• October 2014

    Question:
    I am a general ophthalmologist and completed my residency two years ago. After a 70-year-old patient presented to me a few months ago with bilateral visually significant cataracts, I performed cataract surgery and noticed a break in the posterior capsule. Since I did not feel that the posterior capsular break resulted in any complications, I did not mention this to the patient. On postoperative day one, the patient’s vision was 20/20 with an intraocular pressure (IOP) of 15 mmHg in the operative eye. A week later, the vision had decreased to 20/200 with an IOP of 35 mmHg and microcystic corneal edema. Although the view to the posterior chamber was hazy secondary to the corneal edema, I dilated the patient and did not observe any retained lens material in the anterior segment or vitreous cavity. The patient was started on IOP-lowering drops and asked to return in two days.

    On follow-up exam, the IOP was still elevated at 40 mmHg, and the corneal edema was worse. Although I had discussed potential postoperative complications during the informed consent, the patient was still very unhappy. She wanted a second opinion, but I felt that a second opinion was not warranted at that time and started the patient on oral acetazolamide. The patient returned several days later without improvement. At that time, I referred the patient to my senior associate, who then consulted the local vitreoretinal surgeon, Dr. X. Examination by Dr. X identified retained lens material, and pars plana vitrectomy was performed to remove the retained lens nucleus fragments. What could I have done differently, and was there anything unethical about how I managed this situation?

    Answer: Depending on the circumstances, disrespecting the patient’s wishes to see another physician for a second opinion may be unethical. Also, you should have informed the patient of the break in the posterior capsule during the surgery. Being transparent with the patient about any intraoperative or postoperative adverse events and having open communication is critical for the overall care of the patient. It can be difficult for young ophthalmologists to feel comfortable referring complicated patients to more senior associates; however, it is important to always act in the best interest of the patient.

    The situation you encountered is common and can be handled in two ways. The patient may seek a second opinion independently, or the physician may recommend other physicians that the patient can see. If a patient requests a second opinion, it is in the physician’s and the patient’s best interest for the patient to see a skilled and qualified ophthalmologist who can manage the patient appropriately. It is also critical that there is communication between the physicians and that accurate information is shared regarding the patient’s condition.

    To submit a question, contact the Ethics Committee staff at ethics@aao.org.