Risk Management

Delay in Diagnosis Key to Endophthalmitis Claims

By Kirk H. Packo, MD

Argus, July 1997

Although endophthalmitis is an accepted rare complication of cataract surgery, it remains a common cause of malpractice claims. Of all claims related to retina-vitreous complications of cataract surgery, endophthalmitis heads the list over other problems, such as dropped lens nuclei and IOLs, expulsive hemorrhage, needle perforation, vascular occlusion, and cystoid macular edema. Endophthalmitis claims filed with OMIC over the past 10 years universally were associated with a poor visual outcome. While it is true that a poor visual result following an accepted complication does not automatically imply malpractice, it definitely invites a closer look from a plaintiff’s attorney.

 The Endophthalmitis Vitrectomy Study (EVS), a randomized trial studying the treatment of postoperative bacterial endophthalmitis, showed that management of postcataract infection can result in a reasonable visual outcome. Indeed, 74% of patients managed in the EVS obtained a final visual acuity of 20/100 or better, with 53% achieving 20/40 or better. Still, 26% of patients ultimately ended up with poor final vision, and it is this group that presents the greatest potential liability for the ophthalmologist. (Archives of Ophthalmology, December 1995; 113: 1479-96.)

 Initial Acuity Important Predictor

An important predictor of poor visual outcome for all treatment groups in the EVS was the initial presentation acuity. Eyes with worse initial acuity ultimately ended up with worse final vision regardless of the treatment method employed. One-quarter of the eyes managed in the EVS presented with light perception only vision, and this group as a whole ultimately did worse than the remaining 75% presenting with acuity of hand motion vision or better. It stands to reason that from a risk management standpoint alone, one would want to diagnose and treat patients before they have dropped to the light perception only level. The EVS was set up to compare the efficacy of vitrectomy with injection of intravitreal antibiotics vs. vitreous tap/biopsy alone with injection of intravitreal antibiotics. Vitrectomy was found to be superior to tap/biopsy only in the group presenting with light perception only vision. A less invasive vitreous tap/biopsy was equally effective as vitrectomy for the larger group presenting with hand motion or better initial acuity. The EVS thus demonstrated that a more aggressive vitrectomy procedure should be utilized in light perception only patients which, as previously noted, is the group with the largest potential liability.

Delay in Diagnosis Key

The time delay from onset of symptoms to referral to a retinal specialist also correlated with bad initial acuity. Of patients enrolled in the EVS, 26% presented without pain and another 14% presented without hypopyon, two usual “hallmarks” of endophthalmitis. Delaying the diagnosis, particularly in patients who have no pain or hypopyon, “hoping that the postop inflammation will go away” can have disastrous implications for the patient’s final vision. Most OMIC endophthalmitis claims that have settled with indemnity centered on delay in diagnosis as the key element.

 Many patients enrolled in the EVS had the use of various routes of preop and intraop antibiotics such as topical, subconjunctival, and within the infusion fluid. While the EVS was unfortunately not set up to determine risk factors for endophthalmitis, it is clear that the use of pre- and intraoperative antibiotics does not totally prevent the occurrence of postop infection. Individual surgeons still must establish their own standard of care for the use of prophylactic antibiotics. The EVS has clearly demonstrated, however, that the use of intravenous antibiotics as utilized in the study is unnecessary in the management of post cataract endophthalmitis.

Endophthalmitis is a potentially devastating complication of intraocular surgery. The mere occurrence of endophthalmitis alone, despite its acceptance as a recognized complication of cataract surgery, still may invite an attempted malpractice claim. The key to success in avoiding liability in these cases is to try to obtain the best final visual outcome possible. The EVS has given ophthalmologists several key risk management principles in this regard.