The plaintiff alleges that on June 17, 2013 she underwent a second surgery on her left eye to install the proper implant and that afterward she continued to have difficulty seeing out of the eye. Review of the literature indicates that complications associated with retained lens material include inflammation, corneal edema, elevated intraocular pressure, hypotony, subluxation or dislocation of IOL, retinal tears or detachments, vitreous hemorrhage, choroidal hemorrhage, cystoid macular edema, epiretinal membrane, and endophthalmitis. Most previous studies on malpractice claims compared only the groups that went on to indemnity payment vs no payment. Studdert DM, Mello MM, Gawande AA, et al. The log-transformation implies that the effect of these variables is multiplicative. Half of all claims in this study were referred within 1 week of cataract surgery or the same day as detection of the retinal detachment. An opening in the inferior portion of the posterior capsule was seen and retinal detachment was confirmed. The number of ophthalmologists being insured by OMIC grew steadily from 1,027 in 1989 to 4,107 in 2009 (Figure 1). In some cases, the cause of capsular tear and resulting complication of retained lens fragment was due to circumstances other than the surgeons surgical technique. Attempts for post-trial settlement were rejected by the plaintiff. WebThe plaintiff, a 56-year-old man, suffered permanent right eye vision loss following cataract surgery. Claims, errors, and compensation payments in medical malpractice litigation. Wilkinson CP, Green WR. However, the patient did not show up for appointments, despite being sent no show letters. In addition to the original cataract surgery, patients underwent a mean of 1.3 additional surgeries (range, 04) where one or more combined procedures were performed. Ross WH. Management of dislocated lens material. Their analysis also found that vitrectomy on the same day and up to 2 days after the cataract surgery had poorer visual outcome. Lifshitz T, Levy J. Posterior assisted levitation: long-term follow-up data. Your use of this website constitutes acceptance of the Terms of Use, Supplemental Terms, Privacy Policy and Cookie Policy. Duty to treat means that a doctor-patient relationship must be established prior to the alleged negligent act. Oruc S, Kaplan HJ. Physicians with higher clinical activity also may have greater exposure or deal with more complex medical situations. In 3 cases, malfunctioning or unavailability of necessary equipment resulting in prolonged cataract surgery time was thought to have contributed to the patient movement and complication of capsular tear. It involved a 70-year-old female patient who went from preoperative visual acuity of 20/60 to final visual acuity of no light perception. The estimates show the odds ratio of being in a more severe category as opposed to less severe category when the predictor is changed by one unit; for categorical variables (corneal edema and elevated intraocular pressure), it means a change from the unlisted group to the listed one, whereas for continuous variables (visual acuity and time to referral), it means an increase in one unit. Therefore, appropriate management of elevated intraocular pressure is necessary to reduce poor patient outcome. This trend may reflect increased popularity and adaptation of phacoemulsification by cataract surgeons in the mid-1990s and increased complication rates during transition period from extracapsular cataract surgery. When the complication of a retained lens fragment has been encountered, the cataract surgeon should closely follow the patient and monitor for complications associated with retained lens fragment and consider timely referral to a specialist for management of further complications that may contribute to poor visual acuity outcomes. The first categorization was needed to evaluate legal costs incurred for each category of legal outcomes. Medical malpractice and respondeat superior. The needle impaled the lens and tore the lens capsule. The most common additional surgical procedure was pars plana vitrectomy to remove retained lens material or to manage retinal detachment, but procedures to manage IOL, glaucoma, corneal decompensation, and strabismus were also performed (Table 3). The third claim alleged decreased vision following negligent vitrectomy surgery to manage retained lens fragment. Another claim alleged that there was a delay in time to pars plana vitrectomy by the retinal surgeon to manage the elevated intraocular pressure. Of these cases, 11% went to trial, 28% settled, and 61% were dismissed. When evaluated for indemnity payment or no payment, the male-to-female physician ratios were 27:5 and 66:9, respectively. Among the 108 cases in this study, the final dispositions of the claims were as follows: 12 cases (11%) were resolved by a trial, of which 2 cases (17%) resulted in a verdict in favor of the patient plaintiff and 10 cases (83%) cases with a verdict in favor of the physician defendant; 30 cases (28%) were settled; and 