Of the 12 claims that went on to a trial, there were 5 claims from Illinois, 2 claims from Arizona, and 1 claim each from Colorado, Florida, Kentucky, Rhode Island, and Texas. The retina specialist confirmed that the IOL was well positioned without vitreous in the anterior segment. In one case, the surgical technician failed to securely attach the cystotome to the needle, and the cystotome shot off during injection of the viscoelastic material. The mean defense cost for 12 cases that went on to a trial was $96,464 with a mean defense cost of $97,924 for cases with a defense verdict and $95,004 for cases with a plaintiff verdict; the mean expense for claims that were dismissed was $9,226. Studdert DM, Mello MM, Gawande AA, et al. There was a trend toward significance for increasing time to referral, but this was not statistically significant (P=.053). If these cases are excluded, there was a mean of 1.5 return visits to the operating room among 94 patients who had additional surgical procedures. Claims were excluded when found not to pertain to retained lens fragments but were due to dislocated intraocular lens (IOL), wrong intraocular lens, endophthalmitis, or retinal detachment following cataract surgery. The mean defense costs were significantly lower in cases that were dismissed but were considerably higher in cases that went on to a trial, even when there was no indemnity paid. Financial Disclosures: Mr Weber is an employee of Ophthalmic Mutual Insurance Company. WebAllegation Wrong power IOL insertion led to complicated lens exchange surgery. If you have experienced complications after cataract surgery because of surgical error, consult with the St. Louis surgical error attorneys at Zevan and Davidson Law Firm, LLC at (314) 588-7200. Whereas the majority of claims were dismissed, claims associated with greater visual acuity decline, corneal edema, or elevated IOP were more likely to result in a trial or payment. Rosenbaum JT, Samples JR, Seymour B, Langlois L, David L. Chemotactic activity of lens proteins and the pathogenesis of phacolytic glaucoma. Closed claims data related to cataract surgeries complicated by retained lens fragments (1989 through 2009) from an ophthalmic insurance carrier were reviewed. Although the final visual acuity was important, the most important factor associated with going to a trial or resulting in an indemnity payment was found to be the amount of visual acuity loss following cataract surgery complicated by retained lens fragments, such that the greater the difference between the baseline visual acuity and the final visual acuity, the greater the likelihood of a claim resulting in a trial or indemnity payment. Of the 108 physician defendants, 94 (87%) were men and 14 (13%) were women. Through highlighting circumstances of pertinent claims and identifying factors associated with malpractice claims resulting in an indemnity payment or going to a trial, this current study sought to ascertain steps that can be taken by ophthalmologists to improve patient care and safety as well as assist in risk management when cataract surgery is complicated by retained lens fragments. Whereas indemnity payment is usually associated with all settled claims, claims that go on to a trial may or may not result in an indemnity payment, depending on the verdict. Furthermore, there was a wide variation in the size of indemnity payment (payment to a plaintiff) across specialties, and the specialties that were most likely to face indemnity claims were often not those with the highest average payments.5 For example, pediatrics was 24th among 25 specialties with regard to proportion of physicians facing a malpractice claim annually, but it had the highest mean amount of indemnity payment. The .gov means its official. Kim JE, Flynn HW, Jr, Smiddy WE, et al. The difference between the preoperative visual acuity and the final visual acuity was predictive of an indemnity payment (odds ratio [OR], 2.28; P=.001) and going to a trial (OR, 2.93; P<.001). Claims from Florida were evenly split between those closing with an indemnity payment and those with no payment, whereas the overwhelming majority of claims from Louisiana ended with a dismissal and no payment. The negligent act must be a proximate cause of the plaintiffs injuries, which means the act was necessary for the injury when and in the manner it occurred, and the injury must be a foreseeable consequence of the negligent act. The aims of this study were to evaluate the medical malpractice claims resulting from the retained lens fragments during cataract surgery and to identify