Why Ophthalmology is Vulnerable to Malpractice Litigation?

Ophthalmology is Vulnerable


Introduction | Expert Homeopathy
Description of ocular disease and their treatment from a part of the oldest medical treatises, the Sushruta Samhita. The Indian surgeon, Sushruta, described the technique of cataract surgery in 800 BC India.
For the next 2000 years there were no major breakthroughs until the invention of ophthalmoscope that enabled direct visualization of retina. Introduction of intraocular lens implants in the 1940s, lasers in the 60s and phacoemulsification in the 70s transformed the practice of ophthalmology dramatically.

Ophthalmology has since evolved into a very 'high-tech' specialty involving highly complex surgical procedures. While many retinal conditions like macular holes which were considered untreatable can now be cured with surgery, several types of Lasers have been used to burn unwanted tissues/blood vessels, to make holes in the soft eye structures to clear the path of vision and to reshape cornea to change the refractive power of the eye aiming to remove the need for glasses, last on involving the most popular technique called LASIK. The other significant developments have been in the pharmaceutical area, where an array of therapeutic options has become available for glaucoma, macular degeneration and retinal vascular disorders like diabetic retinopathy. These have brought new problems to the fore as updated knowledge about suitability or otherwise of all available options become imperative for practicing ophthalmologists.


Vulnerability in ophthalmology
In addition to the already proven, highly effective therapies, recently there have been a series of reports about emerging treatments of yet incurable eye conditions involving stem cells, artificial retina (micro-chip-implants) and gene therapies making this field of the most rapidly advancing ones in whole of medicine. The latest technology addition to this armamentarium has been Laser assisted cataract surgery that seems to be raking up a storm of controversy. This rapid advance and high-tech status brings its own challenges to the practicing ophthalmologists. Patient expectations have become very high due to the media hype as well as very high cost of these new procedures. When complications occur or just the result is suboptimal, the risk of medical negligence litigation in a consumer court rises sharply. This chapter will help the readers to become aware of the specific risks and to reduce them significantly by following the guideline and suggestions. There have been studies done to determine the relative percentage of medical negligence cases in various ophthalmic subspecialties.


Medico-legal issues in Ophthalmology
Medico-legal awareness is a must for ophthalmologists. They may be commonly involved in medico-legal cases in the following three circumstances:

1. As treating doctor where legal proceeding has been started against him/her for negligence or malpractice, which could be civil or criminal depending on the seriousness of the allegations.

2. When the ophthalmologist has examined or treated a patient as an expert in civil or criminal matters unrelated to their own involvement in that patient's care.

3. As a third party expert witness in a Government inquiry, investigating committee, police or court of law for giving evidence in cases of mishaps like cluster infections, camp surgery complications or complex medical conditions treated by other ophthalmologists.


Vulnerable domains in ophthalmic  practice
LASIK Complications
(Suboptimal Visual Outcome)
LASIK (Laser Assisted In Situ Keratomileusis), a type of refractive surgery for the correction of myopia, hypermetropia and astigmatism. The surgery is performed with the help of laser or microkeratome to reshape the cornea in order to improve visual acuity. The popularity of refractive surgery has been rising rapidly, especially in India, where many young girls and some boys was to get their glasses removed, apparently to improve their matrimonial prospects. This popularity has also increased the expectations to a very high level. Furthermore, since LASIK is a cosmetic surgery, any complication as a result of the procedure is totally unacceptable since the visual result would have been netter if no surgery was done. These factors have made refractive surgeons much more vulnerable to malpractice claims. This is reflected in the Medical Protection Society or Medical Defense Union subscriptions in the UK, which are highest for refractive surgeons.


Cataract Surgery
Cataract surgery is one of the safest and most rewarding surgical procedures ever devised in ophthalmology. Often, the surgery is usually performed in an ambulatory setting under local anesthesia, causing little or no discomfort to the patient. Current success rate in experienced hands is close to 97%, but that also means that 3% of patients do suffer from untoward complications, which does not allow their vision to improve or even deteriorate further.
One of the most controversial and medico legally challenging issues is the recently introduced femtosecond laser assisted cataract surgery. The surgery is being promoted as the best and  safest, and charging two to three times more for the procedure as compared to well established phacoemulsification. However, there is no firm evidence in literature till date that results are any better or the complications are any less. In fact there is a steep learning cure which may result in more complications. Surgeons should be careful in making those claims of superiority without evidence from peer reviewed literature, otherwise they are liable to medical negligence claims.


There are more negligence like Ocular Trauma, Retinal Conditions, Missing Serious Systemic Diseases, Organ Donation...


Conclusion
Most of the complaints against the ophthalmologists are driven by unfavorable outcomes. Ophthalmologists must explain to their patients that poor outcomes may occur unavoidable without negligence. Risk management strategies must be followed to improve the patient safety as well as professional safety. Good communication along with appropriate documentation, maintenance of high standards in daily practice, and keeping oneself abreast with the latest trends in ophthalmic practice can go a long way in improving the professional safety of the ophthalmologists.


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