Medical malpractice experiences of vitreoretinal specialists: risk prevention strategies

PURPOSE

To provide ophthalmologists treating patients with vitreoretinal diseases the means by which to improve patient care and risk management.

METHOD

The members of the Macula, Retina, and Vitreous Societies were mailed questionnaires regarding their malpractice litigation experience, and the responses were analyzed.

RESULTS

Rhegmatogenous retinal detachment was the most common presenting diagnosis in these lawsuits. The most frequent modality of management was pars plana vitrectomy (40%). Negligent treatment (surgical or medical) (63%) was alleged more than negligent diagnosis (10%). Decreased vision after treatment (40%), failed surgery (13%), and no improvement in vision (10%) were the most common medical misadventures.

CONCLUSION

Vitreoretinal specialists are at risk for malpractice litigation because a high percentage of the diseases they manage have significant potential for severe visual impairment or blindness and because most vitreoretinal surgery is more complex in nature than general ophthalmic surgery. Rhegmatogenous retinal detachment is the most common presenting diagnosis in most studies on ophthalmic malpractice litigation, and most of these patients are treated by vitreoretinal specialists. Many vitreoretinal patients present for treatment of trauma or failed treatment by another practitioner and may be more prone to litigation. As consultants, vitreoretinal specialists are at risk for being included in lawsuits primarily directed toward other physicians. These risks are a strong indication for a thorough discussion of informed consent and the development of a good physician-patient relationship.

Ocular explosions from periocular anesthetic injections: a clinical, histopathologic, experimental, and biophysical study

OBJECTIVES

An increasing number of cases are being recognized in which a periocular anesthetic for cataract surgery has been inadvertently injected directly into the globe under high pressure until the globe ruptures or "explodes." The objectives of the current study were to (1) analyze this injury clinically and histopathologically through a series of seven case reports; (2) reproduce the injury experimentally in human eyebank eyes, live anesthetized rabbit eyes, and human cadaveric eyes; (3) investigate the biophysical basis of the injury; and (4) outline recommendations to help decrease the risk of ocular rupture with periocular injections. DESIGNS/PARTICIPANTS: Clinical, histopathologic, experimental animal, autopsy eye, and theoretical biophysical study.

METHODS

The clinical and histopathologic findings of the patients' eyes were documented. Human eyebank eyes, live anesthetized rabbit eyes, and human cadaveric eyes were exploded via direct intraocular saline injection. The laws of Bernoulli, LaPlace, Friedenwald, and Pascal were used to investigate theoretically the biophysics of the injury.

RESULTS

The findings of anterior and posterior scleral rupture, retinal detachment, vitreous hemorrhage, and lens extrusion were observed clinically and experimentally. In some clinical and experimental cases, the anterior segment appeared entirely normal despite a posterior rupture. The surgeon proceeded with and completed the cataract surgery in two of the seven clinical cases without knowledge of the rupture. The pressure required to produce such an injury is in the range of 2800 to 6400 mmHg, and this pressure is more easily attained with a 3-ml syringe than with a 12-ml syringe.

CONCLUSIONS

Explosion of an eyeball during the injection of anesthesia for ocular surgery is a devastating injury that may go unrecognized. The probability of an ocular explosion can be minimized by (1) the use of a blunt needle and a 12-ml syringe, (2) aspirating the plunger and wiggling the syringe before injection, (3) discontinuing the injection if corneal edema or resistance to injection is noted, and (4) inspecting the globe for evidence of intraocular injection before ocular massage or placement of a Honan balloon. On recognition of an ocular explosion, immediate referral to and intervention by a vitreoretinal surgeon is optimal.