By Oksana Mensheha, MD
[Argus, August, 1991]
It is estimated that approximately 25 million people in the United States wear contact lenses. Historically, ophthalmologists were cautious in prescribing this modality to correct refractive errors; they feared that hard lenses might cause possible damage to the eye. We now know that severe side effects rarely occur. But when they do, they may be quite serious and could theoretically lead to liability actions.
With so many people wearing contacts, familiarity sometimes leads to carelessness. This is particularly true of younger patients. As myopes under the age of 14 move into contact lens wear, there is a greater possibility for complications. Liability for contact lens fitting in children also is greater since children maintain a longer time period during which they can bring a suit against a physician. Parental consent should always be obtained before fitting patients under 18.
One of the primary risk management issues in contact lens fittings relates to the physician's duty to disclose potential risks and alternatives. Side effects of contact lens wear differ for rigid and soft lenses. Problems with rigid lenses may include intolerance, corneal edema with ulceration, blurred vision due to poor wetting, keratoconus from lens warpage, irritation from chipped or broken lenses, corneal flattening, and an inability to see well with glasses. Problems with soft lenses may include irritation from solutions or protein build-up, giant papillary conjunctivitis and, rarely, severe and potentially blinding corneal infections such as those caused by Endamoeba histolytica.
One way to reduce potential liability exposure is through increased patient education activities. Infections complicating contact lens wear usually occur from a breakdown in hygiene. Hand washing must be carefully taught, and the use of sterile solutions to disinfect or clean lenses is a must. Enzyme tablets, for example, are to be dissolved only in sterile solutions, preferably in aerosol form, not in unsterile tap water nor in bottled distilled water.
To aid your patient and to protect yourself, be sure to provide each new contact lens wearer with written information on the risks and care of contact lenses. Personally instruct each patient about the hygiene of contact lens care and, before the lenses are purchased, explain the cost of fitting. Stress the need for routine follow-up care on a regular basis. It is of critical importance that you document in the patient's record that such information was given. Some ophthalmologists have even developed an informed consent sheet that their contact lens patients must sign. Documentation-related problems continue to be the single most significant risk management concern in ophthalmic malpractice claims.
Infections from contact lenses have been shown to be a greater problem with all soft lenses, but particularly with extended wear lenses. Disposable lenses have not decreased this risk. Again, the risk here is greater for children who are more active, tend to play in a more contaminated environment, and are less likely to practice good hygiene with their lenses.
Patient anger and poor physician-patient communications contributed to one OMIC malpractice claim involving contact lens fitting. Although the patient was unable to wear her contact lenses, she was aggressively pursued for collection of the final portion of her bill. Communication between the ophthalmologist and patient broke down, and the patient felt her only recourse to get her doctor's attention was to sue. A few patients do not tolerate contact lenses well even when they are fitted properly. Such cases are disappointing to both the doctor and the patient. The resolution of charges for unsuccessful results should be approached with kindness and compassion.
As a general rule, contact lens wear is popular and appreciated by many patients. Ophthalmologists should nonetheless be sensitive to those areas of potential liability relating to prescribing and fitting contact lenses. Communication with patients, disclosure of risks and alternatives, emphasis on proper hygiene and follow-up care, plus a compassionate approach to the problems of contact lens wear help lower physician liability and contribute to improving long-term patient-physician rapport.