66 cases (61%) were dismissed. The same study showed that, in terms of compensation for medical errors, the system gets it wrong about equally on both sides such that 27% of claims involving errors were uncompensated and, on the flip side, the same percentage of compensated claims did not involve an error. The documentation includes informed consent, office examination notes, operative notes, any conversation with the patient before or after the cataract surgery, as well as any discussions with a specialist. Therefore, it appears that earlier referral is one of the ways a cataract surgeon can improve risk management. There were 25 cases of retinal detachment, 21 cases of corneal edema or corneal decompensation, and 18 cases of cystoid macular edema. Since it takes over 44 months on average between cataract surgery and close of a claim, there still may be open claims from years 2006 and forward. AC IOL, anterior intraocular lens; OD, right eye; OMIC, Ophthalmic Mutual Insurance Company; OS, left eye; PC IOL, posterior intraocular lens; VA, visual acuity. Kane CK. Pars plana vitrectomy for the management of retained lens material after cataract surgery. Another study found that 7.4% of all physicians had a malpractice claim each year, with 1.6% having a claim leading to a payment.5 The proportion of physicians facing a claim each year ranged from 2.6% in psychiatry to 19.1% in neurosurgery. Twelve (11%) of 108 claims were resolved by a trial, 30 (28%) were settled, and 66 (61%) were dismissed. Scott IU, Flynn HW, Jr, Smiddy WE, et al. You will probably need to find a medical expert witness who has adequate knowledge of (or experience with) performing cataract surgeries (usually a practicing ophthalmologist) to testify as to what the proper standard of care was, and then to show that not only did your ophthalmologist fall short of that standard, but that you were also injured because of that sub-standard care. In 7 cases, the cataract surgeon documented an intraoperative attempt at retrieval of the lens fragment (Table 2). Malpractice claims involving delayed diagnosis or treatment of endophthalmitis tend to have a high amount of indemnity payments.10 The largest amount of indemnity payment in this study was also for a claim from a patient who developed endophthalmitis in the setting of retained lens fragment but allegedly had a delayed diagnosis and referral for management of endophthalmitis. ACOG Committee Opinion No.374. Through highlighting circumstances of pertinent claims and identifying factors associated with malpractice claims resulting in an indemnity payment or going to a trial, this current study sought to ascertain steps that can be taken by ophthalmologists to improve patient care and safety as well as assist in risk management when cataract surgery is complicated by retained lens fragments. Other studies also found that good visual outcomes do not prevent legal actions.10,92. From 1989 through December 2009, OMIC had a total of 2,854 closed claims. Claims that settled during the trial or prior to the start date of the trial were included in the settlement group. More than 50% of obstetricians and gynecologists have already been sued before they reached the age of 40 years, and 90% of general surgeons aged 55 years and older have been sued. Final visual acuity was the last recorded visual acuity. Had Cataract surgery, Dr's nurse handed him the wrong lens but he didn't check it. Although the final visual acuity was important, the most important factor associated with going to a trial or resulting in an indemnity payment was found to be the amount of visual acuity loss following cataract surgery complicated by retained lens fragments, such that the greater the difference between the baseline visual acuity and the final visual acuity, the greater the likelihood of a claim resulting in a trial or indemnity payment. Yet three or four years ago, UCLA surgeons Furthermore, there was a wide variation in the size of indemnity payment (payment to a plaintiff) across specialties, and the specialties that were most likely to face indemnity claims were often not those with the highest average payments.5 For example, pediatrics was 24th among 25 specialties with regard to proportion of physicians facing a malpractice claim annually, but it had the highest mean amount of indemnity payment. Transactions of the American Ophthalmological Society, http://www.amaassn.org/ama1/pub/upload/mm/363/prp-201001-claim-freq.pdf, http://www.omic.com/about/financial_info/members_rpt.cfm, MVR blade to impale the fragment that landed on optic nerve, Duration of claim opening to closing (months), Duration between surgery and claim occurring (months), Duration of claim opening to closing (Months). 