalmologist A.


Risk management considerations 
An obstacle in this case was the missing data from the initial A-scan measurements taken before the left cataract surgery. The results were not available to Ophthalmologist A before the surgery and are missing from the medical record entirely.

In this ophthalmologist’s office, the measurements are kept in the machine for a period of time and then erased. They are usually printed to the medical record, but were not in this case. The data used to develop a treatment plan for patients should be a permanent part of the medical record. The Texas Medical Board rule within Chapter 165.1 states that the rationale for and results of diagnostic and other ancillary services should be included in the medical record. (1)

Also, there was speculation by Ophthalmologist A that the technician performed the A-scan measurement incorrectly. She believes the technician did not have the patient remove his contact lens prior to testing. This made the measurements to the left eye incorrect.

Employees of a physician practice are subject to supervision. The Medical Practice Act (MPA) establishes general parameters for physician delegation in Texas. According to the Medical Practice Act, a physician may delegate to a qualified and properly trained person acting under the physician’s supervision. The delegating physician remains responsible for the person performing the delegated acts. (2)

Training and evaluation of skills is an important part of the hiring and ongoing staff evaluation process. A skills checklist is a beneficial tool that practices can develop and use as part of the evaluation process for staff. The checklist should be specific to the type of practice and skills performed within the practice. Training documentation should be kept as a permanent part of the employee file.
 

Sources

  1. Texas Medical Board. Texas Medical Board Rules Chapter 165.1. Available at http://www.tmb.state.tx.us/rules/rules/bdrules.php. Accessed February 28, 2013.
  2. Texas Occupations Code. Chapter 157 Authority of Physician to Delegate Certain Acts. Available at http://www.statutes.legis.state.tx.us/Docs/OC/htm/OC.157.htm. Accessed February 28, 2013.

 

These closed claim studies are based on an actual malpractice claims from TMLT. These cases illustrates how action or inaction on the part of physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. These studies have been modified to protect the privacy of the physicians and patients.

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