Risk Management



Delayed Diagnosis of Endophthalmitis Following Cataract Surgery

Digest, Winter, 1994

ALLEGATION Insured ophthalmologist allegedly delayed diagnosis of endophthalmitis following cataract surgery.

DISPOSITION   Case was settled for $50,000.

Background
Claims against ophthalmologists frequently arise from cataract treatment. Improper performance of surgery is the most common allegation related to the treatment of cataracts followed by failure to recognize and treat a complication of surgery. Careful postoperative evaluation and documentation is crucial for successful defense of these claims.

Case Summary
The patient was an elderly male who presented to the insured’s office for decreased vision in the right eye. V.A. was 20/80 OD with correction. The patient was scheduled for a cataract extraction OD with insertion of a posterior chamber IOL. Surgery proceeded without complication although toward the end of the procedure the ophthalmologist noticed a rent in the inferior posterior capsule. Maxitrol and Pilocarpine drops were instilled.

The patient was doing well on the first day post-op. The record for this visit noted that the vitreous had moved forward to occupy 3/4 of the anterior chamber. The patient was continued on Maxitrol TID and scheduled for another visit in six days. There was no record of visual acuity or a fundus examination on this date. On the third day post-op, the patient called the insured’s office complaining of a very severe sharp pain in the right eye. No record was made of the call. The following day, the patient came to the office complaining of increased discomfort and decreased vision. V.A. was 20/200 OD. 2+ cells and a cloudy vitreous were noted. No fundus examination was documented. The patient was scheduled for another exam the next day by which time the cells had increased to 3+ and were described as being deposited on the posterior cornea. The insured documented a “faint red reflex.” No visual acuity or fundus examination was recorded. When the patient was seen on the sixth day, the record noted that a vitreous tap had been scheduled for the following day. But again, there was no description of an examination or findings to explain why the tap had been scheduled. The insured attempted the vitreous tap but was unable to aspirate despite trying several size needles. Findings in the record noted substantial membranes within the vitreous cavity.

Eight days after the initial surgery, the patient was referred to a retinal-vitreal specialist who diagnosed an endophthalmitis that already had created permanent and extensive damage to the retina.

A culture indicated a bacterial strain sensitive to multiple antibiotics. Although the retinal specialist was able to preserve the eye’s structure, the infection had caused functional loss of the retina. One year after the cataract surgery, the patient’s vision was count fingers at two feet OD.

Outcome

This case presented documentation issues that made it difficult to defend. The insured’s medical record was replete with questionably substandard examinations, inconsistencies and incomplete descriptions of findings. Notes were in the form of computer billing printouts and did not follow chronologically. The insured was criticized by defense experts for not doing a more thorough examination when he noticed the vitreous had moved to occupy 3/4 of the anterior chamber, and in the presence of cloudy vitreous and a “faint red reflex.” Furthermore, the ophthalmologist failed to record visual acuities and to explain why he decided to “proceed with vitreous tap.” When the vitreous tap was unsuccessful, the insured was criticized for not referring the patient immediately to a retinal specialist and for not administering a proper dose of antibiotics in the meantime. Another 24 hours elapsed before the patient was seen by the retinal specialist. Earlier intervention with antibiotic therapy may have saved the eye.

Risk Management Principlesand Commentary

When a claim arises related to a post-op complication, the experts reviewing the case have only the patient’s record to assist them in evaluating whether treatment of the patient was reasonable. An ophthalmologist often will be given the benefit of the doubt by a reviewer if there has been documentation of the reasoning behind certain judgments at critical decision points. Careful documentation alone may not be enough to overcome claims of a delayed diagnosis; however, patently inadequate documentation is likely to raise doubts about whether the treatment met the applicable standard of care.

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