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

Canadian legal cases in ophthalmology: a closer look at 40 years' worth of data

OBJECTIVE

To assess the characteristics of malpractice lawsuits against Canadian ophthalmologists and the predisposing factors leading to claims.

DESIGN

Retrospective case series.

METHODS

A systematic search of the 2 largest Canadian online legal databases, LexisNexis Canada and Westlaw Canada, was performed to collect cases against ophthalmologists in Canadian courts from 1977 to 2021.

RESULTS

This study comprised 68 legal cases, including 52 lawsuits, 14 cases appealed once, and 2 cases appealed twice. Most cases concerned surgical procedures (46.2%), followed by misdiagnoses or lack thereof (32.7%) and nonsurgical procedures (21.2%). Half the cases (n = 26) were immediately dismissed by the judge in favour of the ophthalmologist, though among the remaining half that proceeded to trial the majority (88.5%) were won by the patients. All appeals by patients were dismissed by the judge. The median monetary value of damages awarded was $308,202.

CONCLUSIONS

This study is the first to report on ophthalmology-involved medical litigation cases in Canada. Most cases were ruled in favour of the ophthalmologist, but most of those that were not immediately dismissed by the judge were ruled in favour of the plaintiff. Notably, a plurality of these cases argued for a lack of informed consent, and every case in which a lack was successfully pleaded was ruled in favour of the plaintiff, highlighting the importance of appropriate informed consent. The findings of this study give Canadian ophthalmologists insight into areas of practice that commonly lead to litigation and can aid in improving clinical practice and risk management.

Fraud Claims Filed Involving Practicing Ophthalmologists from 1985 Through 2020

Introduction

Like all United States physicians, ophthalmologists may be implicated in lawsuits claiming fraudulent medical practice. In order to educate, raise awareness, and mitigate fraudulent practice, we reviewed a legal database and analyzed fraud claims in ophthalmology lawsuits.

Methods

A retrospective legal literature review was performed on jury verdicts and settlements from the online legal database LexisNexis Academic from 1985 through 2020 that were filed by or against an ophthalmologist, involved a fraud claim, and included a final decision or settlement. Cases were evaluated for factors including demographics of plaintiffs and defendants, type of fraud claim, ophthalmologist party status (plaintiff or defendant), decision outcome, and amount awarded (when applicable).

Results

Of the 27 cases analyzed, all ophthalmologist defendants involved were male and the most common sub-specialty for an ophthalmologist defendant was refractive surgery. The most common fraud type was a fraud claim involving a malpractice lawsuit (12 of 27), followed by contract fraud and billing fraud. While the ophthalmologists in malpractice-related fraud cases experienced more rulings in favor of the defendant on the fraud claims (8 of 12), ophthalmologists in billing fraud cases experienced fewer rulings in their favor (0 of 5).

Discussion

Ophthalmology lawsuits involving fraud claims occurred in various settings, including malpractice lawsuits, contract cases, and Medicare and Medicaid billing. Defendants were all male and most commonly refractive surgeons.

Glaucoma-related malpractice litigation in the United States: A review of the WestLaw database

Purpose

Gaining understanding of glaucoma-related malpractice litigation may highlight ways to improve patient care and minimize risk of litigation. This study aims to analyze the outcomes and characteristics of glaucoma-related malpractice litigation.

Materials and Methods

The Westlaw legal database (Thomson Reuters, New York, NY, USA) was used to identify cases regarding ‘malpractice’ AND ‘glaucoma’ or related terms. Cases were analyzed for characteristics such as alleged cause of malpractice, outcome, and demographics.

Results

The initial search terms yielded 498 results, 107 of which met further inclusion criteria. 38 (36%) were resolved via jury trial. Of these, verdicts in favor of the plaintiff were issued in 14 cases (34%), with median adjusted damages of $702,986. Of all 107 cases in the study reviewed, 65 (61%) resulted in verdicts in favor of the defendant. Ophthalmologists were named as defendants in 85% of the cases (with glaucoma specialists representing 7% of the ophthalmologists); optometrists in 24%. Sixty percent of the cases involved non-surgical treatment. The most common medical reasons for litigation were failure to diagnose (38%), and inappropriate/negligent treatment (36%). The most commonly litigated surgical procedures were cataract surgery (48%) and iridotomy/iridectomy (19%).