19851989. Do Not Sell or Share My Personal Information, Do Not Sell or Share My Personal Information, improper application of anesthesia, such as globe perforation, and, a variety of post-operative complications, such as swelling, Pre-suit requirements like screening panels, advance notice of the lawsuit, mandatory settlement negotiations and ", Expert witnesses experienced in the particular field of health care must testify on behalf of either, The total amount a plaintiff can recover from a health care provider might be limited by a ". To review malpractice claims associated with retained lens fragments during cataract surgery to identify ways to improve patient outcomes. Even when a trial ended in favor of a defendant and no payment was made to the plaintiff, the legal expenses were nearly twice that of claims that settled. Holak sued Tyson and Eye Associates. Abbott RL. Poorly documented cases were deemed more difficult to defend, whereas claims with aggressive intraocular manipulation by the cataract surgeon resulting in retinal detachment were more likely to result in poor final visual acuity and were more likely to go to a trial or settle. One month after the cataract surgery, the patient called and reported that the vision in the right side of the left eye was gone. He was seen on the same day and found to have visual acuity of 20/400 with a superotemporal retinal detachment. Continuous irrigation was performed, but the nuclear fragment could not be elevated. If observation is considered, close follow-up is recommended for timely detection of increased intraocular pressure, cystoid macular edema, or retinal detachment. If a physician had multiple claims from separate cataract surgeries, each was counted separately. Of the 108 defendants, 105 (97%) were cataract surgeons and only 3 (3%) were retinal surgeons. Although there were no cases involving residents, there was one claim against a policyholder ophthalmologist who was overseeing a colleagues attempt at learning cataract surgery. Among 108 patient claimants, 54 were men and 54 were women. The largest indemnity payment case, with a payment of $500,000, closed in 2005 with a settlement. Thirty-four cases had other complications, including endophthalmitis, vitreous hemorrhage, choroidal detachment, macular hole formation, central retinal artery occlusion, uveitis, anterior ischemic optic neuropathy, floaters, and epiretinal membrane. Although documentation of informed consent does not prevent a malpractice claim, a better informed decision process may set realistic expectations by a patient, and presence of an appropriate informed consent is crucial when there is a malpractice claim. If you have experienced complications after cataract surgery because of surgical error, consult with the St. Louis surgical error attorneys at Zevan and Davidson Law Firm, LLC at (314) 588-7200. Distribution of closed claims related to retained lens fragments by region in the United States. Each log unit of visual acuity loss resulted in more than a twofold increase in likelihood of a claim going to a trial or resulting in an indemnity payment. One of the most devastating complications after any ophthalmic surgical procedure that can result in profound visual loss is endophthalmitis. Brazitikos PD, Androudi S, Alexandridis A, Ekonomidis P, Papadopoulos NT. One month later, she developed a tractional retinal detachment, ciliochoroidal detachment, and hypotony. Intraocular lens was implanted in 85 (90%) of 94 cases where this was recorded, with 63 (67%) being posterior chamber IOL and 22 (23%) being anterior chamber IOL. She underwent pars plana vitrectomy, scleral buckling procedure, membrane peeling, removal of IOL, endolaser, and gas-fluid exchange. The cataract surgeon felt strongly that he was not at fault and wished to go to a trial rather than settle. Expert testimony. WebCataract surgery injury occurs in approximately 12% of cases. Hui JI, Fishler J, Karp CL, Shuler MF, Gedde SJ. In another study, the number of claims resulting in indemnity payment for ophthalmology was similar to the number for dermatology, internal medicine, and gastroenterology, and the mean and median payments for ophthalmology claims were slightly less than the mean indemnity payment of $274,887 and the median of $111,749 across 25 specialties.5 Therefore, the claims related to retained lens fragments appear to have lower indemnity payment on average when compared to malpractice claims across all specialties. However, optimal timing of vitrectomy is unknown, and the effect of vitrectomy timing on clinical outcomes has been highly controversial.2041,74,78 Therefore, there is currently no clarity in best time to refer to a specialist in cases of cataract surgeries complicated by retained lens fragment or the time between referral to vitrectomy. Therefore, while retained lens fragment is an infrequent complication of cataract surgery, this complication has a potentially high likelihood of legal consequences. Retained lens fragment in the anterior segment as a cause of recurrent anterior uveitis. Dr. Poole performed cataract surgery on DeFrankos eyes over the course of one month. Murat Uyar O, Kapran Z, Akkan F, Cilsim S, Eltutar K. Vitreoretinal surgery for retained lens fragments after phacoemulsification. Beckman HB, Markakis KM, Suchman AL, Frankel RM. Given this time lag