In comparison, 30% of 108 claims related to retained lens fragments resulted in an indemnity payment with an average payment of $117,688. Immediate pars plana vitrectomy improves outcome in retained intravitreal lens fragments after phacoemulsification. Therefore, it would be interesting to continue to monitor closed claim incidence trends of this complication. Therefore, claims related to cataract surgery accounted for 33% of all closed claims during this period, and cataract surgeries complicated by retained lens fragments accounted for 4% of all closed claims and 12.5% of cataract-related claims. Closed claims data related to cataract surgeries complicated by retained lens fragments (1989 through 2009) from an ophthalmic insurance carrier were reviewed. Bohigian GM, Wexler SA. The first case closed in 1992 for $125,000, and the second case closed in 2002 for $250,000. 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. An example of one unit change in visual acuity would be going from 20/20 to 20/200. Accounting for these factors, there were 108 unique cataract surgeries that met the inclusion criteria and were the basis for the current analyses. Clinical predictors and outcomes of pars plana vitrectomy for retained lens material after cataract extraction. ESTIMATES FROM THE MULTIVARIATE LOGISTIC REGRESSION MODEL FOR INDEMNITY PAYMENT AMONG CATARACT SURGERIES COMPLICATED BY RETAINED LENS FRAGMENTS. 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. Lu H, Jiang YR, Grabow HB. He was referred to a retina specialist, who saw him the next day. Medical malpractice predictors and risk factors for ophthalmologists performing LASIK and PRK surgery. Breach of duty occurs when the physician fails to follow the standard of care for the patients condition. They ranged from a low of $7,500 to a high of $500,000. Stenkula S, Byhr E, Crafoord S, et al. In summary, although reported in the literature to be an infrequent complication of cataract surgeries, over 12% of cataract-related closed claims during a 21-year period were found to be associated with the complication of retained lens fragments. Intraocular lens was implanted in 85 (90%) of 94 cases where this was recorded, with 63 (67%) being posterior chamber IOL and 22 (23%) being anterior chamber IOL. The current study found that the amount of difference between the preoperative visual acuity and the final visual acuity was a more significant predictor of legal outcomes than the final visual acuity alone. Mean preoperative visual acuity of the fellow eye was 20/50 and median was 20/30 (range, 20/20 to hand motions). Additional categorization and analyses were performed in this study to include claims outcomes of trial vs settlement vs dismissal in hopes of gaining additional information, such as legal expenses that may differ for these groupings, as well as to highlight factors associated with claims that result in a verdict for the plaintiff vs that for the defendant when there was a trial. Management of nucleus loss into the vitreous: long term follow up in 63 patients. 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 The remaining 76 claims (70%) closed without any payments. Accessibility Most people may get benefited from an IOL transplant during surgery. Retained nuclear fragments in the anterior chamber after phacoemulsification with an intact posterior capsule. Since the number of OMIC-insured ophthalmologists continued to grow each year over this 21-year period, the frequency of closed claims related to retained lens fragments relative to the total number of physicians insured per year was actually the highest in 1997 (Figure 3). Overall, IOL had to be removed, sutured, inserted, or exchanged during pars plana vitrectomy by a retinal specialist in 17 (16%) of 108 cases. The most common risks are: Although you may have experienced an unexpected outcome, even a severe injury, that does not mean medical malpractice is necessarily the cause. Four patients declined any further surgery. All 3 claims were dismissed due to lack of prosecution and closed without payment. Most previous studies on malpractice claims compared only the groups that went on to indemnity payment vs no payment. Total cost of defense for all 108 claims was $3,312,688. Vitrectomy for retained lens fragments after phacoemulsification. The items collected during the review of the claims are listed in Table 1. However, the majority of the claims were dismissed and did not result in an indemnity payment. The estimates show the odds ratio of being in a more severe category as opposed to less severe category when the predictor is changed by one unit; for categorical variables (corneal edema and elevated intraocular pressure), it means a change from the unlisted group to the listed one, whereas for continuous variables (visual acuity and time to referral), it means an increase in one unit. For cataract surgery litigation, 119 cases (21 percent) led to settlements, totaling $22.9 million. HHS Vulnerability Disclosure, Help Teo L, Chee SP. A new trial and correction of the amount of verdict and judgment were all denied by the trial judge. official website and that any information you provide is encrypted Vanner EA, Stewart MW. 