Risk Management

Medicolegal Implications of Fluorescein Angiography

By Arthur I. Geltzer, MD

Digest, Spring, 1991

A large number of ophthalmologists consider baseline fluorescein angiography an unnecessary procedure given the threat of serious complication and even fatality, according to an informal survey of 670 retinal specialists. A majority of those surveyed said they would perform a baseline angiography study only if they clinically suspected choroidal neovascularization or diabetic retinopathy.

Survey Response

Problems with fluorescein angiography have come to light in recent years because of malpractice litigation questioning the appropriate timing and initiation of therapeutic measures following fluorescein administration. In 1990, OMIC received responses to a written questionnaire mailed to 1,540 ophthalmologists identified by the American Academy of Ophthalmology as retinal specialists to evaluate their practices and views regarding fluorescein angiography as a diagnostic tool. A relatively high response rate of 42% was obtained by using a simplified questionnaire which did not request a yearly rate computation of complications. Thus, the resulting information is not presented as a scientific study, but rather to provide guidelines to OMIC insureds and the ophthalmic community about the indications, timing and potential risk management issues involved with fluorescein angiography and laser treatment.

Complications Cited

Respondents to the informal poll reported a variety of complications associated with fluorescein angiography including syncope, myocardial infarction/cardiac arrest, skin slough, anaphylaxis, asthma, hypotension, seizures, respiratory arrest, severe Meniere’s attack, and in some cases death.

Given the possibility of serious complications, most respondents indicated they would question performing angiography as a baseline study unless the patient presented with evidence of choroidal neovascularization.

Emergency Capabilities

The presence of a physician in the office during fluorescein angiography appears to be a widely accepted practice among almost all respondents. Those who do not require it are frequently in a hospital setting where emergency medical care is readily accessible. In fact, 96% of respondents reported having emergency capabilities available, the largest consensus in the survey. While most respondents indicated that a certified ophthalmic technician may not be required to perform an angiogram, they do believe the procedure should be supervised by a retinal specialist who is qualified to perform laser therapy if indicated. Most agree that recorded photographs would be very beneficial and should be obtained.

Communicating Test Results

After the clinical diagnosis of choroidal neovascularization in age-related maculopathy is made, a large majority of ophthalmologists polled indicated they would perform an angiogram, communicating the results to the patient and/or referring physician within 72 hours. Because of the potential rapid progression of choroidal neovascularization, most retinal specialists consider laser therapy to be urgent in treatable cases. The ophthalmologist who procrastinates, either in fluorescein diagnosis or therapeutic measures, may face increased liability exposure in addition to potentially increasing the likelihood of a disappointing outcome.

Risk Management Considerations

Since the results of this informal survey are not presented as pure scientific data, they are not intended to suggest a standard of care. However, readers may wish to consider the following risk management implications of this poll:

While fluorescein angiography is an important diagnostic tool for the ophthalmologist, its use as a baseline indicator in diabetic retinopathy or age-related maculopathy may not be appropriate unless the patient shows signs or symptoms of significant diabetic retinopathy, loss of vision, Amsler grid pattern changes or choroidal neovascularization.

As a general rule, a physician should be present in the office during fluorescein administration and emergency equipment should be available, including pharmacologic agents.

Finally, patients who have been clinically diagnosed with choroidal neovascularization should receive prompt treatment by a retinal specialist, including fluorescein angiography and laser therapy if indicated.