Medical-Legal Triage Case Study: Cataract

A 70-year-old diabetic male with a multi-year history of declining vision OD (right eye) is diagnosed with a cataract. Ophthalmologist removes the cataract by phacoemulsification but after the aspiration and irrigation, i.e., during the IOL (intraocular lens) placement, the lens is dropped from the anterior chamber into the vitreous, landing around the retina. Ophthalmologist, realizing the severity of this complication goes ‘fishing’ for the lens. During this attempt to retrieve the lens which is sitting on the retina, the retina is damaged. Ophthalmologist closes and, a few days later the patient’s OD vision is not restored but, rather, is manifesting the symptoms of retinal injury.

Who should review it?

Most attorneys would seek out an ophthalmologist as an expert based on the ‘obvious’ need to have an expert in the same field as the defendant. So, why isn’t the analysis that simple? Because the lens fell not only into the eye, but “into” a subspecialty of ophthalmology called retina-vitreous ophthalmology. Subspecialists in that field are most equipped to assess the etiology, severity, and prognosis of retinal injuries. Also, did the attorney check if the patient was a diabetic? If so, for how long? Was it under control? Were there prior diabetic retinopathy symptoms? It is important to appreciate the ramifications of a diabetic diagnosis in a case involving a retinal injury.

What does diabetes have to do with cataract surgery?

Diabetics are prone to small vessel disease as the disease progresses. The smallest of the vessels in the body include those that are smallest and/or in the most distal periphery, like in the ends of the toes, the ends of the fingers, the kidneys, the brain, the penis . . . and the retina. Like the canary dying in the coal mine, these are the first to suffer the effects of diabetes, which is why, for example, diabetics will develop insufficiently perfused toes or have erectile difficulties amongst their first vascular symptoms. For diabetics, there might be very large, potentially dispositive, issues regarding the etiology of the retinal damage: was it caused by the instrumentation or was it from the preexisting diabetes? and, if so, can it be proven?

But the patient did not have retinal damage preoperatively, so isn’t it irrelevant?

Well, maybe and maybe not. It depends on the patient’s diabetic severity, duration, and control. Even if there was no known retinal detachment, the ophthalmology records might document diabetic retinal damage that might have been imminent. If such facts exist, it is better to know about them up-front and not be surprised at trial. In such a case, one should consider having a retina-vitreous ophthalmology expert review the case.

So, does this mean that a retina-vitreous ophthalmologist is the best expert?

It depends. On one hand, retinal detachment etiology should be a major focus (sorry for the pun) in such a case. On the other hand, if state law mandates that a medical malpractice deviation expert be in the same field as the defendant (specifically, that a generalist is needed as medical expert if the defendant is a generalist), then a (general) ophthalmologist will be needed–eventually–as an expert. Again, eventually.

There are (at least) two major sources of issues. Chronologically first is whether dropping the lens was a deviation, whether there was deviation in the attempt to retrieve it, and whether the operating surgeon should have been the one to attempt the retrieval (versus a retina-vitreous ophthalmologist). The second source of issues is the previously discussed etiology of the eventual retinal damage (idiopathic v. natural progression of the disease (perhaps inevitable)) and, if so, whether the retinal injury hastened the retinal damage to the patient’s vision. Having a retina-vitreous ophthalmologist is a way to have one expert opine on all the issues as every ophthalmologist has performed phacoemulsifications at least during training.

So, the retina-vitreous ophthalmologist is the easy choice.

It (still) depends. Even compared to general ophthalmologists, they are extremely well paid for what they do so they tend to be very reluctant to want to get involved as medical experts. Add to that they get their cases from (general) ophthalmologists (as well as endocrinologists and internists) primarily so they especially don’t want to get a reputation for testifying against any ophthalmologists at all. They are relatively hard to find and also relatively expensive.

What about having a (general) ophthalmologist as an expert first?

Well, the more likely dispositive issues in many of these cases tend to be regarding the retina-vitreous causation/damages, so one could spend money getting the easier issues reviewed rather than going for the likely dispositive ones on the first review. Besides, again, there may be a possibility to have only one expert (a retina-vitreous ophthalmologist) on the case.

One thing is certain, if there is a legitimate retinal detachment etiology issue, it could be fatal to the case to miss it until such time that adding a retina-vitreous ophthalmology expert is precluded.