Malpractice Litigation in Ocular Oncology.

AIMS: The aim of this study was to report and analyze the causes and outcomes of ocular oncology malpractice litigation. METHODS: The WestLaw® database was reviewed for all litigation related to ophthalmology in the United States from 1930 to 2014. All ocular oncology cases were included in this analysis and compared to other ophthalmic subspecialties. RESULTS: Sixteen ocular oncology malpractice cases were included in this study. Overall, 56.3% of the cases were resolved in favor of the defendant. A total of 62.5% of cases were resolved via jury verdict, with 30.0% resulting in plaintiff verdicts with mean adjusted awards of USD 511,244.48, comparable to ophthalmology as a whole. Three cases (18.8%) resulted in settlements with mean adjusted indemnities of USD 828,928.14. A total of 87.5% of cases alleged insufficient intervention resulting in loss of vision and/or death. The most common clinical entities were uveal melanoma (31.3%), retinoblastoma (12.5%), and sebaceous cell carcinoma (12.5%). CONCLUSIONS: Ocular oncology malpractice litigation was relatively rare and outcomes generally favored defendants; however, unlike other subspecialties in ophthalmology, blindness or premature death were common to all cases, highlighting both the importance of prompt diagnosis and treatment and the difficulty inherent in diagnosing ocular malignancies.

Malpractice Litigation in Cornea and Refractive Surgery: A Review of the WestLaw Database.

PURPOSE: To report and analyze the causes and outcomes of malpractice litigation in cornea and refractive surgery. METHODS: The WestLaw database was reviewed for all malpractice litigation related to ophthalmology in the United States between 1930 and 2014. Search terms included ophthalmology or ophthalmologist and malpractice anywhere in the retrieved results. All cases involving cornea and refractive surgery were included in this analysis, and results were compared with ophthalmology as a whole. RESULTS: One hundred fifty-nine cornea and refractive surgery cases between the years 1964 and 2014 were included. Ninety-three cases (58.5%) were resolved through a jury trial, 21.5% of which were associated with plaintiff verdicts with a median adjusted jury award of $588,896 (mean $1,518,686). Nineteen cases (11.9%) resulted in settlements with a median adjusted indemnity of $782,533 (mean $761,963). Commonly litigated scenarios included laser-assisted in situ keratomileusis (74.2%) and corneal transplantation (8.2%). Overall, 88.7% of cases involved surgical or procedural claims, 8.8% involved noninterventional claims, and 2.5% involved medical claims only. CONCLUSIONS: Cornea and refractive surgery is a high-risk subspecialty of ophthalmology. Laser-assisted in situ keratomileusis and corneal transplant claims were the most commonly litigated entities in this series. Many cases focus on failure to achieve patients' desired expectations after elective refractive procedures or the negligent performance of refractive surgery on patients with contraindications to surgery, both highlighting the importance of detailed informed consent discussions, realistic goal setting with patients, and thorough examinations and preoperative evaluation.

Modified second stage Hughes tarsoconjunctival reconstruction for lower eyelid defects.

To describe a novel technique utilizing an amniotic membrane graft (AMT) to create the mucocutaneous portion of the lower eyelid margin in a modified Hughes eyelid reconstruction for secondary revision or prevention of a hyperemic, hypertrophic conjunctival margin with excessive discharge. This was a retrospective, non-comparative interventional study. Thirty consecutive patients who underwent a modified Hughes reconstruction were included. The first step of the reconstruction was performed in a standard fashion using a tarsoconjunctival flap from the ipsilateral upper eyelid. The second stage was accomplished by the division of the tarsoconjunctival flap. The modification of the procedure included the addition of AMT (Ambio 5®, IOP Ophthalmics, CA) to the new mucocutaneous junction. Main outcome measures included the post Mohs surgery defect size, post-reconstruction complications. One patient received AMT for a revision of a hyperemic lid margin following reconstruction, while 29 subsequent patients received AMT as a primary procedure. The mean size of the post-Mohs defect was 23.75 ± 6.6 mm2 horizontally and 9.1 ± 5.4 mm2 vertically, involving 79.53 ± 16.8% of the lower eyelid. There was no evidence of hyperemic or hypertrophic margin at a mean follow-up of 4.41 ± 2.91 months. The addition of an AMT for the revision, or as a primary procedure for prevention of a hyperemic, hypertrophic eyelid margin with excess mucus production in the post-Hughes lower eyelid reconstruction has favorable outcomes in this preliminary study, however warrants further investigation with larger number of patients and longer follow-up.

