How and when do you share with a patient they had a complication during surgery?
By Damien Luviano, MDA 59-year old woman with a history of diabetes complains of failing her vision exam during her driving license renewal. She currently only wears glasses to read, but only with minimal improvement. Upon examination, her uncorrected distance vision is 20/100 in both eyes. Her vision corrects to 20/30 with +3.75 sphere in both eyes. Her brightness acuity testing (BAT) is 20/60. Her exam is unremarkable except for +2 nuclear sclerotic cataracts. The conversation between doctor and patient is as follows:
Patient: I have cataracts?
Patient: I have cataracts?
Doctor: Yes.
Patient: Are they going to get worse?
Doctor: Yes.
Patient: Are they going to get worse?
Doctor: Yes.
Patient: Is that why I don’t see well?
Doctor: Yes.
Patient: How can you help me?
Doctor: I can remove the cataract with ultrasound in about five minutes.
Patient: Wow! Do you think I will be able to see better?
Doctor: Yes. In fact, you will probably have 20/20 vision without glasses.
Patient: Really?
Doctor: Yes, but only for driving. If you want to have 20/20 for reading, you have to pay extra for premium lenses, which is about $4,000 for both eyes. In the long run it is cheaper to pay upfront than to buy glasses every year at $500 a pop. Think of the convenience of waking up in the morning and being able to see the time on the alarm clock, read a menu at a restaurant, and drive, all without glasses! It is a small price to pay for your eyes.
Patient: I really can’t afford that right now.
Doctor: Okay, then we will help you see 20/20 for distance.
Patient: When can I have surgery?
Doctor: Likely within the next two week. On the way out, my front desk will give you all the details you’ll need to prepare for surgery.
Patient: What are the risks involved with this surgery?
Doctor: Complications are rare and like any surgery, they include things like infections, retina detachments, etc. The risk is of losing vision is less than 10,000.
POST-OP WEEK ONE: Right Eye 20/25 uncorrected, 20/20 with correction
Patient: Doctor, you are amazing! I never had any pain and now I can see perfectly – already 20/25 without glasses. Just so you know, your lobby is packed with other patients you operated on last week and they are all talking about how good you are.
Doctor: Thank you! Do you think you’re ready to have surgery on the other eye?
Patient: Yes.
POST-OP DAY ONE: Left eye 20/40 uncorrected, 20/30 with correction
Patient: Doctor, why did the surgical center nurse mention that I was back too quick for a “broken capsule?” Is something broken?
Doctor: Nothing is broken, exactly. The bag that holds the plastic lens in the right eye is not intact because it opened during the removal of your cataract. Everything is fine. You see fine.
Patient: I know, I see perfect! My reading is better too, even with weaker readers.
Doctor: Your left eye is doing well too.
POST-OP WEEK SIX: OD 20/30 OS 20/20 uncorrected vision. OD 20/25 and OS 20/20 corrected vision
POST-OP WEEK SIX: OD 20/30 OS 20/20 uncorrected vision. OD 20/25 and OS 20/20 corrected vision
Patient: Doctor, the right eye is not as good as the left. Why is that?
Doctor: Well, your right eye will be able to see the same as left with a mild prescription of glasses.
Patient: So, what is my vision?
Doctor: Your distance vision without glasses is 20/30 in right eye and 20/20 left eye.
Patient: You promised I was going to be 20/20!
Doctor: I never promised. I said that I would try to help you see 20/20. Also, not all surgeries are perfect, and not all patients heal perfectly.
Patient: Why does my right eye seem so much blurrier if the difference is only two lines between the two eyes?
Doctor: Because the prescription is needed.
Patient: Why is the prescription needed? Because of the broken capsule?
Doctor: You are so smart! Yes, the lens I used could not be placed in the bag, so I placed it in the front of the bag, which changed the prescription.
Patient: I see.
POST-OP WEEK EIGHT: Best corrected OD 20/80. OS 20/20
POST-OP WEEK EIGHT: Best corrected OD 20/80. OS 20/20
Patient: I think the right eye is worse. Your office could not get me in last week. Do you think the diabetes is hurting my eyes?
Doctor: I think you are worrying too much about that prescription power. However, I will order a retina scan.
Patient: No, really the vision was clearer in the first weeks of surgery and now it’s definitely more blurry. Even straight lines look wavy now with the right eye.
Doctor: The optical coherence tomography of the retina reveals that you have cystoid macular edema and your best corrected vision is 20/80.
Patient: Both eyes?
