Risk Management

Negligent Administration of Retrobulbar Anesthesia

Mary Kasher, MSN, JD, OMIC Claims Manager

Digest, Spring 1998

Allegation

Lack of informed consent and negligent administration of retrobulbar anesthesia.

Disposition

Lawsuit dismissed by plaintiff.

Case Summary

A 61-year-old woman with macular degeneration and corrected vision of 20/400 in the right eye had been under the care of the insured ophthalmologist for several years when she presented with complaints that her left eye was losing vision and had dropped to a corrected acuity of 20/80. The insured diagnosed a +3 nuclear sclerotic cataract OS and discussed the pros and cons of cataract surgery with the patient, who decided to put off surgery as long as possible since she relied on her left eye for vision. Shortly before this visit, the patient had been given a new prescription for glasses and instructed to return in six months.

A month later, the patient returned stating she had noticed no improvement with the new glasses and wished to have cataract surgery. She was scheduled for outpatient cataract extraction three days later. In the operating room, retrobulbar anesthesia was administered with no apparent complication. Prior to prepping, however, it was noted that the lids were firm and swollen. The insured performed a lateral canthotomy to relieve the pressure and elected to postpone surgery because of an apparent retrobulbar hemorrhage. The patient remained under observation until the eye stabilized and she could be discharged for follow-up the next day.

At the insured’s office the next morning, the patient’s vision in the left eye was count fingers only. The pupil was mid-dilated and somewhat fixed; the retina revealed signs of hemorrhage and swelling in the macular region. The insured referred the patient to a retina specialist who saw her later that day. Fluorescein angiography showed spotty hemorrhages on the surface of the retina consistent with circulatory compromise. Examination of the macula revealed significant retinal thickening and nerve fiber layer opacification in the presence of a central cherry red spot. The retina specialist’s impression was vascular occlusion on the left with secondary macular ischemia and infarction. The patient did not regain vision in the left eye.

Analysis

At deposition, the plaintiff claimed that the insured failed to warn her of the risks associated with anesthesia injection and that had she been advised of these risks, she would have requested an alternate procedure to “sticking a needle into my eye.” Fortunately, the insured presented chart documentation and consent forms that proved otherwise, and the plaintiff ultimately lost the informed consent argument. Still, the plaintiff’s attorney was able to hold up the needle used in the procedure and with the plaintiff’s own statements demonstrate the visual aversion it creates in a lay person.

The defense produced a strong, charismatic expert who relied upon the insured’s well-documented records and clearly stated diagnosis to refute the plaintiff’s claims. The expert was able to present clinical facts in support of the insured’s decision to use injectable anesthesia and to pinpoint which factors were and were not responsible for the patient’s injury. It was primarily because of this testimony that shortly after OMIC’s expert witness was deposed the plaintiff dismissed the case.

Risk Management Principles

Probably the most difficult aspect of puncture cases is explaining to a lay jury that a needle puncture is a known complication of administering anesthesia when the needle itself looks so ominous and the outcome can be so devastating. It is extremely important that the defense expert be engaging, honest and believable, able to employ scientific facts to support the use of this technique and explain to the jury how it is possible to cause significant damage in the absence of negligence.

As with any malpractice litigation success story, however, the most critical factor is documentation. In this case, the plaintiff attorney was foiled at every juncture with a clearly set forth argument by the defense that was readily supported by the medical record.