Conclusion

Glaucoma-malpractice litigation has increased, with medical mismanagement alleged in the majority of cases. Defendants are frequently successful in obtaining pre-trial dismissal, but the risk of liability increases in cases going to trial. A minority of cases involved glaucoma specialists. This historical analysis of glaucoma-related malpractice cases might provide perspective and aid physicians seeking to avoid litigation.

VISION-RELATED MALPRACTICE INVOLVING PRISONERS: Analysis of the Westlaw Database

PURPOSE

To characterize vision-related malpractice litigation involving prisoners.

METHODS

Retrospective legal database review using the Westlaw database was performed to identify vision-related malpractice lawsuits involving prisoners in the United States from 1914 to 2020. Main outcomes and measurements were allegations of malpractice, verdicts, and settlements.

RESULTS

Sixty-four vision-related malpractice lawsuits involving prisoners were identified. Mean defendant age was 49 years (range, 28-74 years). Fifty-seven percent of the defendants were ophthalmologists and 43% were optometrists. The cases were most commonly from the South and Midwest (n = 19 [30%] for each). Allegations of malpractice included inadequate medical care or treatment refusal (n = 21 [33%]), failure to treat fully leading to continued suffering (n = 18 [28%]), and delay in treatment or referral (n = 17 [27%]). Retina-related diagnoses were most common (n = 18 [28%]). Forty-six (72%) cases were closed, 14 (22%) were open, and four (6.3%) were partially closed. Only two (3.1%) cases were decided in favor of the plaintiff. The most common reason for an unsuccessful suit was lack of deliberate indifference by the eye care professional (n = 21 [46%]).

CONCLUSION

The most common reasons for vision-related malpractice brought forth by prisoners were inadequate or incomplete eye care and treatment refusal. Retina was the most commonly involved subspecialty. However, the success rate of these suits was extremely low.

Medicolegal Considerations Regarding Steroid Use in Otolaryngology: A Review of the Literature

OBJECTIVE

To review the literature on corticosteroid use and provide recommendations on patient counseling and/or consent to promote judicious prescribing and reduce the incidence of corticosteroid-related lawsuits.

METHOD

A conventional literature search of PubMed on corticosteroid-related medicolegal cases was undertaken. Search terms included "medicolegal," "otolaryngology," and "adrenocorticosteroids." A medical subjects headings search with the keywords "adrenal cortex hormones" and "jurisprudence" was also performed.

RESULTS

Corticosteroids have been reported as the third most frequent medication involved in malpractice claims, oftentimes leading to disproportionately costly payments. The most common specialties found to be involved in corticosteroid related medicolegal cases included dermatology (12%), primary care (10%), and neurologists or neurosurgeons (6%). The most common complications encountered were avascular necrosis (39%), changes in mood (16%), infection (14%), and vision changes (14%). Only a few cases corticosteroid-related litigation regarding otolaryngologists were identified. More frequent causes for otolaryngology claims were intraoperative complications, deficits in diagnoses, and failures or delays in treatment. Three medicolegal pitfalls regarding corticosteroid use were identified from this review included: (1) insufficient advising, (2) lack of or incomplete informed consent, and (3) the significance of the patient-physician relationship.

CONCLUSION

Despite the scarcity of corticosteroid-related medicolegal literature pertaining to otolaryngologists, corticosteroids are one of the most widely prescribed medications in the field of otolaryngology and have been shown to have a high rate of medical malpractice claims in medicine. Counseling and consenting the patient, as well as developing a strong physician-patient relationship, are integral processes in addressing any adverse effects occurring during therapy, and may also help to decrease the incidence and success of litigation against otolaryngologists.

Malpractice Litigation in Glaucoma

PURPOSE

To analyze and report the causes and outcomes of malpractice litigation for patients with a diagnosis of glaucoma.

DESIGN

Retrospective case series.

PARTICIPANTS

Malpractice litigation cases.

METHODS

The WestLaw database was reviewed for all malpractice litigation with ophthalmologist defendants in the United States between 1930 and 2014. All litigation involving glaucoma was included in this analysis and was compared with litigation in ophthalmology as a whole.

MAIN OUTCOME MEASURES

The primary outcomes were the number of cases, jury award amounts, whether the case resolved in favor of the defendant, and the type of glaucomatous disease or procedure with the highest amount of litigation.