between the cataract surgery and beginning of litigation and the long duration to resolve a claim, the documentation is the most important supporting material to any case. Retained lens fragments can be successfully managed by the retina specialists in most cases. A retrospective review was performed of all closed claims during the 21 years from 1989 through 2009 of those insured by OMIC to identify cases associated with cataract surgeries complicated by retained lens fragments (see Inclusion and Exclusion Criteria section that follows). Medical malpractice predictors and risk factors for ophthalmologists performing LASIK and PRK surgery. There were differences between claims associated with retained lens fragments that went on to a trial vs settled vs dismissed and whether indemnity payment occurred or not. For statistical purposes, only the data from the primary surgeon was analyzed in the study. The number peaked in 1997 with 11 cases and again in 2001, 2003, and 2004 with 13 cases each year. Bettman JW. Federal government websites often end in .gov or .mil. Bethesda, MD 20894, Web Policies The most common complications were elevated intraocular pressure requiring initiation of pressure-lowering medications and development of visual field damage due to elevated intraocular pressure. Vitrectomy with endoscopy for management of retained lens fragments and/or posteriorly dislocated intraocular lens. Light sensitivity after cataract surgery After cataract removal, a little bit of light sensitivity is expected due to dryness in the eye. Whether the findings of this study are representative depends on whether physicians who were covered by the insurance carrier of this study were more or less likely to be sued than physicians who were insured elsewhere. All variables significant at a 10% level in the univariate analyses were included in a multivariate proportional odds regression model. Why do people sue doctors? Time to additional surgical procedures such as vitrectomy was at the discretion of the subspecialist. Development of corneal edema was statistically significantly associated with an indemnity payment but not for a trial. Among the 108 cases, two physicians had multiple claims relating to retained lens fragments, with 2 claims each. Although these findings may cause fear and increased practice of defensive medicine by physicians, better understanding of the incidence, associated factors, and outcomes of medical malpractice claims may result in increased knowledge to the physicians and more effective and improved care to the patients. Because the surgeon ultimately becomes responsible for the outcome of the surgery, it is important to communicate with the anesthesiologist as well as to oversee and proactively troubleshoot any preventable disasters in the operating room.93. Initiation and compliance with any medications to treat inflammation or increased intraocular pressure should be documented. Follow Posted 4 years ago, 24 users are following. Most cases of elevated intraocular pressure can be managed with medication or be resolved with pars plana vitrectomy.2024,2834,50,51 However, there were claimants in this study who required glaucoma surgeries to lower intraocular pressure and others who had suffered permanent visual field loss despite improved visual acuity. As noted already, the majority of claims are dropped, dismissed, or closed without payment. Every year, millions of people have routine surgery to replace a cataract that is, a lens in the eye that has become clouded. On average, a claim took 28.8 21.2 months to close. ESTIMATES FROM THE MULTIVARIATE LOGISTIC REGRESSION MODEL FOR INDEMNITY PAYMENT AMONG CATARACT SURGERIES COMPLICATED BY RETAINED LENS FRAGMENTS. Physicians Insurers Association of America . Baldwin LM, Larson EH, Hart LG, et al. The possible outcomes are assumed to be ordered: Trial with a verdict > Settled > Dismissed and the accompanying P value indicates whether a change in the predictor is associated with a more severe outcome. These transformed variables were used in further analyses. Ways to reduce significant vision loss, including improved management of corneal edema and IOP, and timely referral to a subspecialist should be considered. Of the 12 claims that went on to a trial, there were 5 claims from Illinois, 2 claims from Arizona, and 1 claim each from Colorado, Florida, Kentucky, Rhode Island, and Texas. During the 21 years from 1989 through 2009, OMIC had 937 closed claims related to cataract surgery, and, of these, 117 closed claims from 108 cataract surgeries were related to the cataract surgery complicated by retained or dropped lens fragments. Bessant DA, Sullivan PM, Aylward GW. Therefore, it would be interesting to continue to monitor closed claim incidence trends of this complication. In the current study, closed claims from cataract surgeries complicated by retained lens fragments were evaluated to identify factors that are associated with indemnity payment or resulting in a trial. The patient complained of a black spot with decreased