This retrospective analysis studied anesthesia-related closed claims and their contributing factors using data from Ophthalmic Mutual Insurance Company (OMIC).
Study design
Investigators analyzed 63 closed anesthesia-related claims or suits filed by 50 plaintiffs over a 10-year period. Plaintiffs who filed a professional liability claim or suit against an OMIC-insured ophthalmologist, ophthalmic practices or surgicenters where the case occurred were included.
Outcomes
Globe perforation (n=17) was the most common injury, followed by death (n=13), retrobulbar hemorrhage (n=7) and optic nerve damage (n=4). Two deaths were related to brainstem anesthesia. Most of the plaintiffs who died had known medical problems, including diabetes mellitus and atherosclerotic cardiovascular disease.
The type of anesthesia that led to these claims or suits was primarily retrobulbar and peribulbar anesthesia (n=16 each, 32 total). Ophthalmologists administered the retrobulbar or peribulbar injection in 27 of 32 (84%) of closed-claim cases, anesthesiologists in 3 (9%) and certified registered nurse anesthetists in 2 (6%). Retina procedures accounted for the second most claims (n=12, 24%) after cataract surgery (n=24).
Globe perforations were the most common and most expensive injury resulting in a payment for 6 claims averaging $271,000. Forty-eight (75%) cases closed with no indemnity payments.
Limitations
These are malpractice claims and, unlike epidemiological studies, do not represent the true incidence of these various events as there are many reasons why an injured patient may or may not choose to pursue litigation. There also may be some uncertainty on the exact cause of some injuries, such as death. While over-sedation was a common argument, several of these patients had comorbidities that may have contributed. Claims that did not involve OMIC-insured individuals were not accounted for in this study.
Clinical significance
The authors conclude that anesthesia-related claims and suits are uncommon, but anesthesia-related complications can lead to severe injuries. They list several actionable steps that may be taken to limit anesthesia-related complications during ocular surgery.
Given the relatively large percentage of malpractice cases related to retrobulbar and peribulbar blocks, this study reinforces my belief that minimizing the use of these techniques when possible may be warranted. As retina specialist, we do not typically perform cases under topical anesthesia. However, the authors suggest considering conjunctival cut down and blunt cannula injection of anesthetic (sub-Tenon block) particularly in elongated eyes and those a high risk for globe perforation. I would personally argue that this technique may also be safer in general for the majority of cases due to the blunt rather than sharp tip, which should lower the risk of globe perforation, retrobulbar hemorrhage and optic nerve injection.