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. Only the claims that closed by December 2009 were included. Dr. did correction surgery (for free) after finding and admitting his error. Furthermore, these malpractice claims data can be used to identify ways to improve patient safety, develop risk management programs, and provide an excellent opportunity to enhance patient care related to an ophthalmic subspecialty or an ophthalmic procedure. 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). Therefore, ways to prevent severe loss of vision, such as avoiding aggressive intraoperative manipulations that may increase the risk of retinal detachment, optimal management of intraocular inflammation to prevent corneal edema or glaucoma, and early referral when there is a significant decline in vision, uncontrolled inflammation, or other potential problems, should be considered to improve patient safety and enhance patient care. i'm sorry to read of your troubles and I know enough as a practicing physician for 20 years that your course has deviated from the typical cataract 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. CF, counting fingers; HM, hand motions; NLP, no light perception. Other potential associated factors that were identified in univariate analysis but fell out in multivariate analysis for a trial or resulting in an indemnity payment included the duration between complicated cataract surgery and referral to a specialist, and development of elevated intraocular pressure. Do Not Sell or Share My Personal Information, Do Not Sell or Share My Personal Information, improper application of anesthesia, such as globe perforation, and, a variety of post-operative complications, such as swelling, Pre-suit requirements like screening panels, advance notice of the lawsuit, mandatory settlement negotiations and ", Expert witnesses experienced in the particular field of health care must testify on behalf of either, The total amount a plaintiff can recover from a health care provider might be limited by a ". Posterior-assisted levitation in cataract surgery. Among the 12 claims that resulted in a jury trial, 2 cases resulted in indemnity payment. 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. Colyer MH, Berinstein DM, Khan NJ, et al. 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. However, all claims with a record of aggressive intraoperative manipulation by the cataract surgeon resulted in retinal detachment. 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. In addition, there are potential complications associated with any surgical procedure due to unavoidable risks despite appropriate care, complications that are unexpected or unpredictable, or decisions that were made carefully by the patient and physician with informed consent but, in retrospect, were less than optimal owing to the uncertainties inherent to the practice of medicine. However, how this complication was managed intraoperatively and postoperatively, what degree of injury resulted, as well as how the informed consent was presented preoperatively, will determine whether or not malpractice occurred due to substandard care that resulted in harm to the patient. In the univariate analysis the P values for continuous variables were calculated based on nonparametric tests: Wilcoxon rank sum test for two groups (indemnity payment vs no indemnity payment) and Jonckheere-Terpstra trend test for multiple groups (trial vs settlement vs dismissed). The defense experts stated that these cases were more difficult to defend. about navigating our updated article layout. Managing a dropped nucleus during the phacoemulsification learning curve. The model was simplified using backward selection keeping all predictors with a P value of .25 or less. Retained lens fragments can be successfully managed by the retina specialists in most cases. All variables significant in the univariate analyses were included in a multivariate logistic regression model. Schaal S, Barr CC. Causes of cataract surgery malpractice claims in England 19952008. Of the 12 claims resulting in a trial, 30 claims resulting in a settlement, and 66 claims resulting in a dismissal, the male-to-female physician defendant ratios were 12:0, 25:5, and 57:9, respectively. For the current study, the claims were categorized into those that went on to a trial, settlement, or dismissal, and those with or without indemnity payment. Although claims from Illinois, Texas, and California accounted for 42% of all claims, claims from Illinois were more likely to go to trial or settlement, and claims from Texas and California were more likely to be dismissed. May M, Stengel B. The patient was referred 1 month after the initial cataract surgery to a retina specialist and underwent two pars plana vitrectomy surgeries, corneal wound closure, and intravitreal antibiotic injections. Management of dislocated lens material. The largest indemnity payment case, with a payment of $500,000, closed in 2005 with a settlement. In some states, the information on this website may be considered a lawyer referral service. After 2 surgeries within 2 wks on same eye, it is slow to heal, having difficulty seeing, having soreness & pain. Socioeconomic Characteristics of Medical Practice 1990/1991. There were differences between claims associated with retained lens fragments that went on to a trial vs settled vs dismissed and whether indemnity payment occurred or not. Claims were separated into regions of the United States as seen in Figure 4. Ross WH. Physicians Insurers Association of America . This division allowed additional information regarding the duration between opening and closing of the claim and legal expenses for each group. Smiddy WE, Guererro JL, Pinto R, Feuer W. Retinal detachment rate after vitrectomy for retained lens material after phacoemulsification. Because the patient was receiving warfarin therapy, pneumatic retinopexy was performed. 