vision 7 months after the cataract and vitrectomy surgery. In the second case, a male patient with advanced posterior subcapsular cataract in the left eye underwent cataract surgery with phacoemulsification in 1996, reportedly without complications. Dr Kim has been on the advisory board for Alimera Science, Allergan, and Genentech. After the trial, the jurors were polled. CF, counting fingers; HM, hand motion; NLP, no light perception. In summary, although reported in the literature to be an infrequent complication of cataract surgeries, over 12% of cataract-related closed claims during a 21-year period were found to be associated with the complication of retained lens fragments. The overwhelming majority of allegations consisted of negligent cataract surgery with or without subsequent complications, followed by delayed diagnosis or referral, and issues related to preoperative discussions such as informed consent. Of these, 937 claims were related to cataract surgery, and 117 closed claims related to cataract surgery were complicated by retained lens fragments. Since corneal edema is a common finding in eyes with retained lens fragments, close postoperative monitoring and appropriate treatment are advised.2022,27 Furthermore, the cataract surgeon should minimize significant trauma to the cornea intraoperatively during an effort to handle posterior dislocation of the lens material. The mean defense costs were significantly lower in cases that were dismissed but were considerably higher in cases that went on to a trial, even when there was no indemnity paid. Therefore, it appears that same-day vitrectomy is not necessary, and it may be better to allow the eye to recover from the complicated cataract surgery prior to vitrectomy. The vitrectomy probe was inserted in an attempt to aspirate the lens, but the lens could not be aspirated to be removed. Among these, the patients sought a second opinion and referred themselves in 3 cases. According to the 2010 report to the OMIC members, approximately 17% of practicing ophthalmologists in the United States are female and 18% of OMIC-insured ophthalmologists are female.17. In: Gonzalez ML, Zhang P, editors. Blodi BA, Flynn HW, Jr, Blodi CF, Folk JC, Daily MJ. In this study, 23 (72%) of 32 cases with indemnity payments had final visual acuity of 20/200 or worse. Kraushar MF. Many are related to retained lens fragments with 108 unique cataract surgeries, 97% against cataract surgeon and You should consult with an attorney in your state as soon as possible. Time limitations apply so be aware of them. Check Avvo for a listing of atto A retinal surgeon who was called into the operating room was able to remove the nucleus using 3-port pars plana vitrectomy. It is important to remember that the eye with retained lens fragments may have significant inflammation not only from the lens material but also from concomitant infectious endophthalmitis.60 Therefore, vigilant follow-up and prompt referral of patients with suspected endophthalmitis is recommended. Whereas indemnity payment is usually associated with all settled claims, claims that go on to a trial may or may not result in an indemnity payment, depending on the verdict. Retained lens fragments after phacoemulsification. In 6 cases, there was documentation that the defendant had operated on the fellow eye of the claimant previously. The value of a cataract surgery lawsuit can vary depending on the severity of the injury, how it was caused, and the amount of medical care and treatment required. ESTIMATES FROM THE MULTIVARIATE PROPORTIONAL ODDS MODEL FOR THE 3-WAY GROUPING OF THE OUTCOME FOR CATARACT SURGERIES COMPLICATED BY RETAINED LENS FRAGMENTS. Among the 3 claims involving retina surgeons, one claim alleged negligent surgery to remove the dropped nucleus and dislocated IOL, which allegedly led to a subsequent retinal detachment. 23-gauge transconjunctival pars plana vitrectomy for removal of retained lens fragments. Sponsored by the American Academy of Ophthalmology, OMIC is the largest professional liability insurer for ophthalmologists in the United States, currently insuring over 4,300 ophthalmologists throughout the 49 states (all states except Wisconsin). Legal outcomes were categorized as those claims resulting in a trial, settlement, or dismissal, and indemnity payment was evaluated for those claims ending in a settlement or in favor of the plaintiff after a trial. Another analysis was performed with the litigation outcomes grouped as (1) indemnity payment and (2) no indemnity payment. In: Gonzalez ML, editor. Claims with referral within 1 week of the complicated cataract surgery had a lower amount of indemnity payment and were more likely to be dismissed. The site is secure. Medical malpractice experiences of vitreoretinal specialists: risk prevention strategies. Learn more These manipulations included use of a lens loop, an attempt at impaling the lens with a microvitreoretinal blade, irrigation to float the lens, and pars plana vitrectomy by the cataract surgeon. If you've suffered