By Jerome W. Bettman Sr., MD
[Argus, April, 1991]
Trauma was the fifth most frequent condition implicated in 700 ophthalmology claims collected over several decades by this author as reported in Ophthalmology (97:1379, 1990). Several medicolegal hazards exist because ocular trauma cases are frequently emergencies. The receptionist may not recognize the need for a timely appointment. The ophthalmologist may fail to do a complete workup or to examine the uninjured eye. Records may be incomplete, making the defense of a claim more difficult.
Furthermore, a patient may expect excellent results despite a very severe injury. A number of claims are filed for no reason other than surprise over a poor result because the patient is not made aware that the prognosis is poor.
Case Study
Failure to diagnose a foreign body accounts for a significant number of trauma-related suits and frequently results when the ophthalmologist relies on one modality such as x-rays. In one such case, a 31-year-old male was seen in an emergency room following an incident in which he hit a metal bar with a sledge hammer and a foreign body struck his right eye. Visual acuity was 20/20 OU and a wound was noted in the sclera in the infero-temporal region. The foreign body was seen on x-ray, localized 4 mm behind the globe, and the patient was discharged.
Four months later, the patient was seen by another ophthalmologist because the eye had become irritated and painful and vision was blurred. A B-scan ultrasound disclosed a foreign body imbedded in the retina. The ERG was abnormal and some siderosis was noted. The patient was hospitalized and the foreign body removed from the ciliary body region. The operation included vitrectomy, cryotherapy, a sponge and encircling buckle. Three-and-a-half years after the injury, a posterior subcapsular cataract was removed from the eye by phacoemulsification with no complications. An IOL was not implanted but visual acuity was corrected to 20/40.
The patient successfully sued the emergency room ophthalmologist and roentgenologist for the missed foreign body. The subsequent ophthalmologist, who extracted the cataract, was sued for not implanting an IOL, but this claim was dropped.
Lessons to be Learned
There are several lessons to be learned from this case:
- More than one modality should be used to diagnose or localize foreign bodies. It is estimated that 20 percent of foreign bodies perforate the globe without significant pain and approximately the same number enter through the sclera. If the foreign body is very small, the entrance wound may not be apparent. None of the siderosis claims reviewed by the author was defensible;
- Contrary to traditional teachings, siderosis is reversible if diagnosed before the ERG is extinguished;
- In cases such as the one cited here, the prognosis is generally poor and the patient should be informed of this. An unpleasant surprise often triggers a suit;
- Cataract patients should be made aware that not everyone is a suitable candidate for an IOL implant.