Doctor: No, just the right eye.
Patient: The broken thing in the eye, huh?
Doctor: Yes, you are clever.
Patient: Do people with the same broken capsule condition get this macular edema?
Doctor: Some do.
Patient: Maybe we should have done the OCT thing weeks ago.
Doctor: I need to refer you to a retina surgeon.
Patient: For what purpose?
Doctor: Possible injections inside the eye.
Patient: I don’t like the way this is going.
Case Discussion:
Case Discussion:
Several issues arise in the case above, with all of them revolving around the issue of informed consent and indications of surgery. This case is fictional and includes many issues for educational ethics purposes.
- Did the patient need cataract surgery?
- Was proper consent obtained?
- Is this patient a candidate for premium lenses?
- Should this patient have been informed about the broken capsule?
- Should this patient been informed that no new lens calculations were made and that an original lens was implanted in the sulcus?
- Did the patient have second eye surgery too soon?
- Did the surgical staff act inappropriately by mentioning to the patient that she is returning too soon for second eye surgery?
- Was the patient promised 20/20 vision?
- Did the doctor see the patient at appropriate intervals, given the patient’s history of a broken capsule, diabetes, and complaints of vision issues?
- Should surgeons give patients the amount of time it takes to perform a specific surgery?
- Did the surgeon use language that a fifth grade student could understand?
Please discuss these questions below.
posted by MedRounds Publications at 2:55 PM
1 Comments:
1. Did the patient need cataract surgery?
There was no discussion documented about the patient’s difficulty with daily tasks due to her visual decline. Based on the BAT, or glare, testing, her vision decreased to 20/60; however, visual decline alone is not enough for cataract surgery. The surgeon should also state that there is difficulty with daily activities, such as driving, night driving, reading, writing checks, glare/halos, and other problems with her vision.
With new glasses and correctable vision to 20/30, the patient is legal to drive and will pass her driver’s examination. Unless she is bothered by “glare” while driving, there is little indication for cataract surgery. Otherwise, if she is having trouble driving due to glare, then cataract surgery is an option for this patient.
2. Was proper consent obtained?
There was no informed consent obtained by the physician documented. Informed consent should be performed by the surgeon.
3. Is this patient a candidate for premium lenses?
Yes, this patient is a candidate for premium lenses IF she desires to be completely glasses free. There should be a detailed discussion about post-surgical expectations. The vision achieved may not be as good compared to a mono-focal lens with reading glasses or with bifocal glasses.
4. Should this patient have been informed about the broken capsule?
Absolutely! Patients understand that things can happen with surgery. In particular, if there was proper informed consent, this should have been discussed pre-operatively.
5. Should this patient been informed that no new lens calculations were made and that an original lens was implanted in the sulcus?
Yes, absolutely. The significant reason for malpractice suits is non-disclosure on the physician’s part. When the patient finds out, the patient feels like “something is wrong” and that the doctor is “covering something up”.
6. Did the patient have second eye surgery too soon?
I usually wait at least 3-4 weeks before I do the second eye because I want to make sure the first eye does not have any problems to address, such as CME.
7. Did the surgical staff act inappropriately by mentioning to the patient that she is returning too soon for second eye surgery?
Yes, the surgical staff should refrain from making these inappropriate comments.
8. Was the patient promised 20/20 vision?
I think the promise was implied when the surgeon said, “Yes. In fact, you will probably have 20/20 vision without glasses.”
Perhaps a statement like the following is more appropriate, “You will likely see better than when you had the cataracts. In particular, your glare symptoms will be reduced. You may need glasses to see clearly in the distance and at near.”
I do not recommend stating a final visual acuity because you can’t guarantee that the patient will NOT develop CME, an epiretinal membrane, retinal detachment, or endophthalmitis (~1:1000 cases).
9. Did the doctor see the patient at appropriate intervals, given the patient’s history of a broken capsule, diabetes, and complaints of vision issues?
A patient with complaints like the above and complications may need to be followed at least weekly. The patient can also be placed on steroid and NSAID drops for the CME without need for intraocular steroids.
10. Should surgeons give patients the amount of time it takes to perform a specific surgery?
I don’t recommend giving times. You’ll just jinx yourself. If asked, then I give a time frame, “10-20 minutes if all goes well, but if your lens is more difficult to remove, then it may take longer.”
11. Did the surgeon use language that a fifth grade student could understand?
Yes, I think so. But the surgeon should have been more detailed in his/her explanations.
Post a Comment
Links to this post:
Create a Link
<< Home