65 year old female patient undergoes Phacoemulsification of mature cataract of the left eye with posterior chamber intraocular lens placement. It is noted by the opthalmologist that the cataract was phacoemulsified without difficulty. Opthal further notes that during the IA process, a small rent was identified in the posterior capsule but all the cortex was removed. As a precaution one 10-0 suture was placed over the main incision after the viscoelastic was removed. Both incisions were checked for any anterior chamber vitrious and none was found.
Patient seen the following day (4/27/22) and complains of disomfort, sensitivity to light and her vision is more blurry than before. Patient is noted to be very concerned about swelling and blood in her eye. OS: SC Dist- 20/400; PH nNl; refraction -5.50(sph)/+7.00 (cyl)/055 (axis) Exam reveals no signs of infection, small subconjuctival hemorrhage, iop 15. Told to return in 1 week.
Patient returns on 5/2/22 and states eye redness/blood pooling is not improving and vision still very foggy. OS: SC Dist- 20/200; PH 20/80-; refraction +.25/1.25/017. On exam it is noted that the subconjuctival hemorrhage is clearing; vision slightly improved. DO also notes that patient may have macular swelling. Plan is to have patient return in one week, and if vision still blurry, refer to retinal specialist for eval of macula edema. However, patient indicates that she was told to reschedule in two weeks.
Patient returns on 5/16/22. It is noted that the Patient reported that she started to see big black blobs floating in her vision on 5/12/22. By 5/17/22 (Friday), she reported that her vision had become completely cloudy and dark and that she was unable to see since. OS: SC Dist- HM; PH- Nl. DO assessed patient with moderate dislocation of lens inferiorly with anterior chamber vitrious os; suspect retinal detachment. She was referred to retinal specialist.
Retinal specialist sees patient on 5/20/22. He diagnoses patient with total retinal detachment and subluxed IOL. Pars Plana Vitrectomy for retinal detachment repair was performed on 5/23/22. Intraoperatively a retinal vein occlusion was discovered and she was subsequently treated for macular edema related to that problem. She was also later noted to have developed macular pucker. As second Pars Plana Victrectomy for Retinal Detachment repair was performed in December 2022. Last vision exam OS- 20/400.
Did the initial opthalomologist who performed the cataract surgery meet the standard of care both during the procedure and in her subsequent management of the patient's complaints? Given the rent noted during the procedure, should she have been more vigilant in recognizing developing issues in the patient's eye post procedure and refer her to a retinal specialists in a more timely manner.
Finally, if she did not appropriately manage the patient in a timely manner, did the delay more likely than not lead to the permanent visual acuity loss?
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Q: I have been out for 5 years. I can't answer these questions for some reason. When I hover over them it's red. I can comment on this case.
A: —
Do you believe there might have been medical error?
It is common for patients with a mature cataract to require a few weeks for visual recovery. The patients initial complaints of decreased vision, irritation/sensitivity, and blood pooling are all part of the normal healing process after cataract surgery for a mature cataract. When the patient noted the “big blobs” is likely when the detachment occurred and medical attention was given shortly thereafter. One question is whether a retinal detachment was noted on Friday 5/17 and whether it was “macula-on” or “macula-off” - this impacts the appropriate timing of referral to the retina specialist.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above answer. Patient was referred to retina specialist. Timing of referral may have been within standard of care if this was a “macula-off” retinal detachment.
What makes you a good expert for this case?
I perform about 500 eye surgeries a year including complex cataract and glaucoma cases. I work in a multi-subspecialty Center and collaborate closely with retinal specialists.
How often do you encounter cases similar to this one in your practice?
About once a year I see someone who has developed a retinal detachment after eye surgery.
Do you believe there might have been medical error?
The real question is whether there was a breach in the standard of care. It is unclear from the information given if due diligence in the examination was performed, and no details of the intraoperative procedure are given.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
A retinal detachment following a complicated cataract surgery is most likely caused by the cataract surgery It is a known consequence of vitreous loss.
What makes you a good expert for this case?
I have performed thousands of cataract and retinal surgeries. I am fellowship trained in both anterior and posterior segment surgery.
How often do you encounter cases similar to this one in your practice?
I commonly encounter cases of complicated cataract surgery with retinal implications.