Medical Malpractice in Uveitis: A Review of Clinical Entities and Outcomes.

PURPOSE: To guide risk management in uveitis. METHODS: Retrospective review of malpractice verdicts, rulings, and settlements. RESULTS: The WestLaw® database was reviewed for lawsuits related to uveitis in the United States from 1930-2014. Twenty-five cases met inclusion criteria, and 48% of these were infectious. Overall, 64% of outcomes favored the defendant ophthalmologist. The most common diagnoses were viral retinitis (28%), iritis (12%), syphilis (8%), and toxoplasmosis (8%). Seven suits (28%) were resolved by settlement, with mean adjusted indemnities of $724,302 (median, $409,390; range, $127,837-2,021,887). Two cases (8%) resulted in plaintiff verdict, with adjusted awards of $1,399,800 and $630,799. CONCLUSIONS: Despite being a rare diagnosis, viral retinitis (especially acute retinal necrosis) is the most common clinical entity associated with litigation in uveitis and should be considered early. Educating patients about potential adverse events, early testing for syphilis, and maintaining a positive relationship may also minimize risk.

Objective Brow Height Measurements Following Pretrichial Brow Lift and Upper Lid Blepharoplasty.

BACKGROUND: As the ptotic brow drops below the supraorbital rim, it can exacerbate dermatochalasis by pushing the adjacent skin of the upper lid further down. AIM: The purpose of this study was to evaluate the outcomes associated with a combined pretrichial brow lift and upper lid blepharoplasty in patients with dermatochalasis and mild to moderate brow ptosis. MATERIALS AND METHODS: A retrospective case series of 46 patients with dermatochalasis and mild to moderate brow ptosis treated with a combined, bilateral pretrichial brow lift and upper lid blepharoplasty from January 2008 to December 2011. Main outcome measures included measurements of brow lift at 3 months post-operatively, complications encountered, patient satisfaction and surgeon satisfaction. RESULTS: Outcomes from 46 patients were evaluated. The mean brow lift was 1.85 mm at the lateral canthus, 1.54 mm at the lateral limbus, 1.31 mm at the mid-pupil, and 1.07 mm at the medial limbus. Brow lift at the lateral canthus was significantly more elevated than at the medial limbus (P < 0.001). Minor complications were encountered in seven of 46 patients (15.2%). Mean patient satisfaction score was 3.20 and surgeon satisfaction 3.24 (max = 4, very satisfied). CONCLUSIONS: The modified pretrichial brow lift offered effective lateral lift that complements an upper lid blepharoplasty. This technique was met with a high degree of patient and surgeon satisfaction, and had a minimal complication profile.

Foveal hypoplasia in autosomal recessive spastic ataxia of Charlevoix-Saguenay.

A 14-year-old boy presented with a presumed diagnosis of autosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS). The neurological examination, nerve conduction study, and brain imaging results were all consistent with the diagnosis. The ophthalmologic examination was notable for a prominent myelinated nerve fiber layer extending from the disk along the major temporal arcades in both eyes. Loss of foveal depression was noted clinically and on spectral domain optical coherence tomography. This case highlights a novel finding that may aid in the diagnosis of ARSACS.

Assessment of Office-Based Practice Patterns on Protective Eyewear Counseling for Patients With Monocular Vision.

