Ординатура / Офтальмология / Английские материалы / Risk Prevention in Ophthalmology_Kraushar_2008

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22.Lustgarten JS, Podos SM. Topical timolol and the nursing mother. Arch Ophthalmol 1983;101:1381–1382.

23.Boniuk V, Nockowitz R. Perforation of the globe during retrobulbar injection: medicolegal aspects of four cases. Surv Ophthalmol 1994;39:141–145.

24.Iezzoni LI. Discharge blindly. Agency for Healthcare Research and Quality (AHRQ) Web Morbidity and Mortality (Web M&M) Rounds on the Web. Case and Commentary. December 2005. Available at: http://www.webmm.ahrq.gov/case.aspx?caseID=111.

25.Zimmerman T. Facilitating patient compliance in glaucoma therapy. Surv Ophthalmol 1983;289(Suppl):S252–S257.

26.Deutsche RA. Discuss potential side effects of eye drops. OMIC publication archives. Argus, January 1992. Available at: http://www.omic.com/resources/risk_man/deskred/clinical/9.cfm.

body carry a significant risk of permanent severe vision loss or cosmetic deformity despite appropriate, competent, and successful management. For this reason, it is of paramount importance to provide to the patient pertinent information regarding risks, benefits, and alternatives by means of a discussion of informed consent that is properly documented in the record.

Responsibility

There are many causes of unfortunate outcomes. Assigning responsibility to only the treating physician for any adverse event is unwarranted. Consultants may also commit errors. Paramedical personnel may give false reassurance or inaccurate information to patients. Certain diseases are unfortunately beyond the scope of treatment. Patients may delay seeking consultation for conditions that if treated at an earlier time would more likely than not have had a favorable outcome. An infant or child is dependent on the attentiveness and diligence of the parent or guardian. After urgent treatment has been rendered, patients may also neglect instructions for subsequent care.

Common misdiagnoses or omissions by responsible medical personnel occur as a result of hasty evaluation and disposition or the assumption that the patient’s complaint is trivial. If misdiagnosis, faulty treatment, or false reassurance occurs, it is often assumed that the patient will return or seek another opinion. Unfortunately, this is not always the case. An abatement of symptoms may cause a delay in a patient’s return. Strangely, there is often a feeling by the physician of indemnity against malpractice comparable to a motor car accident in that the misfortune always happens to another person. Every step of patient care should be planned with the benefit of the patient as the objective and not for the purpose of avoiding malpractice litigation.

Emotional Issues

In any medical consultation, there is patient anxiety. Emotion in urgent matters, which are of greater concern to the patient, is invariably involved to varying degrees in litigation. Strong emotional reactions are often seen on the part of patients, concerned relatives, physicians, and attorneys. A patient’s concerns, concepts, understanding of disease, expectations, or demands are often bizarre but need to be addressed. Attempts should be made by all responsible medical personnel to explore the facets in every situation. One must not assume anything without questioning and definition.

No encounter between a physician and a patient is satisfactory without allaying the patient’s fears and formulating a comprehensible plan for treatment of the disease or injury. Often when asked if he or she has any questions, a patient feels lack

of sufficient knowledge to respond. Use of unexplained medical terminology may also be confusing. It is best to ask, “What worries you about your eyes?” In addition to an oral explanation, written material given to the patient may be helpful.

Communication

Lack of continuous communication between physician and patient and among physicians caring for a patient is a serious concern. A common patient allegation is “I was not told anything.” If the physician appears overwhelmed or rushed or is abusive to the office staff, an unfavorable impression is created.

If there is an untoward occurrence, some medical practitioners attempt to escape by withdrawing and remaining incommunicative. Others manifest hostility toward the patient. Both of these defense mechanisms are very harmful.

Paramedical personnel may be culpable. One lawsuit involved a patient postoperatively suffering excruciating pain caused by very high intraocular pressure following vitrectomy with fluid–gas exchange. Paramedical personnel caring for the patient failed to notify the surgeon and the patient was blinded. The verdict was against the hospital and its personnel.

History

A history given by the patient may be inaccurate but must be recorded with care. If a history is written by a medical assistant, it must always be evaluated by the treating physician. If an injury occurs while a patient is at work, the date, time, location, and names of companies and individuals involved must be documented in the medical record.

Examination

The patient’s visual acuity must always be noted. An examination must not be abbreviated or terminated because the patient is difficult or uncooperative. Sedation or general anesthesia may be necessary for some patients, especially children. Struggling with a patient needs to be avoided and can cause serious damage if there is a lacerated globe. A common mistake is reflex recording of PERLA (pupils equal in size, react to light and accommodation) despite the fact that the examination has not been performed. In general, consultation with an appropriate specialist is advisable when there is any uncertainty of findings or disposition. Consultations may involve ophthalmologists, otorhinolaryngologists, radiologists, neurologists, neurosurgeons, plastic surgeons, pediatricians, internists, and anesthesiologists.

