Risk Management

Untruth and Consequences (Complications of RK Surgery)

 By Karen W. Oxford, MD

Argus, October, 1995

Open and honest communication is the foundation of good patient relations and a prophylaxis against malpractice claims and lawsuits. The following case study illustrates the serious consequences that can result when there is a communication breakdown between ophthalmologist and patient.

Case Study: Bilateral Simultaneous RK Enhancements

A 38-year-old man underwent bilateral simultaneous radial keratotomy (RK) enhancements. Only the right eye was patched after the procedure and on the first postop day, the patient was told by another ophthalmologist that his right cornea had been perforated during the enhancement and the wound was leaking. The original surgeon did not examine the patient postoperatively and had not mentioned the complication to him after the surgery. A technician inserted a collagen shield and the patient was started on hourly Ciloxan.

On the second postop day, the wound continued to leak and cells were noted in the anterior chamber. The ophthalmologist who had examined the patient the previous day informed him of the possibility of infection and administered a subconjunctival antibiotic injection. The patient was sent home with instructions to remove the patch from his right eye after several hours. Upon removing the patch, he looked into the mirror and was shocked to see a large amount of conjunctival swelling and hemorrhage extending over the lower eyelid and covering the lashes.

The patient immediately called the second ophthalmologist’s office and was connected with the answering service. He explained the urgency of his problem and was told that the doctor on call would call him back. An hour later, the on-call doctor finally returned the patient’s second call and told the patient there was nothing he could do for him. He suggested that the patient try to get in touch with the surgeon directly, and then he hung up on him.

Meanwhile, his wife had contacted a fourth ophthalmologist, who examined the patient within 20 minutes of the call and diagnosed a corneal perforation with persistent wound leak and a large subconjunctival fluid accumulation. This ophthalmologist explained the situation to the patient in detail, including the risks, benefits, and alternative treatments for his condition. The patient declined suturing of the wound in hopes that the leak would spontaneously heal. The eye was patched and follow-up was scheduled for the next day.

On postop day three, re-examination by the fourth ophthalmologist showed a persistent wound leak. The physician applied a bandage contact lens and urged the patient to consider having the wound sutured closed. He was given the alternative of contacting his surgeon and having her perform the surgery at no cost since this was a complication of the enhancement procedure.

The patient saw the surgeon later that day in her office. During the examination she stated that the leak was really “just a pinpoint” but that a collagen shield would be placed as a preventive measure. The patient was brought into an operating room in the office and prepped for insertion of the shield. When the patient asked why all of this was necessary since the first collagen shield had been inserted by a technician who had not even washed her hands, the surgeon ignored the question and proceeded to insert the collagen shield. Angry that the ophthalmologist was not addressing the seriousness of his eye condition, the patient refused further patching.

On postop day four, the patient returned to see the fourth ophthalmologist, who noted a persistent wound leak and scheduled the patient for surgery. At the time of the surgery, the wound opening measured 4 millimeters in length and required two sutures to stop the leaking.

Risk Management Commentary

Initially, the surprise element sparked the patient’s anger and frustration. According to the patient, at no time during the informed consent process did the surgeon discuss the possibility of perforation, infection or loss of the eye. Furthermore, when the patient experienced a complication of surgery, this information was withheld from him. The surprise of bad news was further compounded when a third party communicated this information because the surgeon had failed to examine the patient postoperatively. The on-call physician’s failure to respond to the patient in a timely manner only inflamed the situation by adding a sense of abandonment to the patient’s feeling of surprise and anger.

This case might have been handled to the patient’s satisfaction if he had been properly informed of the risks of RK at the outset, and if the surgeon had been truthful about the situation after complications did arise instead of dismissing the patient’s concerns. The untruth led to consequences: The patient called his attorney.