Presentation

On April 16, 2017, a 58-year-old man came to Ophthalmologist A for cataract surgery consultation. The patient had a history of hypertension, hypercholesterolemia, and type-2 diabetes mellitus.

The patient reported that both his near and far sight was poor, with vision in the right eye worse than the left. His visual acuity without correction was 20/150 in the left eye and hand motion in the right eye.

Physician action

Ophthalmologist A diagnosed cataracts in both eyes with conjunctivitis and hypertensive retinopathy in the left eye. He prescribed moxifloxacin for the conjunctivitis, which resolved a week later.

Ophthalmologist A recommended bilateral cataract surgery with implantation of an intraocular lens (IOL) in both eyes. The patient was informed of possible complications including hemorrhages, infection, and rupture of the posterior capsule and lenticular material in the vitreous cavity and that if any of these complications occurred, additional surgeries would be required to repair them.

The patient agreed to the cataract surgeries. The plan was to operate first on the right eye, followed by the left eye two weeks later.

On July 26, Ophthalmologist A performed surgery on the patient’s right eye. During surgery, a posterior capsular rupture without vitreous loss occurred; a dense, hard cataract was removed; and an anterior chamber IOL was placed.

At a follow-up visit the next day, Ophthalmologist A documented pseudophakia of the patient’s right eye with some corneal edema. The patient’s visual acuity was hand motion without correction. The patient was prescribed prednisone acetate, moxifloxacin 0.5% eye drops; bromfenac ophthalmic eye drops; and sodium chloride hypertonic ophthalmic. He was told to avoid strenuous activity and heavy lifting.

Ophthalmologist A saw the patient four times in August. The patient’s condition was unchanged, but at the fourth visit his right eye vision had decreased to hand motion, and microcystic edema was noted. The lens was well-centered, but the patient’s right intraocular pressure was elevated to 31 mm Hg. Oral acetazolamide, and brimonidine tartrate/timolol maleate drops were given to the patient, which improved his vision and eye pressure.  

On September 18, the patient returned with right eye pressure elevated at 22 mm Hg. Ophthalmologist A noted that the IOL was dislocated. The haptic — designed to hold the IOL in place — had dislodged and was now in the surgical incision. The patient said he had done some heavy lifting, which Ophthalmologist A believed caused the dislocation.

Ophthalmologist A recommended an additional surgery to replace the IOL with a new sclerally glued posterior chamber IOL to be placed in the sulcus position.

On October 4, the surgery was performed. The following day, eye pressure was at 8 mm Hg with mild edema. The new posterior chamber IOL was noted to be in good position, and the patient was started on normal postoperative medications. At an appointment on October 14, the patient’s eye pressure was 14 mm Hg and vitreous was noted in the anterior chamber. His vision was counting fingers.

On October 26, the patient reported that he had recently fallen and hit his head. Ophthalmologist A recommended an anterior vitrectomy, which was performed on November 9 without complications.

The patient returned two more times in November, and the IOL remained well-positioned.  The patient’s eye pressure ranged between 17-19 mm Hg and some edema was still present. He continued taking prednisone acetate and sodium chloride hypertonic ophthalmic as prescribed.

On January 4, 2018, the patient returned with pain, decreased vision, and edema in the right eye. The patient said he had not been using his eye drops for the last two weeks. A follow-up appointment was scheduled in two weeks.

The next day, January 5, 2018, the patient went to Ophthalmologist B for a second opinion. Examination of the patient’s right eye revealed corneal edema, adhesions, and a dislocated posterior chamber IOL with the optic (lens) touching the cornea temporally. Diffuse microcystic edema with iridocorneal adhesions; multiple iris defects; and fundus at a cup-to-disc ratio of 0.2 with a poor view were also noted. Visual acuity was counting fingers.

The patient’s left eye was noted as being at 20/70 acuity with dense nuclear sclerotic and cortical cataract and normal fundus.

Ophthalmologist B referred the patient to Ophthalmologist C, who performed a corneal transplant, anterior vitrectomy, IOL exchange, and iris repair in the right eye on June 8, 2018. The surgery improved the patient’s vision in his right eye, but some blurriness and pain were still present. 

During a follow-up visit in March 2019, Ophthalmologist C documented that the patient had secondary glaucoma of the right eye and that the patient’s cystoid macular edema was being managed by Ophthalmologist D.

Allegations

A lawsuit was filed against Ophthalmologist A, alleging failure to:

• correct the right anterior chamber IOL haptic in a timely manner;
• refer the patient to a cornea specialist to expedite the haptic repair; and
• correct the faulty position of the posterior chamber IOL.

The allegations included gross negligence.

Legal implications

The patient came to Ophthalmologist A with severely impaired vision and an extremely dense, mature cataract. Ophthalmologist A performed cataract surgery, followed by a lens exchange and anterior vitrectomy. The patient ultimately required a corneal transplant and had a poor visual outcome.  

Defense consultants were supportive of the initial surgery but had concerns about the second surgery. Specifically, they felt that Ophthalmologist A could have exercised better judgement and referred the patient to a corneal specialist rather than proceed independently. Another consultant stated that the complications were likely the result of “patient-related factors,” such as a severely diseased eye, underlying systemic conditions (possible diabetes and hypertension), non-compliance, and trauma from a fall.

Ophthalmologist B testified that when he saw the patient in January 2018, his eye showed a dislocated lens touching the cornea, severe diffuse corneal edema, and iris trauma — findings inconsistent with a successful cataract surgery. He believed the lens had likely been improperly positioned for an extended period causing progressive corneal damage.

An expert consultant for the plaintiff stated that Ophthalmologist A’s delayed management of the IOL haptic in the wound and subsequent poor placement of the scleral-fixated posterior chamber IOL caused progressive, irreversible corneal damage. This consultant stated that timely diagnosis and treatment could have preserved the patient’s vision.

Disposition

This case was settled on behalf of Ophthalmologist A.
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