ways to improve patient outcomes. The verdict was 6 for plaintiff and 2 for defendant. AC IOL, anterior intraocular lens; OD, right eye; OMIC, Ophthalmic Mutual Insurance Company; OS, left eye; PC IOL, posterior intraocular lens; VA, visual acuity. Time to additional surgical procedures such as vitrectomy was at the discretion of the subspecialist. In 11 eyes, the operated eye was the better eye. The documentation includes informed consent, office examination notes, operative notes, any conversation with the patient before or after the cataract surgery, as well as any discussions with a specialist. Vitrectomy with endoscopy for management of retained lens fragments and/or posteriorly dislocated intraocular lens. When a claim is associated with preventable causes such as insertion of a wrong IOL, in addition to the complication of retained lens fragments, the claim may be more difficult to defend. The items collected during the review of the claims are listed in Table 1. In: Gonzalez ML, Zhang P, editors. The attorney listings on this site are paid attorney advertising. The first categorization was needed to evaluate legal costs incurred for each category of legal outcomes. Scott IU, Flynn HW, Jr, Smiddy WE, et al. Yet three or four years ago, UCLA surgeons Acuity improved to 20/200, but eventually the eye became phthisical with light perception vision at 19 months after the initial cataract surgery. Arbisser LB, Charles S, Howcroft M, Werner L. Management of vitreous loss and dropped nucleus during cataract surgery. Of the 108 defendants, 105 (97%) were cataract surgeons and only 3 (3%) were retinal surgeons. Baldwin LM, Larson EH, Hart LG, et al. Blodi BA, Flynn HW, Jr, Blodi CF, Folk JC, Daily MJ. However, optimal timing of vitrectomy is unknown, and the effect of vitrectomy timing on clinical outcomes has been highly controversial.2041,74,78 Therefore, there is currently no clarity in best time to refer to a specialist in cases of cataract surgeries complicated by retained lens fragment or the time between referral to vitrectomy. Since it takes over 44 months on average between cataract surgery and close of a claim, there still may be open claims from years 2006 and forward. An example of one unit change in visual acuity would be going from 20/20 to 20/200. Federal government websites often end in .gov or .mil. However, the patient did not show up for appointments, despite being sent no show letters. The majority of eyes developed one or more ocular complications following surgery, many of which contributed to poor visual outcome. If a surgeon and the hospital or the practice (entity) were named in the claim, only the surgeons data was analyzed to avoid duplicity. Duty to treat means that a doctor-patient relationship must be established prior to the alleged negligent act. The number of claims per 100 physicians was more than 5 times greater for general surgeons and obstetricians and gynecologists than it was for pediatricians and psychiatrists. All variables significant in the univariate analyses were included in a multivariate logistic regression model. WebIt was discovered that a 23-power lens was inserted in the left eye, instead of the intended 20-power lens. These are a miniscule fraction of the tens of millions of cataract surgeries performed over the same period. Mean change in visual acuity between preoperative visual acuity and final visual acuity for all patients was a worsening of 2 lines. The patient complained of a black spot with decreased vision 7 months after the cataract and vitrectomy surgery. Although documentation of informed consent does not prevent a malpractice claim, a better informed decision process may set realistic expectations by a patient, and presence of an appropriate informed consent is crucial when there is a malpractice claim. This study was not designed to answer whether claims resulted from lack of adherence to practice guidelines or standard of care. Review of claims data in this study found that those claims with poor documentation were deemed more difficult to defend by the defense experts. When there was a trial, the verdict was likely to be in favor of the defendant, similar to most malpractice claims. More than 50% of obstetricians and gynecologists have already been sued before they reached the age of 40 years, and 90% of general surgeons aged 55 years and older have been sued. The patient refused laser treatment for vitreolysis. Mean final visual acuity was 20/200 (range, 20/20 to no light perception). Another study found that 7.4% of all physicians had a malpractice claim each year, with 