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. Time between cataract surgery and referral to a subspecialist was a median of 7 days, ranging from the same day as the cataract surgery to 15 months after cataract surgery. Physicians with higher clinical activity also may have greater exposure or deal with more complex medical situations. Rosenbaum JT, Samples JR, Seymour B, Langlois L, David L. Chemotactic activity of lens proteins and the pathogenesis of phacolytic glaucoma. Development of corneal edema was statistically significantly associated with an indemnity payment but not for a trial. Socioeconomic Characteristics of Medical Practice 1997/98. Ophthalmic malpractice lawsuits with large monetary awards. The number of closed claims related to cataract surgery complicated by retained lens fragments each year from 1989 through 2009. The amount of indemnity payment according to the final visual acuity and by amount of change between preoperative visual acuity and final visual acuity is summarized in Table 9. There are reports of using a technique called posterior-assisted levitation by cataract surgeons to attempt removal of posteriorly dislocated lens fragments.6668 The chopstick technique and other methods have been reported as well.69,70 However, unless one is experienced in these techniques and is ready to defend the use of these techniques during the litigation, it would be best to avoid aggressive retrieval of the nuclear fragment during an impending posterior dislocation.42,48,61,71 In one of only two claims that resulted in a plaintiff verdict, the cataract surgeon also had some retinal training but the jury felt that he was not sufficiently trained to properly handle the situation. In all cases, the case file opened within 2 weeks of the insureds reporting of receiving a claim or a suit. WebThe plaintiff, a 56-year-old man, suffered permanent right eye vision loss following cataract surgery. From 1989 through December 2009, OMIC had a total of 2,854 closed claims. Their analysis also found that vitrectomy on the same day and up to 2 days after the cataract surgery had poorer visual outcome. In one of the claims, the cataract surgeon, who had some retinal training, attempted retrieval of the posteriorly dislocated lens material. The value of a cataract surgery lawsuit can vary depending on the severity of the injury, how it was caused, and the amount of medical care and treatment required. The purpose of this paper is to explore the use of the Systems Engineering Initiative for Patient Safety (SEIPS) framework to sustainably reduce wrong intraocular lens (IOL) implants in cataract surgery. The final visual acuity for claims resulting in indemnity payment vs no payment is shown in Figure 5. After performing an anterior vitrectomy, the cataract surgeon may consider putting in an IOL at the time of complicated cataract surgery but should have the correct type and power of IOL available in order to avoid poor visual outcome and subsequent allegations. Each claim was counted separately as a unique case. In the multivariate analysis, only the amount of change between preoperative and final visual acuity ( logMAR visual acuity) was found to be statistically significant in predicting more severe legal outcome. Lifshitz T, Levy J. Posterior assisted levitation: long-term follow-up data. Ali N, Little BC. Previous studies of cataract surgery claims have also shown that the largest group of claims resulting in indemnity payments had poor final visual acuity.10,15 However, another way to look at this finding is that not all cases with poor final visual acuity ended up with a trial or a settlement, nor did good final visual acuity of the patient protect the physician from being sued. If a physician had multiple claims from separate cataract surgeries, each was counted separately. Follow Posted 4 years ago, 24 users are following. Postoperatively, the patient developed hypotony and fibrin reaction. Management of retained lens fragments in complicated cataract surgery. In contrast, among the 47 cases where referral to a specialist was earlier than 1 week, only 28% went on to a trial or settlement. In another study with anesthesiologists, approximately 40% of the claims did not involve substandard care but 42% of these claims ended with an indemnity payment.81, Therefore, it is difficult to clearly predict which physicians will get sued or what the final outcome of the malpractice suit will be. Kane CK. Delay in diagnosis or delay in referral was alleged in 12 (11%) of 108 claims. Schwartz SG, Holz ER, Mieler WF, Kuhl DP. 