Documentation

Detailed documentation is of the utmost importance. Meticulous record keeping includes history, findings on examination, results of tests, diagnosis, treatment, and prognosis. If an invasive procedure is contemplated, a signed informed consent from the patient must be obtained. Informed consent, including the probable outcome without treatment, the risks and benefits of treatment, and the likely results, is for the benefit of the patient, enabling him or her to make an intelligent choice. However, informed consent does not protect the physician from a malpractice suit.

The following example illustrates oversight in treatment and documentation. A patient with intraocular pressure elevated to a dangerous level was given medication to reduce the intraocular pressure and sent home without further evaluation. This assumption of intraocular pressure control was erroneous and led to blindness. In such a case, one must not discharge the patient until the intraocular pressure is reduced to an acceptable level. This involves noting specific treatment and measurements of intraocular pressure, including the time interval. Malpractice litigation has occurred because this information was not obtained and documented and excessively elevated intraocular pressure resulted in injury to the patient.

If a patient is referred to another physician, an appointment should be made and the patient provided with the name, address, and telephone number of the physician to whom the referral has been made. An explanation for the reason of referral is also important.

Contents of telephone conversations, persons communicating, and dates and times should be recorded in the patient’s history. Documentation of a patient’s refusal of testing, treatment, or referral or leaving against medical advice must be made.

Special Case Situations

Children, if frightened or in pain, may present particular problems in evaluation. Child abuse must always be considered. For children, sedation, a papoose board, or even general anesthesia are options. A child’s vision may sometimes be evaluated by using the “E” game or Allen pictures. Although a child may not always be examined with a slit lamp, the use of a magnifying lens with a penlight held by an assistant is very helpful. Often injuries to children occur while playing with another child when adults are not observing. Perforation of the eye with a sharp object is common. An asymmetry of the pupil may be seen in such injuries but is easily missed if the child is not calm and the examiner does not have adequate magnification and illumination. On occasion, intoxicated adults or adults in extreme pain present problems in examination.

Ancillary Tests

Commonly used tests to evaluate an urgent situation, especially one involving trauma, are computed tomography (CT) scan, magnetic resonance imaging, ultrasound, and conventional x-rays. In acute trauma, CT is good for bone imaging. There is no contraindication for use in cases of suspected or confirmed ironcontaining foreign body, pacemakers, or external life support. Computed tomography may be useful for patients with suspected intraocular foreign body, hemorrhagic chemosis, orbital fracture, intracranial or orbital hemorrhage, or ruptured globe.

Magnetic resonance imaging is advantageous for evaluation of vascular lesions, intracranial diseases, intraocular tumors, cavernous sinus thrombosis, and optic nerve lesions. In general, soft tissue resolution is better with magnetic resonance imaging than with CT. Magnetic resonance imaging is, however, contraindicated for metallic foreign bodies, especially those containing iron, cochlear implants, cardiac pacemakers, intracranial magnetic vascular clips, and claustrophobic patients.1

Conventional x-rays are useful for visualization of foreign bodies, especially metallic. When CT is unavailable, an x-ray is often satisfactory and in some cases is preferable even when more sophisticated technologies are available.

Emergencies

Most ocular disease or trauma is not emergent. Some argue that there is no ophthalmologic emergency. Others, however, regard chemical burns and retinal artery occlusions as emergencies.

Chemical Burns

Irrigation of the eye with water immediately after contact with a potentially damaging chemical solution is the best and often only treatment available. This must be performed at the workplace, as delay caused by transportation of the patient to an emergency room or physician’s office may result in additional damage. The eye must be thoroughly irrigated and the lids retracted. Particulate matter must be removed from the fornices. Retained granules of lye may cause damage to the overlying retina if the chemical passes through the sclera. When there is extensive destruction of tissue, adequate subsequent treatment should be planned to prevent symblepharon.2 Thermal burns may also create deformity or malfunction.

Central or Branch Retinal Artery Occlusions

Treatment of central and branch retinal artery occlusions is controversial. Many ophthalmologists regard these occlusions as untreatable, and some regard them as indications of acutely threatening systemic disease. Central retinal artery occlusions may rarely be a manifestation of giant cell (cranial) arteritis. Evaluation by an internist is advisable and must extend beyond carotid artery auscultation and Doppler studies.3 Other physicians regard treatment with pentoxifylline, hyperbaric oxygen, intravenous recombinant tissue plasminogen activator, or selective ophthalmic artery catheterization with infusion of recombinant tissue plasminogen activator or urokinase to be helpful.4 Such treatments are not of incontrovertible efficacy and are not available in every medical facility.

Urgent Conditions

Some conditions in and of themselves may not be urgent but may have an accompanying complication or occurrences that may require urgent treatment.