an adverse outcome after cataract surgery, you might be wondering if you can or should sue your eye doctor for medical malpractice. This article discusses the most common risks of cataract surgeries, how to prove medical malpractice, and the challenges you will face in a cataract surgery medical malpractice lawsuit. Other potential associated factors that were identified in univariate analysis but fell out in multivariate analysis for a trial or resulting in an indemnity payment included the duration between complicated cataract surgery and referral to a specialist, and development of elevated intraocular pressure. Please reference the Terms of Use and the Supplemental Terms for specific information related to your state. What helps? The estimated incidence of the complication of retained or dropped lens fragment in the literature is 0.1% to 1.6% of cataract surgeries, but in the current study 12.5% of closed claims related to cataract surgery were associated with retained lens fragments. The issue of malpractice has wide-ranging stakeholders, including our society. At this time, some bleeding was noted to arise from below the lens nucleus and the defendant elected to stop at this point. However, how this complication was managed intraoperatively and postoperatively, what degree of injury resulted, as well as how the informed consent was presented preoperatively, will determine whether or not malpractice occurred due to substandard care that resulted in harm to the patient. Funding/Support: Supported in part by an unrestricted grant from Research to Prevent Blindness, Inc, New York, New York (J.K.) and by grant 1UL1RR031973 from the Clinical and Translational Science Award program of the National Center for Research Resources, National Institutes of Health (A.S.). According to the Physician Insurers Association of America (PIAA), a large multispecialty liability insurance carrier, the following occurred in 2008: 65% of claims were dropped, dismissed, or withdrawn; 25.7% were settled; 4.5% were decided by alternative dispute mechanism; and 5% were resolved by trial, with the defendant prevailing in 90% of those tried cases.79, It is important to point out that the claim frequency should not be used as an estimate of the error rate or malpractice rate in medicine. Ho and colleagues37 recommended that cataract surgeons refer patients with retained lens fragments to a retina specialist within 7 days for consideration of a pars plana vitrectomy to decrease the risk of developing secondary glaucoma. 5.3k views Reviewed >2 years ago. One of the ways to reduce the complication of retained lens fragments could be monitoring and reducing the possibility of a sudden patient movement during surgery. Merani R, Hunyor AP, Playfair TJ, et al. The amount of indemnity payment for each grouping of final visual acuity among cataract surgeries complicated by retained lens fragments. Management of dislocated lens fragments following phacoemulsification surgery. WebIt was discovered that a 23-power lens was inserted in the left eye, instead of the intended 20-power lens. An example of one unit change in visual acuity would be going from 20/20 to 20/200. Bohigian GM, Wexler SA. Fastenberg DM, Schwartz PL, Shakin JL, Golub BM. A recent study recommended that the cataract surgeon perform an anterior vitrectomy and place a posterior chamber IOL if possible, prior to referral to a subspecialist in order to achieve better visual outcome.37 Based on the current study findings, it is recommended that the cataract surgeons avoid aggressive intraoperative manipulations to remove retained lens fragment in order to minimize the risk of retinal detachment. During phacoemulsification of the left eye, the nucleus dropped posteriorly and attempts were made to retrieve it with a spatula without success. A steroid drop prescribed by your ophthalmologist can help. Retained nuclear fragment in the anterior segment. Of the 66 claims that were dismissed, Texas had the most claims with 14, followed by Louisiana with 9, California with 8, Illinois with 7, Virginia and Florida each with 4, Kentucky and Colorado each with 3, Arizona, Michigan, and Missouri each with 2, and Alabama, Massachusetts, Nevada, North Carolina, Ohio, Pennsylvania, West Virginia, and Washington, DC, each with one claim. In the multivariate analysis, only the amount of change between preoperative and final visual acuity ( logMAR visual acuity) was found to be statistically significant in predicting more severe legal outcome. Overall, IOL had to be removed, sutured, inserted, or exchanged during pars plana vitrectomy by a retinal specialist in 17 (16%) of 108 cases. Smiddy WE, Guererro JL, Pinto R, Feuer W. Retinal detachment rate after vitrectomy for retained lens material after phacoemulsification. Cheney FW, Posner K, Caplan RA, Ward RJ. In another case, the operative note was the usual macro for standard cataract surgery and did not seem to take into account the problems encountered during the surgery.
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