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 number of ophthalmologists being insured by OMIC grew steadily from 1,027 in 1989 to 4,107 in 2009 (Figure 1). Over 3 million cataract surgeries are performed annually in the United States.18 Given the frequency of this procedure, perhaps it is not surprising that cataract surgery is the single most frequently named procedure in malpractice actions against ophthalmologists.1315 An uncommon but potentially devastating complication of cataract surgery that can affect both the anterior segment and the posterior segment surgeons is posterior dislocation or retention of lens fragments during cataract surgery. In 7 cases, the cataract surgeon documented an intraoperative attempt at retrieval of the lens fragment (Table 2). Kwok AK, Li KK, Lai TY, Lam DS. Even when an IOL has been inserted by the cataract surgeon, the retinal surgeon should be prepared to manage subsequent complications of dislocated or malpositioned IOL, as was the case in some of the claims in this study. Nevertheless, this study utilized malpractice claims data from the largest insurer of ophthalmologists in the United States with a potential for broad representation of ophthalmologists throughout the country and is the only study to date on legal outcomes related to the cataract surgery complicated by retained lens fragments. Therefore, cases that start out with poor visual acuity and end up with poor final visual acuity are less likely to result in a trial, settlement, or indemnity payment than cases with relatively good preoperative visual acuity that end up with poor final visual acuity. One of the ways to reduce the complication of retained lens fragments could be monitoring and reducing the possibility of a sudden patient movement during surgery. Mello MM, Chandra A, Gawande AA, Studdert DM. The number peaked in 1997 with 11 cases and again in 2001, 2003, and 2004 with 13 cases each year. 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. Medical malpractice and respondeat superior. Federal government websites often end in .gov or .mil. von Lany H, Mahmood S, James CR, et al. Retained lens fragments in resident-performed cataract extractions. Medical malpractice experiences of vitreoretinal specialists: risk prevention strategies. A claim may include institution of a lawsuit or arbitration proceedings against the insured. Preoperative visual acuity was the visual acuity shortly prior to cataract surgery. The average insurance company payment - mostly settlements -- in these cases were $112,000. There appeared to be differences in legal outcomes depending on the state where the physician practiced, such that claims from Louisiana were most likely to be dismissed. She underwent corneal transplantation, pars plana vitrectomy, membrane peeling, and silicone oil placement. Cases to be included in the study were identified based on OMIC coding for claims resulting from complications related to cataract surgery. 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. Risk management lessons from a review of 168 cataract surgery claims. The frequency of claims related to retained lens fragments compared to the number of policyholders for each year from 1989 through 2009. The defendant prevailed in 83% of trials. The cataract surgeon felt strongly that he was not at fault and wished to go to a trial rather than settle. Practice styles and preferences of ASCRS members1994 survey. What is the recovery after cataract or lens replacement surgery? Rofagha S, Bhisitkul RB. Horozoglu F, Yanyali A, Macin A, Nohutcu AF, Keskinbora KH. The current study is not inclusive of all claims related to retained lens fragments in the United States that occurred during the study period. 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. DESCRIPTIVE STATISTICS OF THE ANALYSIS VARIABLES BY CLAIMSOUTCOME ASSOCIATED WITH RETAINED LENS FRAGMENT. Learn more Early vitrectomy was considered to be between days 3 and 7 after the cataract surgery in their study. Characteristics of physicians with obstetric malpractice claims experience. FOIA During the immediate postoperative period, the visual acuity was 20/40 and the posterior chamber IOL was documented to be in good position. According to the Physician Insurers Association of America (PIAA), a large multispecialty liability insurance carrier, the following occurred in 2008: 65% of claims were dropped, dismissed, or withdrawn; 25.7% were settled; 4.5% were decided by alternative dispute mechanism; and 5% were resolved by trial, with the defendant prevailing in 90% of those tried cases.79, It is important to point out that the claim frequency should not be used as an estimate of the error rate or malpractice rate in medicine. The mean age was 69 years (range, 4090 years). Dr. Poole performed cataract surgery on DeFrankos eyes over the course of one month. The needle impaled the lens and tore the lens capsule. WebUltrasound: The predominant technology for cataract removal is ultrasound. Light sensitivity after cataract surgery After cataract removal, a little bit of light sensitivity is expected due to dryness in the eye. Boscher C, Lebuisson DA, Lean JS, Nguyen-Khoa JL. 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