PURPOSE: To investigate the practice patterns of office-based counseling on the importance of protective eyeglasses in monocular patients and to offer our counseling recommendations. METHODS: In this cross-sectional study, data were collected in the form of surveys. Surveys were administered at an oculoplastic ophthalmology clinic in Michigan. Inclusion criteria included adults with vision of 20/400 or worse in only 1 eye. Survey questions were focused on whether patients with monocular vision recall being previously counseled by their primary ophthalmologist about wearing eye protection. RESULTS: A total of 60 surveys were completed. The average age was 62.2 years old (range: 23-90 years old). Of the completed surveys, 56.7% (34/60) did not recall receiving education about wearing protective glasses over their better seeing eye, while 35.0% (21/60) recalled having received education from their referring ophthalmologist about eye protection, and 8.3% (5/60) were uncertain about receiving eye protection counseling. Twenty (33.3%) patients reported the reason for decreased vision. Of those, 35% (7/20) of patients reported monocular vision resulting from trauma, while 65% (13/20) reported vision loss due to other reasons. There was no significant difference in recall of receiving counseling about the importance of eye protection between the 2 groups (p = 0.74). CONCLUSIONS: The results of this study highlight the current counseling short-comings, as more than half (56.7%) of patients surveyed did not recall being counseled on the importance of protecting their better seeing-eye, or ways of doing so. More counseling on protective eyewear needs to be incorporated into the preferred practice pattern for care of patients with monocular visual impairment because these patients are vulnerable to the devastating consequences of complete blindness as a result of an injury to their functioning eye.

Refractive outcomes of combined cataract and glaucoma surgery.

PURPOSE: This study was designed to evaluate the refractive outcomes of combined cataract extraction and glaucoma surgery. DESIGN: Retrospective case series. METHODS: A retrospective chart review of patients undergoing simultaneous cataract extraction with trabeculectomy or glaucoma drainage device surgery was performed. The main outcome measure evaluated was whether or not spherical equivalent of -1.00 to +0.50 D was achieved at 3 to 6 months postoperatively. Secondary outcomes included: reduction in intraocular pressure, amount of cylinder induced by combined surgery, and individual patient characteristics that may have affected refractive outcome. Outcomes were compared with an age-matched and sex-matched control group of patients who had uncomplicated cataract surgery during the same time period. RESULTS: Forty-three eyes of 36 patients underwent combined cataract extraction and glaucoma surgery. A refractive outcome of spherical equivalent between -1.00 and +0.50 D was achieved in 32 of 43 eyes (74%) at 3 to 6 months after surgery. Logistic regression analysis found a 1.14 increased risk of the refraction being outside this defined refractive range in older compared with younger patients (by year, 95% CI, 1.04-1.27). Type of lens implant used, type of glaucoma surgery, and preoperative best-corrected visual acuity did not significantly affect refractive outcome. In a subset of 22 eyes with available preoperative keratometry measures, a mean 1.31 D (SD=0.86; range, 0.26 to 3.76) of corneal astigmatism was induced by combined surgery. In comparison, a matched control group who had cataract surgery alone achieved target refractive outcome in 34 of 40 eyes (85%, P=0.001) and had a trend for less induced cylinder (0.99, SD=0.72, P=0.11). CONCLUSIONS: Favorable refractive outcomes were achieved in the majority of patients despite the potential alteration of preoperative measurements and introduction of error into lens selection when using a combined approach. There does not seem to be a difference in the refractive outcome with regard to the type of glaucoma surgery performed. Control patients who had cataract surgery alone had a higher percentage of achieving target refractive goal and less induced cylinder.

Anophthalmic syndrome: a review of management.

