Authored by Edward Goodman
For lawyers and lay people alike, the field of ophthalmology is very confusing. The medical terms are unfamiliar and sound strange. The purpose of this article is to provide lawyers and patients with some basics in ophthalmology and to identify areas that frequently give rise to ophthalmology cases.
A helpful jumping off point is a basic dictionary defining the anatomic parts of the eye:
The sclera is the white part of the eye; the conjunctiva is the clear layer of tissue that covers the sclera.
The iris is the colored part of the eye.
The pupil is the opening in the center of the iris. The size of the pupil determines the amount of light that enters the eye.
The anterior chamber [“AC”] of the eye is the space between the iris and the cornea. The AC is filled with aqueous humor, clear watery fluid that flows between and nourishes the lens and the cornea. It is secreted by the ciliary processes
The cornea is the transparent front part of the eye (dome-like structure) that is in front of the iris, pupil and anterior chamber. Light passes into the eye through the cornea, allowing vision. The cornea has five layers.
The lens is a transparent body that, along with the cornea, refracts light and focuses it on the retina: The lens is considered part of the anterior segment of the eye.
The posterior chamber is the small space behind the posterior part of the iris and the anterior part of the lens.
The posterior segment is behind the lens and is filled with vitreous humor, a gel like substance that fills the eye between the lens and the retina.
The retina is a light-sensitive layer at the back of the eye. Photosensitive cells called rods and cones in the retina convert incident light energy into signals that are carried to the brain by the optic nerve. In the middle of the retina, is a small dimple called the fovea or fovea centralis. The fovea is the center of the macula. It is the center of the eye’s sharpest vision and the location of most color perception.
The macula is located roughly in the center of the retina, temporal to the optic nerve. It is a small and highly sensitive part of the retina responsible for detailed central vision.
The fundus refers to the back of the eye and includes the retina and macula (part of the retina).
A cataract is an opacity (cloudiness, haziness) of the natural lens of the eye. A cataract impedes light from getting from one side of the lens to the other. Cataracts are very common, and become more likely, as a person ages. Cataracts are progressive (although the rate at which they progress varies from person to person).
The purpose of cataract surgery is to remove the patient’s natural lens, which has become cloudy, and to replace it with a new man made lens. The new lens is called an intra-ocular lens [“IOL”].
Cataract surgery is primarily done by phacoemulsification [“phaco”]. The phaco machine uses high frequency vibrations to chop up the nucleus of the lens and suck it out. (The phaco probe consists of a hollow cylindrical tip surrounded by an irrigation sleeve. When activated, the probe tip oscillates rapidly, creating ultrasonic waves that disrupt the lens). An older procedure used to perform cataract surgery is called extra capsular cataract-extraction (ECCE). Some surgeons who were originally trained to use this procedure still use it. While both ECCE and phaco are both outpatient procedures, ECCE requires a larger incision and is more invasive.
There is some thought that a surgeon who performs ECCE has an ethical obligation to advise a patient that he/she is a candidate for phaco. If the surgeon has such an obligation and fails to do so, a potential informed consent case can result if the patient has a complication resulting from the ECCE that would not have resulted from a phaco.
Part of cataract surgery involves opening the lens capsule (“bag”) in order to remove the natural lens and place the IOL. The potential for a malpractice case often arises if the surgeon damages the bag and fails to recognize that he did so, as this can lead to the IOL lens being displaced. In many phaco procedures the surgeon makes a suture-less incision that seals itself. It is incumbent upon a surgeon doing so to check that the wound is water tight at the end of the procedure. If the surgeon fails to do so, the wound can become a port for bacteria to enter the eye.
A recognized complication of a phaco procedure is a phaco burn. A phaco burn can occur if the phaco probe tip gets too hot during the procedure. While a phaco burn is a rare occurrence, it is a recognized complication of the procedure. If a burn does occur, it is incumbent upon the physician to recognize the burn and to treat it intra-operatively. The failure to treat a phaco burn immediately can leave an opening for bacteria to enter the eye and cause endophthalmitis. The failure to recognize and/or timely treat a phaco burn can give rise to a malpractice case.
The other aspect of cataract surgery that often gives rise to malpractice cases is a failure of the doctor to recognize and/or treat signs and symptoms that are present during post-operative visits and examinations. A doctor’s failure to appreciate a decrease in vision, pain, redness, discharge, floaters or flashes can all give rise to potential malpractice cases.
