Dear YO Info:
I just started practicing and, given that I have a pretty open template, I am getting a lot of second opinion evaluations. A recent patient has persistent blurry vision after cataract surgery by another doctor in town. On examination, she had a best corrected visual acuity of 20/80; there was a vitreous strand to the surgical wound with a peaked pupil, a sulcus intraocular lens (IOL), and optical coherence tomography (OCT) revealed macular edema. The operative note stated that the IOL was placed in the bag, and there were no complications. How do I approach counseling this patient? How should I tell the patient about what appear to be surgical complications that are likely contributing to her suboptimal visual acuity?
Stuck Between a Rock and Hard Place
Dear Stuck:
I agree — this is a delicate situation. The first thing you need to do is gather all pertinent facts and data. This includes a thorough patient history, a comprehensive ocular examination, a review of the prior ophthalmologist's medical and surgical records, and ideally, a verbal discussion with the surgeon. Think about how you would want to learn about your own surgical patient’s complication. I tell the patient that I would like to gather all information, and I personally call the surgeon to discuss it.
Only after all this information has been gathered can the patient be properly diagnosed and fully informed. While you are waiting for all the information, offer advice and treatment. I often find myself answering the question, “Was this preventable?” or “How long has this been present?” I always deal with facts, which protects you and the surgeon: “Ma’am, I’m sorry that you’re not seeing the way you would like after cataract surgery. I’m not sure what you looked liked on your last examination with the surgeon, but today I see the vitreous strand, which can occur after a cataract surgery. To improve your vision, we have to do a laser to cut this strand and put you on some more eye drops.”
You may even want to encourage patients to discuss questions about the prior physician’s care and treatment with the other surgeon themselves. If they push for more information, I often repeat myself: “I hear your frustration. This is what I am seeing today, and this is the path forward.”
After reviewing all the information, remind yourself that your primary responsibility is to offer the second opinion which the patient is seeking, and to act in the patient’s best interest. Often, sympathetic and careful management is enough to mitigate a patient's dissatisfaction and avert malpractice litigation.
Avoid remarks about the other surgeon’s procedure, like “I don’t know why they didn’t see this”; “I have no idea why they did that”; or “I’d never do something like that!” You avoid this firstly because you may encounter unforeseen and unpredictable complications in your own career. Secondly, you’ll never know exactly what the other surgeon encountered intraoperatively.
Take care of your patient. Watch what you say, and call your colleague.
Evan Silverstein, MD
Chair, YO Info Editorial Board
- Rule 4. Other Opinions. Ophthalmologists should be cognizant of the limitations of his/her knowledge and skills and be willing to seek consultations in clinical situations where appropriate. The patient's request for additional opinion(s) should be respected.
- Rule 14. Interrelations Between Ophthalmologists. Interrelations between ophthalmologists must be conducted in a manner that advances the best interests of the patient, including the sharing of relevant information.