Do you believe there might have been medical error?
preoperative and operative records needed . patient is a high myope and needed a very adeaquate retinal exam both preop and possibly post op . did patient lose vitrous ?? notes needed
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
poor preop exam and possible mistake inOR ???
What makes you a good expert for this case?
40 years of p[ractice and teaching as chief of retina in a major teaching hospital voted by my peers into the retinal hall of fame my CV speaks for itself
How often do you encounter cases similar to this one in your practice?
everyday i see and deal with these complications .
Do you believe there might have been medical error?
It is not possible to render a definitive opinion without seeing the medical records. Furthermore, the law governing experts requires us to use sound methodology and provide expert opinions based on a detailed review of the facts, not just give our "beliefs". That said: Posterior capsule rupture happens to all surgeons, especially with mature cataracts, and is not per se a breach in the SOC. Such cases have an inherently higher risk of retinal detachment than routine cases. Depending on the findings at surgery, it may or may not have been a breach to not perform a limited anterior vitrectomy. Based on the symptomatology, it seems unlikely that the detachment developed before May 16 or 17. An earlier retinal exam might or might not have detected a retinal break. Treatment of a retinal break might or might not have prevented the detachment. From the description, it is unclear whether a dilated exam was performed during the postop period (prior to 5/17), before pt saw the retina specialist. If an early dilated exam was performed, that would be helpful to the defendant. If a postop dilated exam prior to 5/17 was not performed, it would be helpful to plaintiff. However, although I think it is best practice to dilate all cataract pts postop, many cataract surgeons do not do so. Therefore, it is difficult to definitively state that a dilated exam within a specific period of time is the SOC. Unfortunately, our published guidelines are generally silent on this point. The symptoms of hemorrhage, blur, discomfort, swelling, etc. are not relevant to retinal detachment, and are common after surgery for a mature cataract. They do not materially impact the analysis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is not possible to render a definitive opinion without seeing the medical records. Furthermore, the law governing experts requires us to use sound methodology and provide expert opinions based on a detailed review of the facts, not just give our "beliefs". That said: The ultimate vision loss may have been due to a pre-existing epiretinal membrane, which would not have been diagnosable prior to removal of the dense cataract. Or, the ERM may have developed subsequent to the retinal detachment. In this sort of case it can be difficult or impossible to determine its onset. Similarly, depending on the location and severity of the retinal vein occlusion, that could have been a significant cause of vision loss, and would have presumably occurred even if the retina had not detached. However, it is also possible that earlier dilation and identification of a retinal tear might have prevented a detachment and potentially better final vision. Depending on the laws of the state, the pt might have some degree of contributory negligence by waiting until the cataract was mature, and therefore high-risk, before agreeing to have it removed.
What makes you a good expert for this case?
I have performed over 8,000 cataract procedures and actively teach cataract surgery. I am one of the few cataract surgeons who also diagnoses and treats (non-surgical) retinal disease (including retinal tears, vein occlusions, and macular edema). I hold an academic appointment at two highly-ranked ophthalmology residency programs, and have made cataract policy at the regional and national level by virtue of my leadership positions in ophthalmology. I have been qualified as an expert in state and federal courts and never disqualified. In addition to reviewing over 200 injury and malpractice cases (most of which have settled after my reports), I have worked on high-profile pharmaceutical patent and antitrust cases where hundreds of millions of dollars are at stake. Please note that in spite of whatever this intermediary website may specify, I draw up an individual contract for each case, and the amount of the initial retainer is determined by the number of pages to be reviewed. I do not accept any obligation until a contract is negotiated and signed directly between myself and the retaining law firm, without intermediaries. Upon request, I can provide redacted sample reports, and reviews from attorneys I have worked with.
How often do you encounter cases similar to this one in your practice?
I actually invented an instrument for removal of mature, high-risk cataracts, and have removed many such cataracts over the years. I am therefore very familiar with the complications of mature cataract surgery, including retinal detachment. Fortunately, most such cases can have a good outcome if handled correctly.
Do you believe there might have been medical error?
Rents can occur but important to dilated retina and check for rd and for the patient to be counselors on rd symptoms and to return immediately for eval and the urgent retina eval if rd suspected.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Delayed RD repair results in vision loss
What makes you a good expert for this case?
I do cataract surgery and manage complicated cataracts and referalls for complications of surgeries performed elsewhere
How often do you encounter cases similar to this one in your practice?
I see patients like this maybe once a month
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