RESULTS

Sixty-nine glaucoma malpractice cases were included. Overall, 62.3% of cases were resolved in favor of defendants. Twenty-nine cases were resolved via jury trial, 8 of which were associated with plaintiff verdicts with a mean adjusted jury award of $994 260. Ten cases resulted in settlements with mean adjusted indemnity of $1 210 414. Commonly litigated allegations included mismanagement of glaucoma (20.3%), failure to diagnose glaucoma (17.4%), failure to diagnose or mismanagement of angle-closure glaucoma (18.5%), adverse drug effects (14.5%), and trabeculectomy complications (8.7%). Overall, the median plaintiff award for all of glaucoma litigation was $977 476; the median award across all ophthalmic subspecialties was $568 302 (P = 0.25). For jury verdicts alone, the median award in glaucoma was $977 474, compared with $604 352 for all ophthalmology (P = 0.05). For settlements alone, the median indemnity payment in glaucoma was $955 988, compared with $827 051 for all ophthalmology (P = 0.24).

CONCLUSIONS

Overall, the rate of plaintiff verdicts was similar in glaucoma and in ophthalmology as a whole; however, the magnitude of plaintiff awards was higher in glaucoma than in ophthalmology overall. Common scenarios leading to litigation included failure to diagnose or mismanagement of glaucomatous disease, as well as adverse drug effects and surgical complications. Many cases could have been avoided with careful examinations, thorough documentation in the patients' charts, and detailed conversations with patients.

Malpractice Litigation in Ophthalmic Trauma

Objective

To report and analyze the causes and outcomes of malpractice litigation in ophthalmic trauma.

Methods

The Westlaw^® database was reviewed for ophthalmology litigation in the United States between 1930 and 2014. All ophthalmic trauma cases were included and compared to non-traumatic ophthalmology malpractice cases.

Results

Forty-four ophthalmic trauma cases were included. Of these cases, 90.9% of ophthalmic trauma plaintiffs were male compared to 54.8% of plaintiffs in ophthalmology as a whole (P=<0.001); 34.1% of cases involved minor plaintiffs compared to 6.4% in ophthalmology as a whole (P=<0.001). Cases involving minors were more likely to be resolved in favor of the plaintiff than cases involving adult plaintiffs (53.3% vs 37.9%); however, this was not found to statistically significant (P=0.35). Overall, 54.5% of cases were resolved in favor of defendants; 40.9% of cases were resolved via jury trial with 50.0% resulting in payments to plaintiffs compared to the 29.6% rate of plaintiff verdicts in ophthalmology as a whole. Open globe injuries represented 61.4% of cases; 55.6% of these cases had intraocular foreign bodies and 37.0% developed endophthalmitis. Most cases (63.6%) alleged insufficient intervention. Of these cases, 31.8% of cases involved surgical or procedural claims, and 4.5% involved medical claims only.

Conclusion

Males and minors were overrepresented among plaintiffs in ocular trauma litigation. Most cases involved open globe injuries, often complicated by retained intraocular foreign bodies and endophthalmitis. Analysis of malpractice litigation in ophthalmic trauma calls attention to commonly litigated scenarios to improve clinical practice and to inform risk management.

Malpractice Litigation in Vitreoretinal Surgery and Medical Retina

BACKGROUND AND OBJECTIVE

To report and analyze the causes and outcomes of vitreoretinal surgery and medical retina malpractice litigation.

PATIENTS AND METHODS

The WestLaw database was reviewed for all vitreoretinal malpractice litigation in the United States between 1930 and 2014.

RESULTS

One hundred forty-two retina cases were included. Overall, 64.1% of cases were resolved in favor of defendants. Eighty-three (58.5%) cases were resolved via jury trial, 30.1% of which were associated with plaintiff verdicts with mean adjusted jury award of $5,222,894 (median, $691,974). Eight cases (5.6%) resulted in settlements with mean adjusted indemnity of $726,003 (median: $437,165). Jury awards were higher than settlement awards (P = .04). Commonly litigated scenarios included retinal detachment (46.5%) and retinopathy of prematurity (9.2%).

CONCLUSIONS

The complexity of treating vitreoretinal problems and the high potential for vision loss inherent in many diagnoses make treating retinal problems high-risk. Many cases in this series resulted in multi-million-dollar plaintiff awards. [Ophthalmic Surg Lasers Imaging Retina. 2020;51:272-278.].

