Risk Management

Take the Risk Out of Intraocular Surgery in Patients with Corneal Dystrophies

By Dean C. Brick, MD

 Argus, April 1997

Corneal complications of cataract surgery are uncommon and rarely result in professional liability claims. In a recent review of 130 cataract related closed claims from OMIC’s files, only 9 (7%) could be related to corneal complications of cataract surgery. The causes of these claims included corneal edema, corneal burns after phacoemulsification, detached Descemet’s membrane, and corneal ulcers. Of these 9 claims, only 2 (1.5% of total cataract-related claims) resulted in indemnity payments to the plaintiff and, in both cases, the primary cause was not a corneal complication but a surgical complication necessitating a second procedure after which corneal edema developed.

Corneal dystrophies can make visualization during cataract surgery more difficult and result in a higher rate of other complications in these patients. However, despite the frequency of corneal dystrophies in the cataract population, corneal claims are relatively infrequent following cataract surgery. The reason for this dichotomy may be that while most professional liability claims arise because of unexpected outcomes, the findings of a corneal dystrophy are readily visible preoperatively. This allows the ophthalmologist to prepare the patient for possible complications and adverse outcomes and to obtain the proper informed consent, thereby preventing many potential liability suits.

Discuss and Document Preoperative Corneal Findings

While it is not always possible to predict which patients will develop corneal edema or other corneal complications following cataract surgery, the following guidelines may help prevent or mitigate litigation. First, document any corneal findings in the preoperative exam, especially evidence of edema, guttata or other dystrophic changes (such as increased corneal thickness, or pachymetry). Specular microscopy may help document the preoperative condition but is not necessarily a good predictor of endothelial function. If there is evidence of endothelial compromise, make a note in the chart that the increased risks of surgery were discussed with the patient. If you anticipate the possibility of reduced visualization during surgery, discuss this with the patient and document it in the chart.

Second, use your judgment and experience to determine if corneal surgery will be required, and if so, whether it should be performed before, after, or in conjunction with cataract surgery. There are no absolute guidelines because so much depends upon the visual requirements of the patient and other factors unknown preoperatively. If necessary, obtain a second opinion from a cornea specialist or other cataract surgeon.

Use Trusted Surgical Techniques

Third, during surgery, use the techniques you feel will have the least risk of causing further endothelial compromise and document which techniques you used in the operative report; e.g., type of viscoelastic agent or incision used, type of emulsification technique, the use of irrigation or other intraocular drugs, etc. If complications arise during surgery, document your recognition of the complications and the steps taken to minimize their effects. In spite of these precautions, some individuals will unexpectedly develop corneal edema postoperatively. In some instances, this has been traced to preservatives and cleaning solutions retained in the cannulas; therefore, it is imperative that the OR staff notify the ophthalmologist if cleaning procedures are altered and that intraocular medications be used only when necessary.

Finally, if a corneal complication does develop during or after surgery, do not attempt to conceal it from the patient. Discuss it with the patient and obtain a timely consultation from a cornea specialist. Not only does early intervention improve the likelihood of a better outcome, but demonstrating concern for the patient’s welfare can diffuse the anger that leads to litigation.