Giant Cell Arteritis

Giant cell (cranial) arteritis must be considered especially in individuals over 70 years of age complaining of jaw claudication, pain in the head, face, and neck, fever, night sweats, lost of appetite, and general malaise with joint and body aching. Ocular symptoms and findings of giant cell arteritis include anterior or posterior ischemic optic neuropathy, central retinal artery occlusion, cilioretinal artery occlusion, cotton wool spots, poorly reactive pupils, conjunctival injection, corneal edema, low intraocular pressure, homonymous hemianopia, cortical blindness, abnormal extraocular movements from palsy of cranial nerves III, IV, or VI, diplopia, eye pain, and transient obscuration of vision. Similar pains including the eye may occur in internal carotid artery dissection. If the patient has arteritic ischemic optic neuropathy, immediate treatment does not restore lost vision but usually prevents involvement of the fellow eye or more serious fatal complications.5,6 Optic neuritis as a manifestation of giant cell arteritis must be distinguished from nonarteritic ischemic optic neuropathy and optic neuritis.7,8

Some encounters, as in the following case, illustrate complications arising from failure of protracted vigilance. An elderly lady complaining of sudden loss of vision in her right eye was seen in an ophthalmology clinic shortly before 5:00 PM. Markedly reduced vision with a pale swollen optic nerve was noted, and the patient was sent to the laboratory for erythrocyte sedimentation rate and

C-reactive protein evaluations. A note requesting a report of the erythrocyte sedimentation rate and the ophthalmologist’s telephone number was sent along with the patient. She was given an appointment to see an internist early the next morning for evaluation of giant cell arteritis and corticosteroid maintenance or treatment. The laboratory failed to report the erythrocyte sedimentation rate value to the ophthalmologist, and the internist who saw the patient the next morning did not consider it sufficiently elevated to create suspicion of giant cell arteritis. The patient was treated with one aspirin tablet daily. One week later the patient experienced severe visual loss in her fellow eye and was taken to an emergency room. The diagnosis of giant cell arteritis was entertained, and highdose intravenous corticosteroids were instituted. Temporal artery biopsy confirmed the diagnosis of giant cell arteritis. A lawsuit was filed against the clinic, including both the ophthalmologist and the internist. The settlement was in favor of the patient. One must never assume that because the test result is requested that the report will be made. The ophthalmologist’s assumption was that if the result were abnormal a call would be made. Furthermore the patient was to see an internist the next morning was expected to receive appropriate treatment. The ophthalmologist was considered guilty for not diligently seeking the test result by calling the laboratory and the internist for not making the correct diagnosis. Another interesting complexity in this case was that the defense lawyer was hired by the insurance company to represent the clinic and not the individual physicians, who were thus considered equally culpable.

Edema of the Optic Nerve Heads

Edema of the optic nerve head does not always cause decreased vision. Any swelling of the optic nerve head, whether unilateral (disc edema) or bilateral and usually associated with increased intracranial pressure (papilledema), requires prompt investigation. This topic is discussed in greater detail in Chapter 16.

Lid Lacerations

Lacerations of the lids must be carefully repaired. Inattention to canalicular repair or notching of the lower lid margin may cause chronic epiphora. If the levator palpebrae superioris aponeurosis is severed and not repaired, blepharoptosis will occur. While none of the aforementioned injuries threatens blindness, some possible accompanying injury may well do so.9 In any lid trauma, the eye must be inspected as deeper lacerations may involve the eye itself and be associated with a retained intraocular foreign body. In one legal case, a dart had not only perforated the lid but had also entered the eye, creating a hole in the retina that was neglected.

Corneoscleral Lacerations

Corneoscleral lacerations are commonly not diagnosed especially in children with darker colored irides. Such lacerations often occur when the child is playing alone or with other children in which case an accurate history is impossible. With darker colored irides, there is less contrast between the iris and the pupil. Children are often frightened and in pain. Squeezing of the lids is reflex when any form of retraction is attempted. Sedation, magnification, and brighter illumination is required to adequately examine such infants. Delay or failure to repair such lacerations often results in visual impairment or blindness. Conjunctival lacerations must also be carefully examined to be certain that there is no underlying scleral perforation or laceration.10

One legal case involved a young child who was examined and diagnosed with conjunctivitis by an emergency room physician. Antibiotics were prescribed. Another opinion was sought a few weeks later, and a 6-mm corneoscleral laceration with iris incarceration and a teardrop-shaped pupil was seen. Review of the emergency room physician’s notes revealed the notation “PERLA,” which would have been impossible. An asymmetric or misshapen pupil is often a clue to severe trauma and frequently not observed. The child experienced a fibrovascular ingrowth with an irreparable tractional retinal detachment. The legal settlement was favorable to the plaintiff.

Rupture of the Globe

Severe blunt trauma may cause a rupture of the globe. The eye may be deformed with visible loss or incarceration of intraocular content. However, especially with accompanying orbital hemorrhage, the rupture of the globe may be occult. The intraocular pressure may be normal. Surgical exploration may be required and must extend quite far posteriorly, often requiring temporary detachment of one or more rectus muscles to obtain adequate exposure.

Intraocular Foreign Bodies

Occasionally intraocular foreign bodies cannot be distinguished from orbital foreign bodies, which carry much less risk. In any perforation or laceration of the eye, one must suspect and perform appropriate examinations to exclude a retained magnetic or nonmagnetic intraocular foreign body. This is particularly true when there is a history of hammering on metal. Such studies include CT scan, ultrasound, and x-rays.11 Lacerations and perforations of the globe frequently involve extensive surgical repair many times in several stages. Repair of the laceration, removal of a