By E. Randy Craven, MD
[Argus, July, 1996]
Patients occasionally experience pupil disfigurement or pain during pupillary contraction as a result of iris trauma during intraocular surgery. Preoperatively, you may be able to predict which patients are most vulnerable to iris damage: older people with a flaccid iris stroma and small pupil. Prior to surgery, however, you should inform all patients that a potential but infrequent complication of intraocular surgery is trauma to the iris (pupil), which may result in pain, disfigurement or visual impairment.
Two OMIC cases demonstrate the importance of this informed consent discussion. In one case, the patient underwent phacoemulsification with a posterior chamber intraocular lens implant. An iris tear occurred during surgery and was repaired with a suture. During postoperative examinations, the patient complained of glare and sun sensitivity, but the surgeon allegedly ignored the complaints. The patient believed these problems were related to the torn iris and claimed the ophthalmologist never informed her prior to surgery of this possible complication. She left this ophthalmologist's care and was seen by another ophthalmologist. A few years later, a YAG laser capsulotomy finally relieved her glare problems. A lawsuit against the first ophthalmologist was settled without an indemnity payment to the patient.
In another case, the patient underwent an extracapsular cataract extraction with a posterior chamber intraocular lens implant. During surgery, the patient had an incomplete block and experienced a great deal of pain, especially at the conclusion of the procedure when the surgeon injected an antibiotic and a steroid. The iris prolapsed a few weeks after surgery and remained disfigured, not adjusting to light as it normally would. The ophthalmologist continued to see the patient a few times postoperatively, but he soon closed his practice and moved to another city. He failed to contact the patient to discuss the transfer of his care to a local ophthalmologist, even though the patient was scheduled for additional visits.
In a lawsuit against the ophthalmologist, the patient alleged that the disfigurement of the iris was related to the surgical pain he experienced and that he had not been informed about the risk of this type of disfigurement. This case settled with a small indemnity payment to the patient.
Both cases illustrate the importance of informing a patient about the possibility of pain, disfigurement, or impaired vision from iris trauma during intraocular surgery, and of properly handling patients who experience a surgery-related complication. You can take technical measures to help avoid iris prolapse, but when a patient's preoperative cosmetic or visual expectations are not met because of iris trauma, it is important to demonstrate compassion and concern. If a lawsuit arises, show that you discussed this complication with the patient prior to surgery.