1.6% having a claim leading to a payment.5 The proportion of physicians facing a claim each year ranged from 2.6% in psychiatry to 19.1% in neurosurgery. Management of dislocated lens fragments following phacoemulsification surgery. These transformed variables were used in further analyses. Pars plana vitrectomy in the management of retained intravitreal lens fragments after cataract surgery. Among the 3 claims involving retina surgeons, one claim alleged negligent surgery to remove the dropped nucleus and dislocated IOL, which allegedly led to a subsequent retinal detachment. For those claims with greater than 2 logMAR worsening in visual acuity, 62% resulted in an indemnity payment averaging $158,500. Lifshitz T, Levy J. Posterior assisted levitation: long-term follow-up data. Kane CK. Holak sued Tyson and Eye Associates. 8600 Rockville Pike The technical lens was suppose to give me even better vision in the right eye. National costs of the medical liability system. In addition to the review of the closed claim cases related to the complication of retained lens fragments, other data that were thought to be relevant to the study were obtained from OMIC and analyzed for comparison with the findings from this study. The time between the date of cataract surgery and the date of reporting by the insured to OMIC regarding litigation was a mean of 15.5 8.7 months. Furthermore, they estimated that an additional $45.59 billion was spent on defensive medicine, most of which went to pay for tests, procedures, and treatments associated with defensive medicine. This is without adjustment for potential differences in dollar amount due to inflationary changes. In some categories of data, not all data points were available, and those are indicated in the appropriate tables. Clinical features and outcomes of pars plana vitrectomy in patients with retained lens fragments. 5.3k views Reviewed >2 years ago. CF, counting fingers; HM, hand motions; LP, light perception; MVR, microvitreoretinal; NLP, no light perception; PPL, pars plana lensectomy; PPV, pars plana vitrectomy; RD, retinal detachment; VA, visual acuity. Tackling the dropped nucleus. Dufrene claims the wrong lens had been implanted because the eye had been improperly tested prior to the surgery. and transmitted securely. All variables significant at a 10% level in the univariate analyses were included in a multivariate proportional odds regression model. Start here to find personal injury lawyers near you. However, the majority of the claims were dismissed and did not result in an indemnity payment. The frequency of claims related to retained lens fragments compared to the number of policyholders for each year from 1989 through 2009. Learn more Lal H, Sethi A, Bageja S, Popli J. Chopstick technique for nucleus removal in an impending dropped nucleus. This may reflect bias in reporting surgical cases in the literature related to this complication or tendency toward legal actions when the patient feels not enough was done with observation alone. The mean and median indemnity payments for this group of claims were similar to mean and median of all ophthalmology-related claims combined for this single specialty insurance company. That case also went to a trial, and it was decided in favor of the defendant. Most previous studies on malpractice claims compared only the groups that went on to indemnity payment vs no payment. Your use of this website constitutes acceptance of the Terms of Use, Supplemental Terms, Privacy Policy and Cookie Policy. In the first case, the cataract surgery was performed in 1989. Kim IK, Miller JW. From 1989 through December 2009, OMIC had a total of 2,854 closed claims. Every year, millions of people have routine surgery to replace a cataract that is, a lens in the eye that has become clouded. The overwhelming majority of the referrals were to a retina specialist, but referrals also included cornea and glaucoma specialists. Kraushar MF, Turner M. Medical malpractice litigation in ophthalmology: the New Jersey experience. In this analysis, the following factors were found to be statistically significant for more severe legal outcome: logMAR preoperative visual acuity, logMAR final visual acuity, preoperative to postoperative change in logMAR visual acuity, development of glaucoma or elevated intraocular pressure, time to referral, and the duration between opening and closing of a case. Other studies also found that good visual outcomes do not prevent legal actions.10,92. The final visual acuity for claims resulting in indemnity payment vs no payment is shown in Figure 