Ophthalmic malpractice lawsuits with large monetary awards.

Malpractice claims against ophthalmologists that were closed with patient indemnification of at least $250,000(18% of all eye claims closed with payments to patients) were analyzed for risk prevention. The incident of alleged malpractice occurred within 1 month of the initial physician-patient encounter in 43% of claims and on the initial encounter in 17%. Cataract was the most frequent problem for which these patients sought treatment. Eighty-four percent of these patients sustained injuries resulting in legal blindness or worse. The most frequent complication of treatment (25%) was failure or delay in diagnosis of detached retina, or negligent treatment resulting in a retinal detachment. The most frequent factors influencing the decision to seek a settlement included altered records, poor documentation, informed consent problems, failure to see the patient promptly, and failure to obtain or follow the advice of a consultant.

Recognizing and managing the litigious patient.

There is no accurate pre-treatment profile of the litigious patient. It is usually the lawsuit-causing physician who drives the patient to initiate litigation. The establishment and control of the physician-patient relationship are the keys to preventing litigation; this is achieved by improving physicians' ability to communicate, demonstrate empathy and support, and conduct appropriate discussion of informed consent. After treatment, physicians must pay special attention to patients who exhibit certain behavior typical of dissatisfaction. They should be accorded extra time and attention and, in some instances, should be referred to another practitioner for a second opinion and follow-up care.

Miotics and retinal detachment: upgrading the community standard.

The majority of ophthalmologists who responded to a questionnaire regarding the relationship between miotics and retinal detachment felt that such a relationship does exist, and that myopia and aphakia/pseudophakia predispose to the formation of new retinal breaks or to retinal detachment from pre-existing breaks with miotics. Horseshoe breaks and dialyses are pre-existing lesions that should be treated prophylactically prior to miotic therapy. Patients with no predisposing pathology or whose eyes have lattice degeneration or operculated breaks should be warned of possible retinal detachment prior to starting miotics. Not performing a peripheral retina examination prior to prescribing a miotic is acceptable, but not optimal, medical practice. Examining the peripheral retina or obtaining a retina consultation prior to prescribing a miotic may be beneficial to the patient and could be invaluable in the defense of litigation.

Learning scleral depression with binocular indirect ophthalmoscopy.

Scleral depression with binocular indirect ophthalmoscopy will be easier to learn if the examiner observes the patient's pupillary reflex through the ophthalmoscope without looking through the hand-held condensing lens. When the tip of the scleral depressor is properly positioned the pupillary reflex will darken slightly. If the condensing lens is then moved into position the actual scleral depression will be visible.

Retinal neovascularization after branch retinal arterial obstruction.

We examined two eyes from two noninsulin-dependent diabetic patients that developed vitreous hemorrhage secondary to retinal neovascularization after branch retinal arterial obstruction. Although there was no ophthalmoscopic evidence of diabetic retinopathy, diabetes mellitus may have predisposed the retinas to a neovascular response, which was precipitated by the arterial obstruction.

Line copy presentation slides with Kodalith.

Line copy presentation slides with white letters on a blue background can be produced with a two-step process. The slides are more permanent than diazo slides, and the process is faster and less expensive.

Rentrolental fibroplasia in a full-term infant.

A 3,800-g infant, born after 40 weeks' gestation, developed retrolental fibroplasia, documented by indirect ophthalmoscopy. Elevated arterial oxygen tensions may have occurred during brief treatment for two episodes of cyanosis.

Pseudohypopyon in Best's vitelliform macular dystrophy.

We examined ten eyes with pseudohypopyon in seven patients with Best's vitelliform macular dystrophy. Fluorescein angiography showed hyperfluorescent defects in the retinal pigment of the superior half of the lesion in all ten eyes. The electro-oculographic findings were abnormal in all four patients who underwent this test. The fluid shifted slightly in two of six patients whose heads were turned to the side for an hour or longer, indicating that the material was probably located between the retinal pigment epithelium and the sensory retina. The volume of the hypopyon increased in one eye.

Prevention of accidental intraocular injection following inadvertent needle perforation of the eyeball.

To prevent accidental intraocular injection after inadvertent single needle perforation of the eyeball, the authors recommend moving the needle and watching for corresponding movement of the globe following peribulbar or retrobulbar placement of the needle and prior to injecting. The authors have found this technique to be safe and reliable, with negligible morbidity.