PURPOSE: To review and summarize current management of anophthalmic syndrome-enophthalmos, superior sulcus syndrome, lower eyelid laxity, and upper eyelid ptosis. METHODS: The authors performed a PubMed search of all articles published in English on the management of anophthalmic socket syndrome. RESULTS: A review of 37 articles demonstrated that anophthalmic syndrome occurs in a significant proportion of this patient population. Primary prevention through careful selection of primary orbital implant is ideal. Residual mild deficits can then be corrected through prosthesis modification. When modification of the prosthesis is no longer sufficient, specifically targeted procedures become necessary. CONCLUSIONS: Ocularists and oculoplastic surgeons should work together closely to treat anophthalmic syndrome. Future studies should establish uniform measurement criteria as the next step in validating the benefit and limitation of each technique.

Alphasphere as a successful ocular implant in primary enucleation and secondary orbital implant exchange.

PURPOSE: To describe the surgical technique for a novel poly-HEMA (2-hydroxyethyl methacralate)[PHEMA] implant (Alphasphere, Addition Technology, Des Plaines, IL) in primary enucleation and placement of secondary orbital implant. METHODS: Retrospective chart review of all patients receiving an Alphasphere implant for primary enucleation or secondary implant exchange from October 2009 to 2011. Interval follow-up was performed again on January 2013. Patient demographics, indications for surgery, and post-operative complications were reviewed. RESULTS: Twelve patients received an Alphasphere implant for primary enucleation (n = 10) or secondary exchange (n = 2), with follow-up that ranged from 2 weeks to 14 months. The study included 9 adult and 3 pediatric patients with a mean age of 40 years, range 8-82 years. The indication for enucleation included: painful blind eye (n = 9), enophthalmos with difficult prosthesis fit in cases of secondary implant exchange (n = 2), and prophylaxis for sympathetic ophthalmia (n = 1). Only one patient required removal of the implant, due to a sinus infection with subsequent extrusion of the implant. Otherwise, the only other complication experienced was slight implant migration (n = 1). CONCLUSION: This initial report indicates that Alphasphere can be successfully used in the management of an anophthalmic socket. The advantages of the Alphasphere implant include: it does not require tissue wrapping, extraocular muscles can be directly sutured to the implant, it maintains a smooth surface to limit risk of exposure due to conjunctival breakdown, and undergoes anterior orbital fibrovascular ingrowth which optimizes prosthesis location and socket motility.

TB Peritonitis Mistaken for Ovarian Carcinomatosis Based on an Elevated CA-125.

Background. In the United States, tuberculosis (TB) is of relatively low prevalence and most newly diagnosed patients are born outside of the United States. In addition, a large percentage (20.6%) of TB cases initially present with extrapulmonary manifestations (CDC, 2010). Cases of TB peritonitis are a diagnostic challenge in women due to the nonspecific clinical features overlapping with signs of ovarian cancer. (Kosseifi et al., 2009; Rashed et al., 2007; and Xi et al., 2010). We present a 27 year-old woman thought to have ovarian carcinomatosis based on elevated levels of CA-125 who was ultimately diagnosed with TB salpingitis, endometritis, and peritonitis. Methods. This brief report is a retrospective case report. Results. This case outlines the unfortunate consequences of the misdiagnosis of what probably was an antibiotic responsive illness, resulting in an unnecessarily aggressive surgical procedure. The delay in the diagnosis of tuberculous pertitonitis resulted in an unnecessary radical resection of the patient's reproductive organs. Conclusions. Patients with TB peritonitis present with non-specific signs that may be misdiagnoses as ovarian cancer. In differentiating between ovarian carcinomatosis and peritoneal TB, it is vital to consider country of origin, age, CA-125, ascitic fluid analysis, and the use of intra-operative frozen sections.

Cranial nerve seven palsy and its influence on meibomian gland function.

