A 46-year-old female patient saw an ophthalmologist because, as the doctor charted, she was "interested in cataract surgery and not being dependent on any glasses." The patient had hyperopia in both eyes and unspecified astigmatism in the right eye. The ophthalmologist also documented that she had mild nuclear sclerosis in both eyes. He did not document specifically that she had cataracts, but charted that she "desires cataract extraction." After seeing her for several follow-up visits and trialing her with different kinds of contact lenses (monovision vs. multifocals), the doctor performed cataract surgery and implanted artificial lenses. The patient has had pretty bad complications, and believes that she never had cataracts. She admits that she originally sought out implanted lenses only because she did not want to wear glasses or contacts, but says she assumed the doctor would not have agreed to do it if it wasn't OK to do,
If the doctor only charted "mild nuclear sclerosis," does it seem likely that the patient is correct and she did not have cataracts? If she did not have them, was it a deviation from the standard of care to perform cataract surgery?
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Do you believe there might have been medical error?
Examination findings showed evidence of a cataract, which is the nuclear sclerosis. If the patient's vision complaints could be attributed to the cataracts then this would be an indication for surgery and standard of care was likely followed in that regard.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Cataract surgery has known risks. If cataract surgery was indicated and the patient was informed of the risks, accepted the risks, and complications were handled appropriately then this all fits within standard of care.
What makes you a good expert for this case?
I perform over 500 eye surgeries a year including several hundred cataract surgeries with different kinds of lens implants. I practice in a large University referral practice and have encountered and treated many different types of complications related to cataract surgery.
How often do you encounter cases similar to this one in your practice?
Once or twice a year we provide care for a patient that states they did not have a good understanding of cataract surgery and associated risks before having the surgery.
Do you believe there might have been medical error?
The physician clearly documented mild nuclear sclerosis. Nuclear sclerosis is a type of cataract. Therefore it is documented that the patient has cataracts. Whether he/she was truthful in documentation is difficult to prove at this point.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If nuclear sclerosis was present, the patient had cataracts by definition.
What makes you a good expert for this case?
I am an experienced cataract surgeon in practice since 2004.
How often do you encounter cases similar to this one in your practice?
Sometimes, although cataracts in 46 year olds are uncommon but definitely possible.
Do you believe there might have been medical error?
The documentation of "mild nuclear sclerosis" indicates that the physician did notice some early cataract formation. Nuclear sclerosis is the aging type of cataracts, and can often be seen in patients in their early forties. Cataract surgery is typically performed on patients who have visually significant cataracts, which indicates that their vision is not correctable with contact lenses or glasses to an adequate level. In addition, they need to indicate that they were having difficulty with activities of daily living. With those criteria met, the surgery can be billed to insurance and is often covered. Patients can then upgrade their lens option packages to achieve glasses independence, if they qualify. However, in patients seeking glasses independence, we often perform refractive lens exchange outside of insurance. This is typically performed in hyperopic patients, usually in their late 40s to early 60s. This surgery is not usually covered by insurance, with patients paying for the entire amount out of pocket. If the surgeon was able to document impaired vision, even with best correction, then cataract surgery would likely be appropriate. We would need to see the notes/documentation
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The surgery performed could be a cause of injury, but that is a known risk of surgery. If informed consent was obtained, and the patient understood the risk of surgery, then it would be unlikely that the surgery caused unnecessary risk. Of course, examination notes, with indications of risk factors for surgery, along with the operative notes, would be critical for evaluation of the risks of surgery.
What makes you a good expert for this case?
I have performed over 20,000 vision correction surgeries. I specialize in Refractive Lens Exchange and evaluate patients daily who are asking for glasses independence, very similar to the patient described above.
How often do you encounter cases similar to this one in your practice?
I encounter several patients daily who are being evaluated for glasses independence and are in the 40 - 60 age range. I often perform lens replacement on these patients with excellent results. The pre-operative evaluation here is key.
Do you believe there might have been medical error?
The mention of "nuclear sclerosis" in the chart means that cataracts were present. Even if the physician does not explicitly write the word "cataract', the presence of nuclear sclerosis is the same thing. Based on the summary, it seems the doctor did not actually jump right into surgery, but first trialed glasses and contact lenses, which is appropriate. The report cites several follow up visits. There is no indication the doctor rushed the decision to proceed with surgery, Normally, if a patient's vision isn't fully correctable with glasses or contacts (or if they can't tolerate glasses or contacts), then surgery can be considered. Whether the patient had complications after the surgery is irrelevant if the initial decision to undertake surgery was made appropriately.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Complications after cataract surgery are rare but they do occur, The summary above makes no mention of any medical error in surgery. The error it suggests may have taken place was the decision to proceed with surgery in the first place. But here again, it does not show a medical error. In this case, we see a patient who has known cataracts, who - for whatever reason - can't or won't tolerate contacts or glasses. In those cases, surgery is a reasonable option.
What makes you a good expert for this case?
As a retinal surgeon, I manage many of the severe complications of cataract surgery. If this patient is alleging complications after surgery, there is a good chance I have managed similar complications in the past.
How often do you encounter cases similar to this one in your practice?
I frequently encounter complications after cataract surgery, but I do not frequently perform cataract surgery or make the decision to take cataracts out.
Do you believe there might have been medical error?
Everyone develops cataracts. Traditionally, we have made the decision to remove cataracts as a function of the contribution of the cataract to diminishing or scattering light and the ultimate effects that has on the patient’s activities of daily living viz a viz their visual difficulties. As cataract surgery has become safer and more accurate, it has become increasingly common to remove them at an earlier stage for the refractive benefits you can create. It’s kind of like doing lasik, but changing the power of the lens (ie cataract) but changing it out for an artificial lens.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If the patient is having unexpected complications there is a reasonable chance a deviation in the standard of care occurred after the decision to perform cataract surgery such as in the intraocular lens choice or surgery itself.
What makes you a good expert for this case?
I have done thousands of cataract surgeries and have been retained as an expert witness over 50 times in the last four years.
How often do you encounter cases similar to this one in your practice?
I remove cataracts about 5 times a month.
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