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Scleral Depression: Clarifying Standards of Care
We read with interest the article “Malpractice Risk: Retinal Detachments” (Feature, April). In this article, the “standard of care” is discussed for patients at risk for retinal detachment (RD). The standard of care is a legal term, not a medical term, and accordingly has a legal definition (“what a similarly trained practitioner would do under similar circumstances”). This is used as a sort of bottom line conclusion by an expert to characterize the appropriateness of clinical care delivered in a specific setting. While that characterization of appropriate medical care should ideally be supported by evidence-based data, it often represents an extrapolation from the best available data which may be incomplete or not ideally suited to the question at hand. Indeed, there may be more than one unique standard of care in a situation.
We appreciate the importance of timely diagnosis of retinal breaks and RDs, and we recognize the value of scleral depression in selected patients in selected circumstances. However, peer-reviewed evidence is limited specifically regarding the use of scleral depression during indirect ophthalmoscopy. The classic description of scleral depression was published by Brockhurst in 19561 without comparative data. In contrast, the authors of a prospective study of 50 patients (100 eyes) with retinal breaks published in 2015 concluded: “We found that an examination using a [28-D] lens with scleral depression did not provide any additional benefit to an examination without depression during indirect ophthalmoscopy.”2
In the EyeNet article, Dr. George Williams cited the Academy’s Preferred Practice Pattern (PPP) on the topic and said, “As [the PPP] states, the standard of care for any at-risk patient requires a dilated examination of the entire fundus with indirect ophthalmoscopy and scleral depression—period, end of discussion.” In our opinion, this statement requires further discussion and clarification. A literal, noncontextual reading of this statement may create unwanted and unnecessary litigation risks for ophthalmologists who practice appropriate medical care but elect to not use scleral depression. Many patients are intolerant of scleral depression, and others may have a widely dilated pupil allowing an excellent view of the retinal periphery without scleral depression. We further note that the PPP specifically states, “Preferred Practice Patterns guidelines are not medical standards to be adhered to in all individual situations.”3
If there were adequate peer-reviewed evidence to support the need for scleral depression in every at-risk patient, rather than opinions carried forth from older literature, then there would be uniform agreement regarding the standard of care.
Stephen G. Schwartz, MD, MBA
Thomas A. Albini, MD
Audina M. Berrocal, MD
Harry W. Flynn Jr., MD
Jaclyn L. Kovach, MD
William E. Smiddy, MD
Jayanth Sridhar, MD
Justin H. Townsend, MD
Bascom Palmer Eye Institute, Miami
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1 Brockhurst RJ. Am J Ophthalmol. 1956;41(2):265-272.
2 Shukla SY et al. Ophthalmology. 2015;122(11):2360-2361.
3 American Academy of Ophthalmology Retina/Vitreous Panel. Preferred Practice Pattern. Posterior Vitreous Detachment, Retinal Breaks, and Lattice Degeneration. San Francisco, Calif: American Academy of Ophthalmology; 2014. Available at: aao.org/ppp.
A Response From Dr. Williams
The authors raise valid and important issues concerning my use of the term standard of care. I concur that my statements create confusion between what I consider to be a preferred practice as defined in the Academy’s PPP and the legal implications of the concept of standard of care. I agree that, while scleral depression can definitely help detect retinal tears, there are clinical scenarios in which indirect ophthalmoscopy with scleral depression is not possible or necessary. As the Chair of the Board of Directors of the Ophthalmic Mutual Insurance Company (OMIC), I apologize for this error.
Several facts are worth remembering, however. First, missed RDs can lead to severe loss of vision. Second, missed RDs are a not uncommon cause of claims in ophthalmology. (As noted in the article, a recent OMIC analysis of diagnostic errors leading to malpractice claims found the most frequently missed diagnosis was retinal detachment.) Third, patients with the sudden onset of flashes and floaters with pigmented cells or blood in the vitreous are at an increased risk of having a retinal tear. A careful—and documented—examination of the peripheral retina is of paramount importance. In such circumstances, performance of scleral depression may offer diagnostic advantage.
At OMIC, we consider every malpractice claim as an opportunity to improve patient care through analysis of the events leading to the claim. More often than not, our expert review indicates that there is no evidence of malpractice. We vigorously defend such claims and typically are successful. Unfortunately, there are claims for which expert review indicates that defense will very likely be unsuccessful. Lessons learned from these cases inform risk management with the twin goals of improved patient care and diminished liability. Although that message was the intent of the article on diagnostic errors related to retinal detachment, it was lost in my poor choice of words.
I thank my colleagues for their thoughtful comments in the spirit of our mission of protecting sight and empowering lives.
George A. Williams, MD
Royal Oak, Mich.
Regarding Unverifiable Publications on Residency Applications
Tamez et al., in their report as summarized in this issue (Journal Highlights), discovered a 9.2% incidence of unverifiable publication in SF Match applications when any publications were listed. The authors suggested that the SF Match process could be improved to ensure a more accurate application process and to maintain high ethical standards of the applicants.
The Association of University Professors of Ophthalmology (AUPO) oversees the SF Match. As Executive Vice President of AUPO, I certainly concur with this assessment as a prelude to guaranteeing a fair selection process for the applicants and reducing the surveillance burden of training programs.
While some misrepresentations may be intentional, others may result from naiveté or from carelessness. As a method of addressing the latter, including instructions to the applicant defining peer-reviewed versus non–peer-reviewed articles —with a warning that citations are subject to verification—might be a first step. This also could be accompanied by a clarification for the candidate, noting that unverifiable research publications may result in adverse consequences, including disqualification from the SF Match. In the future, SF Match data processing capabilities may be able to provide full surveillance enhancements that would automatically pick up inaccuracies in each applicant’s reporting of research publications.
Steven E. Feldon, MD, MBA
Rochester, N.Y.
PVD and the Standard of Care
As a physician who provides consultative legal services, I enthusiastically welcomed the cover article in April’s issue of EyeNet. I looked forward to the sharing of solid, evidence-based recommendations that reflected the world in which I practice. Acute posterior vitreous detachment (PVD) is a common, low-risk occurrence in our offices. At the very least, I hoped for clarification about what exam characteristics were most likely to increase the risk of retinal holes and tears. Sadly, this was not to be.
With this article, it is my opinion that the Academy has broken its trust with the majority of its membership. The author, invited interviewees, and editors have confused the entity “standard of care” with one that we can refer to as “best practices.” Standard of care is a legal definition that is commonly described as “what a preponderance of practitioners with similar training and experience would do in similar circumstances.” The words “prudent and careful” are sometimes included. In contrast, a best practice is roughly defined as “what can be done under optimal circumstances at any given time to optimize a medical outcome.”
While I believe it was written with noble intent, the article confuses standard of care and best practices. It makes a declaration about examining patients with an acute PVD that is representative of neither the training and experience nor the practices of a preponderance of careful and prudent ophthalmologists who see these patients on a daily basis. After surveying my colleagues, the percentage of my peers who routinely perform scleral depression when they see such a patient was substantially less than 10%.
It is my fervent hope that EyeNet and, by extension, the Academy, will affirm its commitment to those of us who go to work each day and care for our patients to the best of our ability within the standard of care applicable to our practices. We nonretinal specialists are the majority of practitioners who see patients with an acute PVD. Exceedingly few develop a hole or a tear. Sceral depression is not performed by a preponderance of careful and prudent ophthalmologists who are not retina trained. It cannot be the standard of care.
Darrell E. White, MD
on behalf of CEDARS/ASPENS
Westlake, Ohio