Endophthalmitis is an infection inside the eye. It is a potentially very serious condition that requires prompt diagnosis and treatment. Without prompt diagnosis and treatment, it can often lead to blindness or even the loss of the eye. There are two types of endophthalmitis: endogenous (from inside the body) and exogenous (from outside the body). Exogenous is more common and is the type that will be discussed in this article.
For our purposes, endophthalmitis can occur as a post- surgical complication, e.g., after cataract surgery. While rare, the fact that a patient develops endophthalmitis is not malpractice. However, developing endophthalmitis can result from a doctor’s failure to prescribe and administer the proper pre-operative, intra-operative and post-operative antibiotics. Further, a potential malpractice case can result from a doctor’s failure to recognize and appreciate the early signs of endophthalmitis during a post-op visit and exam. If a doctor does not appreciate a patient’s complaint of vision loss, pain, and/or redness, then he/she may not promptly diagnose and treat the condition, leading to a poor outcome. Treatment includes oral antibiotics, an injection of antibiotics into the eye, or even surgery. The patient’s prognosis is dependent upon a number of factors, including timely diagnosis and treatment, the type of organism involved, and the damage done to the eye.
A retinal detachment (“RD”) is one of the most dreaded eye conditions. If RD is not diagnosed and treated in a timely manner, it can lead to blindness. The most common type of retinal detachment is a rhegmatogenous detachment. This occurs when fluid seeps into a hole or tear in the retina and causes the neurosensory retina to be pulled away from the retinal pigment epithelium, causing it to be “detached.” Prior to the retina detaching, a tear typically develops. The retinal tear usually occurs due to posterior vitreous detachment (“PVD”). As people age, the vitreous humor degenerates, shrinks and separates from the retina. This process, PVD, usually occurs gradually without any problems. However, sometimes, the vitreous tugs on the retina as it detaches, thus causing the retina to tear or break.
It is vital that a retinal detachment be diagnosed and treated as soon as possible in order to preserve vision. Oftentimes, ophthalmologists (or optometrists) fail to recognize the signs and symptoms of retinal tears and detachments, with catastrophic results for the patient’s vision. Signs and symptoms of a retinal tear/detachment include floaters or flashes of light. Very often, floaters/flashes are just signs of PVD and do not require any treatment. However, a thorough eye exam can diagnose the cause as a retinal tear or detachment. The failure to do a thorough exam in the face of these signs and symptoms can lead to poor results for the patient and can be malpractice. If a patient complains that it appears that a curtain has come down over part of their visual field, this is almost certainly an indication of a retinal detachment and requires immediate treatment.
Certain risk factors predispose patients to retinal tears and detachments. These include severe myopia (nearsightedness), cataract surgery, lattice (degenerative condition the retina). Doctors must be particularly wary of patients with these risk factors presenting with the above mentioned signs and symptoms.
If a retinal tear is diagnosed, it can be treated by cryopexy (freezing) or photocoagulation (laser) to prevent the hole/tear from becoming a detachment. Once the retina detaches, surgery is required. The three surgeries that are used are pneumatic retinopexy, scleral buckle and pars plana vitrectomy.
ROP is a serious, vision-threatening eye disease. Retinopathy of Prematurity is a disease of the retina seen in premature infants. Premature infants with a low birth weight are at the most risk. The more premature and the smaller the infant at birth, the greater the incidence of ROP. Some babies who are at-risk for ROP will develop the disease which, in some cases, can be progressive. It is unpredictable in which babies ROP will progress and in which it will resolve. The treatment for ROP is to use a laser to slightly burn certain parts of the retina, which prevents abnormal growth of blood vessels which would otherwise pull the retina and cause it to detach.
In order for vision to be preserved, ROP must be diagnosed at the proper time and then treated. In order for ROP to be diagnosed, an eye exam called a screening exam needs to be performed at within the first six weeks or 42 days of life. Failure to screen, diagnose and treat ROP in a timely manner can lead to complete blindness.
Refractive surgery is any surgical procedure that permanently alters the focusing power of the eye in order to change refractive errors (myopia (nearsightedness), hyperopia (farsightedness), astigmatism). Improvement of vision is achieved by re-shaping the cornea. Refractive surgery may include corneal surgery, such as LASIK, LASEK, and PRK. While it is conceivable that malpractice can occur as a result of the physician performing the procedure improperly that is a rare occurrence. More commonly, a malpractice case arises from the doctor performing refractive surgery on a patient that is not a candidate for the surgery due to a pre-existing corneal condition or other reason. For example, keratoconus (a progressive thinning/bulging of the cornea) is a condition which is an absolute contraindication to LASIK. The failure to screen or evaluate the patient properly can lead to permanent and very debilitating injuries.