5. The current study is not inclusive of all claims related to retained lens fragments in the United States that occurred during the study period. Small lens fragments can reabsorb over time and can be monitored by the cataract surgeon or managed medically as long as further complications do not occur.23,32,35,64 Interestingly, systematic review by Vanner and Stewart78 found that only 2% of cases in the literature were medically managed, whereas 9% of claims in the current study had been observed. Most people may get benefited from an IOL transplant during surgery. A retinal surgeon who was called into the operating room was able to remove the nucleus using 3-port pars plana vitrectomy. Retained nuclear fragments in the anterior chamber after phacoemulsification with an intact posterior capsule. A recent study recommended that the cataract surgeon perform an anterior vitrectomy and place a posterior chamber IOL if possible, prior to referral to a subspecialist in order to achieve better visual outcome.37 Based on the current study findings, it is recommended that the cataract surgeons avoid aggressive intraoperative manipulations to remove retained lens fragment in order to minimize the risk of retinal detachment. Each claim was counted separately as a unique case. Kim JE, Flynn HW, Jr, Rubsamen PE, Murray TG, Davis JL, Smiddy WE. Characteristics of physicians with obstetric malpractice claims experience. In this study, 23 (72%) of 32 cases with indemnity payments had final visual acuity of 20/200 or worse. Therefore, it would be interesting to continue to monitor closed claim incidence trends of this complication. What is the recovery after cataract or lens replacement surgery? Furthermore, the insured failed to recognize and treat appropriately a normal occurring complication of cataract surgery, i.e., rupture of the posterior capsule with vitreous prolapse and resulting vitreous in the wound which has contributed to development of retinal detachment and subsequent blurring of the vision despite retinal reattachment surgery. Trial with a verdict was assumed to be a more severe outcome than settled, since historically longer duration between opening and closing of a claim and higher costs are associated with trials compared to settled claims. Dr. Poole performed cataract surgery on DeFrankos eyes over the course of one month. Mello MM, Chandra A, Gawande AA, Studdert DM. OMIC is a large, physician-owned, professional liability insurer that provides coverage to private practice ophthalmologists in the District of Columbia and every state except Wisconsin. Four patients declined any further surgery. To review malpractice claims associated with retained lens fragments during cataract surgery to identify ways to improve patient outcomes. WebSurgery for cataracts involves removing the cataract-ridden lens of the eye and either replacing it with an artificial lens called an IOL implant or compensating for its absence with eyeglasses or contact lenses. Bricks study on cataract surgery claims also recommends earlier referral if there was a potential for retinal complications.10. When evaluated for indemnity payment or no payment, the male-to-female physician ratios were 27:5 and 66:9, respectively. This is understandable, since the impact of poor final visual acuity would be greater for the patients who began with a reasonably good baseline visual acuity, and the degree of dissatisfaction would be greater as well. Their analysis also found that vitrectomy on the same day and up to 2 days after the cataract surgery had poorer visual outcome. Bhan A, Dave D, Vernon SA, Bhan K, Bhargava J, Goodwin H, Medical Defense Union; Medical Protection Society; Medical and Dental Defense Union of Scotland Risk management strategies following analysis of cataract negligence claims. Cases to be included in the study were identified based on OMIC coding for claims resulting from complications related to cataract surgery. Development of corneal edema was associated with an indemnity payment (OR, 3.50; P=.037). On average, a claim took 28.8 21.2 months to close. Fastenberg DM, Schwartz PL, Shakin JL, Golub BM. Claims data from the Ophthalmic Mutual Insurance Company (OMIC) represent a unique opportunity to examine the medicolegal risks associated with ophthalmology. If a physician had multiple claims from separate cataract surgeries, each was counted separately. Both univariate analyses and multivariate analyses were performed using data collected for possible outcomes or final disposition of the claim. The The average cataract surgery settlement was for $192,865. These manipulations included use of a lens loop, an attempt at impaling the lens with a microvitreoretinal blade, irrigation to float the lens, and pars plana vitrectomy by the cataract surgeon. A cataract is a clouding of the natural lens inside the eye due to many different causes, like aging, toxic exposures, or injury. Those with valid cataract surgery malpractice Although there were no cases involving residents, there was one claim against a policyholder ophthalmologist who was overseeing a colleagues attempt at learning cataract surgery. Management of nucleus loss into the vitreous: long term follow up in 63 patients. Medical malpractice predictors and risk factors for ophthalmologists performing LASIK and PRK surgery. Socioeconomic Characteristics of Medical Practice 1990/1991. In 7 cases, the cataract surgeon documented an intraoperative attempt at retrieval of the lens fragment (Table 2). DESCRIPTIVE STATISTICS OF THE ANALYSIS VARIABLES GROUPED BY WHETHER INDEMNITY WAS PAID. The retina initially attached and intraocular pressure improved to 10 mm Hg, but the retina detached again 5 months later and corneal decompensation developed. It also does not answer whether true negligence and damage were present in these malpractice claims. The defense expert stated that (1) it is unclear as to when the vitreous prolapsed, since it was not noted at the time of postoperative examinations by the cataract surgeon or even by the retina specialist at the initial consultation, (2) the standard of care does not require that every rupture of the posterior capsule be recognized, and (3) following treatment for the retinal detachment, the patient attained a visual acuity of 20/25, which indicated a successful management of this complication. Schwartz SG, Holz ER, Mieler WF, Kuhl DP. 0 likes, 62 replies Report / Delete New discussion Reply 62 Replies Once an insured becomes aware that a wrong site surgery or incorrect power iOL insertion has occurred, the incident should be reported to OMICs Claims Department or confidential Risk Management hotline at (800) 562-6642, option 2 Review of the literature indicates that complications associated with retained lens material include inflammation, corneal edema, elevated intraocular pressure, hypotony, subluxation or dislocation of IOL, retinal tears or detachments, vitreous hemorrhage, choroidal hemorrhage, cystoid macular edema, epiretinal membrane, and endophthalmitis. how badly you were actually hurt and how much that injury actually cost you in medical expenses, lost wages, diminished quality of life, etc. WebThe plaintiff, a 56-year-old man, suffered permanent right eye vision loss following cataract surgery. AC IOL, anterior chamber intraocular lens; IOP, intraocular pressure; PC IOL, posterior chamber intraocular lens; VA, visual acuity. Retained intravitreal lens fragments after cataract surgery. From the Department of Ophthalmology (Dr Kim) and the Division of Biostatistics (Dr Szabo), Medical College of Wisconsin, Milwaukee,Wisconsin, and Ophthalmic Mutual Insurance Company, San Francisco, California (Mr Weber). Benson JS, Coogan CL. In one of the claims, the cataract surgeon, who had some retinal training, attempted retrieval of the posteriorly dislocated lens material. Por YM, Chee SP. The estimated incidence of the complication of retained or dropped lens fragment in the literature is 0.1% to 1.6% of cataract surgeries, but in the current study 12.5% of closed claims related to cataract surgery were associated with retained lens fragments. An anterior vitrectomy was performed. The complication of capsular tear and retained lens fragments was further aggravated by development of corneal wound dehiscence, corneal ulcer, and endophthalmitis. The distribution of the number of closed claims related to the complication of retained lens fragments per year from 1989 through December 2009 is shown in Figure 2. When the complication of a retained lens fragment has been encountered, the cataract surgeon should closely follow the patient and monitor for complications associated with retained lens fragment and consider timely referral to a specialist for management of further complications that may contribute to poor visual acuity outcomes. If a surgeon who had some retinal training was deemed not specialized enough to manage such a case, it may be best for most cataract surgeons to seek expertise of a retina specialist and avoid aggressive retrieval. Because the surgeon ultimately becomes responsible for the outcome of the surgery, it is important to communicate with the anesthesiologist as well as