SARI prevents ocular angiogenesis and inflammation in mice

SARI (Suppressor of AP‐1, regulated by IFN‐β) is known to play an important role in some systemic disease processes such an inflammatory conditions and cancer. We hypothesize that SARI may also play a role in ocular diseases involving inflammation and neovascularization. To explore our hypothesis, further, we investigated an endotoxin‐induced uveitis (EIU) and experimental argon laser‐induced choroidal neovascularization (CNV) model in SARI wild‐type (SARI^WT) and SARI‐deficient (SARI^−/−) mice. Through imaging, morphological and immunohistochemical (IHC) studies, we found that SARI deficiency exacerbated the growth of CNV. More VEGF‐positive cells were presented in the retina of SARI^−/− mice with CNV. Compared to SARI^WT mice, more inflammatory cells infiltrated the ocular anterior segment and posterior segments in SARI^−/− mice with EIU. Collectively, the results point to a potential dual functional role of SARI in inflammatory ocular diseases, suggesting that SARI could be a potential therapy target for ocular inflammation and neovascularization.

High drug payload nanoparticles formed from dexamethasone-peptide conjugates for the treatment of endotoxin-induced uveitis in rabbit

PURPOSE

To develop and demonstrate the effectiveness of a novel dexamethasone (Dex) nanoformulation for treating uveitis.

MATERIALS AND METHODS

We designed and screened a dexamethasone-peptide conjugate (Dex-SA-FFFE), formed via a biodegradable ester bond linkage, that could spontaneously form high drug payload nanoparticles in aqueous solution for treating uveitis.

RESULTS

An in vitro release study indicated that Dex and Dex-SA-FFFE sustainably released from Dex-SA-FFFE nanoparticles over a 48 h study period. Meanwhile, the formed Dex-SA-FFFE nanoparticles hardly caused cytotoxicity in human corneal epithelial cell at drug concentrations up to 1 mM after 24 h of incubation but reduced cell viability after 48 h and 72 h of incubation. An in vitro anti-inflammatory efficacy assay showed that the Dex-SA-FFFE nanoparticles exhibited a comparable anti-inflammatory efficacy to that of Dex in lipopolysaccharide (LPS)-activated RAW264.7 macrophages via significant decreases in the secretion of various pro-inflammatory cytokines (e.g., nitric oxide, tumor necrosis factor-α, interleukin-6). Topical instillation of Dex-SA-FFFE nanoparticles showed good ocular tolerance without causing changes in corneal thickness and intraocular pressure during the entire study period. Furthermore, topical instillation of Dex-SA-FFFE nanoparticles displayed a comparable in vivo therapeutic efficacy to that of dexamethasone sodium phosphate (Dexp) aqueous solutions in an endotoxin-induced uveitis (EIU) rabbit model.

CONCLUSION

Based on these results, it is reasonable to believe that the proposed Dex-SA-FFFE nanoparticles might have great application for the treatment of anterior uveitis.

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.

Improving the rates of electronic results acknowledgement at a tertiary eye care centre

Background

Hundreds of thousands of tests are performed annually in hospitals worldwide. Safety Issues arise when abnormal results are not recognized promptly resulting in delayed treatment and increased morbidity and mortality. As a result Singapore’s largest healthcare group, Singhealth introduced an electronic result acknowledgement system. This system was adopted by the Singapore National Eye Centre (SNEC) in February 2016. Baseline measurements show that weekly numbers of unacknowledged results ranged from 193 to 617. The current standards of electronic results acknowledgement posts a significant patient safety hazard.

Methods

Root cause analysis was performed to identify contributory factors. Pareto principle was then used by the authors to identify the main contributory factors. We employed the rapid cycle improvement Plan-do-study-act (PDSA) strategy to test and evaluate implemented changes. Changes are implemented for 2 weeks and data collected prospectively. The data is analyzed the week after and the following PDSA actions are decided and instituted the following week. 3 PDSA cycles were undertaken in total.

Results

The first PDSA cycle focused on raising awareness of the problem at hand, the number of unacknowledged results drastically decreased during the 1^stweek of implementation of our PDSA from 617 to 254. The second PDSA cycle targeted the lack of knowledge of doctors involved in the electronic result acknowledgement process. There was a trend downwards near the end of the cycle which continued through the week after. The third PDSA cycle targeted individual doctors and provided individual remedial training. Second line doctors were also equipped to better handle abnormal results. There was significant improvement with the number of unacknowledged abnormal results dropping to <5 a week.

Conclusions

Multiple factors were identified to contribute to the low compliance to electronic acknowledgement of results. The role doctors play in the issue at hand was paramount and required careful handling in a professional manner with multiple reminders and emphasis on the importance of acknowledging and acting on the results.A significant improvement in the rates of acknowledgement of abnormal results was demonstrated with clear benefits to patient safety. Interventions can be replicated when implementing similar systems to other areas of healthcare.