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Eyes of the storm

14 September 2014

Mr Q, 40 years old, consulted Miss A, a consultant ophthalmologist, with lesions affecting his eyelids. Mr Q’s complex medical history included antiphospholipid syndrome and his drug therapy included anticoagulant and antiplatelet agents, oral corticosteroids and ocular surface lubricants.

Miss A documented lesions on the left upper and lower eyelid margins resembling papillomas. No corneal or tear film abnormality was noted. She advised upper and lower full thickness wedge excision of the lesions under general anaesthesia. Consent was obtained and Mr Q was warned of the risks of bruising, infection, scarring and revision surgery. The surgery was performed a month later and was uncomplicated.

Mr Q reported severe pain in the eye shortly following surgery. Review the next day identified a small central corneal abrasion and two lashes on the lower lid in contact with the cornea. The corneal abrasion was fully healed on the fourth postoperative day and the lid sutures were removed. Ten days postoperatively there was complete dehiscence of the lower lid wound that was repaired under local anaesthesia. Subsequent eye examinations revealed persistent punctate corneal erosions affecting the lower cornea. Mr Q also experienced painful recurrent corneal erosions and a bandage contact lens did not help to alleviate the pain. Over the months that followed, Mr Q continued to experience episodic pain in the left eye despite regular topical therapy. Two years after the initial surgery, worsening symptoms prompted epithelial debridement, stromal puncture and placement of a bandage contact lens but the discomfort persisted.

A subsequent entry in Miss A’s private notes, noted a notch in the centre of the upper eyelid and a note that further surgery may be needed. Her letter to the GP made reference to ocular dryness causing discomfort.

On 24 August 2010, Mr Q saw Mr B, another consultant ophthalmologist, on account of increasing pain in the left eye. He noted a central corneal opacity reducing vision to 6/12 and an overlying area of epithelial loss. Mr B felt the lid notching with central corneal exposure and a deficient tear film were contributing to his corneal problem and referred Mr Q to oculoplastic surgeon, Mr C, for further management.

Mr Q was seen by Mr C in November 2010, who noted a noticeable notch of the upper lid and a subtle notch affecting the lower lid with corneal exposure. He advised surgical correction of the upper lid notch under general anaesthesia.

Mr Q made a claim against Miss A. He alleged that Miss A failed to carry out the first operation correctly, failed to provide adequate aftercare, failed to inform Mr Q of the notches on his eyelids caused by the removal of the warts, and failed to make a proper or adequate examination of Mr Q.

Expert opinion

The expert ophthalmologist was critical of Miss A’s operative technique and aftercare. He also said that during the initial consultation Miss A failed to enquire about dry eye and diseases that can be associated with this. The expert was further critical that Miss A failed to complete consent forms adequately.

The expert believed that a shave excision would have been more appropriate and has fewer risks, so was further critical of the wedge excision of both the upper and lower eyelids, as it was unnecessary and undertaken without careful counselling of the claimant with regard to the effect on the ocular surface disease.

The claim was settled for a moderate sum.

Learning points

  • Careful discussion with the patient of the treatment options and potential complications is important, as is a record of the conversation, decision and consent process. This should include a discussion about the possible interaction(s) with any pre-existing condition.
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