Cataract surgery accounts for the largest share of malpractice claims in ophthalmology due to its high volume, both in the U.S. and UK. However, surprisingly little attention in the literature considers the causes of litigation in modern cataract surgery. This study analyzed all ophthalmology-related malpractice claims submitted to England's National Health Service (NHS) Litigation Authority between 1995 and 2008.
The most common causes were related to negligent surgery, biometry/wrong IOL power/postoperative refractive errors, reduced vision, postoperative endophthalmitis and equipment failure. But the reason patients sued was not due to clinical competence but to physician behaviors, such as rudeness, delays, inattentiveness, miscommunication and apathy.
The authors note that one of the striking findings is the low total number of claims. There were only 324 claims over a 14-year period, equivalent to 23 per year. Given that hundreds of thousands of cataract operations are performed in the NHS per year, only a tiny fraction will lead to a claim.
They also found that reduced vision after surgery and negligent surgery, including posterior capsule tear and dropped nucleus, together make up over one-third of the claims and 43 percent of the damages. Even though routine consent for cataract surgery warns of the risk of standard intraoperative complications and postoperative reduced vision, this does not prevent claims from arising or from being successful in many cases.
Refractive accuracy also has significant medicolegal impact. Biometry errors or wrong IOL lens power were the second most frequent cause of claims and resulted in payment of damages in 62 percent of closed cases. The authors note that as patients' expectations of the refractive outcomes of cataract surgery rise, this area of litigation may well increase.
Claims relating to inadequate anaesthesia or anaesthetic injection complications were particularly hard to defend, accounting for the highest paid:closed ratio (75 percent; complications of anesthetic injections including globe perforation, 67 percent). Endophthalmitis has an incidence of between 0.05 percent and 0.25 percent, yet it accounted for 4 percent of claims. Part of this may reflect the devastating nature of the condition. In several of the claims, it was explicitly stated that it was the delay in diagnosis of endophthalmitis that was the prime cause of the claim.
Ultimately, the authors conclude that the factors that motivate patients to sue center more on behavior than around clinical competence.
"It therefore behoves us to make friends with our mistakes," they write. "After any adverse event, what most patients require is a sympathetic apology that it has happened (which has no legal standing as an admission of liability) and a clear explanation. People are reluctant to sue someone that they like."