PURPOSE: To investigate a possible relationship between cranial nerve seven (CN VII) palsy and meibomian gland dysfunction. METHODS: A prospective case series of 16 patients with unilateral CN VII palsy was evaluated for meibomian gland function. Main outcome measures included the Sunnybrook Facial Grading System for CN VII palsy and a modified version of a noncontact, noninvasive meibomian gland evaluation by Arita et al., Unaffected contralateral eyes were used as the control group for comparison. RESULTS: Sixteen affected eyes were evaluated. The mean Sunnybrook Facial Grading System composite score was 34.19 ± 24 (score = -15 to 100; maximum function = 100). A paired samples t test between affected and unaffected eyes demonstrated a significant difference between mean values for tear break-up time, eyelid abnormality, meiboscore for upper eyelid, meiboscore for lower eyelid, combined meiboscore, and digital pressure. No significant difference was found for superficial punctate keratopathy nor Schirmer's test. A Pearson product-moment correlation coefficient found a significant negative correlation between the Sunnybrook Facial Grading System composite score and all aspects of meibomian gland function, except for the upper eyelid meiboscore, which only approached significance (p = 0.059). CONCLUSION: These findings suggest that a strong relationship exists between cranial nerve seven palsy and meibomian gland dysfunction. Clinical optimization of meibomian gland function may benefit cranial nerve seven palsy patients.

Asymmetric eyebrow elevation and its association with ocular dominance.

PURPOSE: To examine the relation between asymmetric eyebrow elevation and ocular dominance. METHODS: A retrospective cohort study was performed in patients who underwent bilateral upper eyelid blepharoplasty from July 2007 to May 2009. Patients with pre- and postoperative involuntary asymmetric eyebrow elevation were selected from a surgical log database for inclusion in this study. Brow asymmetry was determined by examination of preoperative and postoperative digital photographs and was defined as a measured eyebrow-height difference in conjunction with the asymmetric recruitment of the frontalis muscle. Ocular dominance was determined by using a modified Porta test. Statistical analysis was performed by using the Fisher Exact test. RESULTS: Forty-seven patients met inclusion criteria. Sixty-six percent (31 of 47) involuntarily, asymmetrically elevated the right eyebrow, and 34% (16 of 47), the left. Of the 31 patients with right eyebrow elevation, 87% (27 of 31) were right-eye dominant, and 13% (4 of 31) were left-eye dominant (p < 0.001). Among patients with asymmetric left eyebrow elevation, 62.5% (10 of 16) were left-eye dominant, whereas only 37.5% (6 of 16) patients were right-eye dominant (p < 0.001). CONCLUSION: We report for the first time that involuntary asymmetric eyebrow elevation and ocular dominance are significantly associated. The assessment of ocular dominance should be included in the pre- and postoperative evaluation of patients with asymmetric brow elevation undergoing blepharoplasty. This asymmetry and its etiology must be recognized, so that an attempt to create symmetry does not result in the overcorrection of the contralateral eyelid that may lead to complications such as lagophthalmos and exposure keratopathy.

Delay in diagnosis of cerebral venous and sinus thrombosis: successful use of mechanical thrombectomy and thrombolysis.

Cerebral venous and sinus thrombosis is a relatively rare condition with a variable presentation that can translate into a difficult workup and a delay in diagnosis and treatment. We describe the successful use of mechanical thrombectomy and thrombolysis in the case of an eighteen-year-old woman that presented with progressive thrombosis of the jugular veins and dural sinuses despite adequate anticoagulation. Our case highlights the need for clinicians to include CVST in the initial differential diagnosis of patients in order to prevent delays and poor outcomes.

Undiagnosed HIV Presenting with Lymphoid Interstitial Pneumonitis.

Undiagnosed or untreated human immunodeficiency virus infection can lead to devastating complications. We present a case of a 41-year-old woman who was found to have HIV-related lymphoid interstitial pneumonitis. LIP is uncommon, and its presentation can be quite similar to that of other chronic lung conditions. This case illustrates one of the possible protean manifestations of untreated HIV and is a sobering reminder of the need to screen all adults for HIV infection. Additionally, further invasive diagnostic testing may be required to guide therapy in patients with advanced acquired immune deficiency syndrome. This patient's LIP was likely related to long-standing unrecognized HIV disease.