to oversee and proactively troubleshoot any preventable disasters in the operating room.93. Physician surveys and actuarial data show that one risk factor for lawsuit is the area of specialty, where surgeons, obstetricians, and gynecologists are sued more often than physicians from nonsurgical specialties.25,82 Other studies have shown that the claim frequencies increase with increasing age of the physician, physicians with higher clinical activity, male gender, a previous claims history, and higher frequency of patient complaints. Furthermore, certain eyes are known to have an increased risk for developing this complication, including eyes with prior trauma, pseudoexfoliation, dense cataract, and history of having had prior vitrectomy surgery.42,49 Therefore, additional care should be taken during the cataract surgery in these eyes. 4,11,79,8385 Medical liability claims are more common among older physicians than among young, yet inexperienced, physicians, because the older physicians have been in practice for a longer period of time and have had greater exposure to the possibility of claims. Of the 108 defendants, 105 (97%) were cataract surgeons and only 3 (3%) were retinal surgeons. Although there were no cases involving residents, there was one claim against a policyholder ophthalmologist who was overseeing a colleagues attempt at learning cataract surgery. When the complication resulted in a claim, there was an average of 15.5 months between the cataract surgery and opening of the case by the insurance company, which was soon after the insureds notification of being served with the litigation paper. Among the 108 claims, 107 claims had a record of which eye was operated on; 42 cases (39%) involved the right eye and 65 (61%) involved the left eye. The patient was referred the same day as the complicated cataract surgery to the retina specialist, who performed pars plana vitrectomy on the following day without any complications. Final visual acuity was the last recorded visual acuity. Previous studies have shown that useful information can be gained from evaluation of malpractice claims data.3,515 However, most of the previous studies that estimated specialty-specific malpractice risk from actual claims data are not recent, and only a handful of studies specifically address the specialty of ophthalmology.516 In the most recently published study, Jena and colleagues5 analyzed closed malpractice claims for 40,916 physicians who were covered for at least one policy year from 1991 through 2005, including 807 ophthalmologists insured during the study period. For cataract surgery litigation, 119 cases (21 percent) led to settlements, totaling $22.9 million. Available at: Slora EJ, Gonzales ML. The patient was released to a general ophthalmologist. Distribution of closed claims related to retained lens fragments by region in the United States. sharing sensitive information, make sure youre on a federal Management of retained intravitreal lens fragments after phacoemulsification surgery. CLAIMS WITH INDEMNITY PAYMENT BY FINAL VISUAL ACUITY AND CHANGE IN VISUAL ACUITY AMONG CATARACT SURGERIES COMPLICATED BY RETAINED LENS FRAGMENTS. Therefore, appropriate management of elevated intraocular pressure is necessary to reduce poor patient outcome. This study is limited to those claims from a single insurer, which may not be nationally representative, although it is one of the largest insurers of ophthalmologists in the United States. Of these cases, 11% went to trial, 28% settled, and 61% were dismissed. 19851989. A study based on a survey of retina specialists recommended that vitreoretinal surgeons should place an increased importance on the informed consent process and the patient/doctor relationship in order to improve risk management.16 Informed consent is a process rather than a form. Even when an IOL was initially placed at the time of complicated cataract surgery, subsequent dislocation of IOL occurred in 6 cases. In a study by Mello and colleagues, 95 the investigators broke down the costs of malpractice for the United States in 2008 as follows: indemnity payments of $5.72 billion and administrative expenses of $4.13 billion, which included $1.09 billion in fees to defense attorneys and $3.04 billion in overhead expenses. If you've suffered an adverse outcome after cataract surgery, you might be wondering if you can or should sue your eye doctor for medical malpractice. The number of ophthalmologists being insured by OMIC grew steadily from 1,027 in 1989 to 4,107 in 2009 (Figure 1). 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