By Dean C. Brick, MD
Argus, February, 1996
Complications associated with prescribing and fitting contact lenses are a frequent cause of professional liability claims in optometric practice. Although less common in ophthalmic practice, such claims are still cause for concern because these patients are usually young and complications from contact lenses can be severe -- both factors that tend to drive up indemnity payments.
In many ophthalmic practices, the fitting of contact lenses is regarded as a time-consuming, repetitive task that is delegated to an assistant or a technician. While this is certainly acceptable, the ophthalmologist ultimately bears the liability for any injury caused by staff, and therefore should know the risks associated with prescribing and fitting contact lenses and how to avoid them. These include the fitting process itself, informed consent and patient education, and release of contact lens prescriptions.
Establish Rapport with Patients During Fitting Process
Most often, claims result because contact lenses are poorly fitted or poorly tolerated. Although these are usually resolved without an indemnity payment, good patient communication and a caring attitude by the ophthalmologist and staff may prevent many of these claims.
Another common complaint, eye infections resulting from the fitting procedure, can be avoided by having a documented routine in place that requires all personnel who fit non-disposable trial lenses to clean and sterilize them after each use and to make a point of washing their hands in the patient's presence before handling or inserting lenses. This both reassures the patient that office personnel are careful about cleanliness and emphasizes the importance of cleanliness when patients handle their own lenses.
At the end of the fitting and dispensing session, document in the chart the status of the cornea and the fit of the lens to help prevent later claims of damage during the fitting procedure or from an ill-fitting lens.
Inform Patients of Keratitis Risk
Infectious keratitis poses the most serious threat to the contact lens wearer and the greatest risk to the fitting or dispensing ophthalmologist. Luckily, these claims are rare and can usually be prevented with proper informed consent and patient education. If an ophthalmic assistant carries out these functions, he or she should be formally trained in the fitting and dispensing of contact lenses and well versed in performing and documenting the informed consent process.
Documentation should state that the risks and benefits of contact lenses were discussed, cleaning and sterilizing the lenses were emphasized, and the patient was advised to use only commercial contact lens solution and never tap or distilled water. Explain the signs and symptoms of keratitis and, if extended wear lenses are being fitted, document that the patient was told of the increased risk of keratitis with these lenses. The chart documentation may be a written or stamped note, or a note indicating the patient received an information handout.
Finally, explain and document in the chart any abnormalities of the eye that may indicate an increased risk to the patient, and schedule a return appointment. Guidelines for the frequency of follow-up appointments are set out in the Academy's Preferred Practice Pattern, Low To Moderate Refractive Errors.
Know Your State's Laws Governing Release of Prescriptions
State laws vary on releasing a prescription to a patient who requests it. Check with your state medical board.
Generally, if an ophthalmologist gives a patient a prescription for a contact lens that includes the type of lens, material, power and lens specifications, and the patient has the prescription filled by a third-party dispenser, the ophthalmologist still may be held liable for complications related to that lens. Under these circumstances, the ophthalmologist should educate the patient about the difference between a contact lens prescription and a fitting, and the need for instructions and follow-up. If the ophthalmologist only supplies refractive data and corneal measurements, he or she generally will not be held responsible for the fit or performance of a contact lens fit from that data.
OMIC's Risk Management Committee has developed sample letters for ophthalmologists to send to patients who request their contact lens prescription. To receive a copy, fax your request to OMIC's Risk Management Department, 415-771-7087.
