Mr P, a 40-year-old office worker, had a long history of sino-nasal problems, and had even had a previous septoplasty operation. Soon after returning from a holiday, he consulted his GP, Dr A, with worsening blockage in the left side of his nose. Dr A saw a polyp on this side and referred Mr P to ENT surgeon Mr E for his opinion.
Soon after this, however, Mr P was admitted to hospital with some breathing problems and sinusitis, and was extensively investigated. These investigations included a CT scan of his sinuses.
During this admission, he was seen by Mr E, who also identified the polyp, and a number of other problems on the scan, which he felt would benefit from some endoscopic sinus surgery.
Mr P was readmitted to the hospital a few weeks later for his elective endoscopic sinus surgery. A standard consent form was signed on the morning of the surgery, (including a general mention of risk to eye or brain damage generally, but there was no discussion about specific complications). Surgery took place later that day. During the operation, Mr E suspected that he had breached the lamina papyracea (the thin bony wall separating orbit from nasal cavity). Immediately postoperatively, Mr P was noted to have a swollen left eyelid, which became more swollen over the next few hours. In addition, he complained of pain and blurring of vision.
Mr P was discharged from hospital and an ophthalmology opinion was arranged for a few days later. This confirmed an orbital haematoma and some limitation of movements, but no evidence of alteration to visual acuity.
A second ophthalmological opinion was requested some months later when the symptoms of double vision did not settle. In addition, Mr P described symptoms of dizziness and discomfort in the affected eye. This limited his ability to drive and rendered him unable to work. Sadly, no curative interventions were available.
Varifocal lenses were suggested to try and help Mr P with his vision, along with the hope that things might improve further with the passage of time. More positively, his chronic sinus problem appeared to have been successfully addressed.
Expert opinion determined that the breach in the lamina papyracea and the subsequent orbital haematoma had been the cause of Mr P’s visual problems, by limiting the movements of the superior oblique muscle. This is a rare but well-known complication that can happen even to experienced surgeons.
Expert opinion found a breach in the standard of care around the process of consent. Mr E did not appear to explain that the surgery was for quality of life and therefore not essential, or that ongoing medical treatment was a therapeutic option. Nor did he specifically warn Mr P that orbital damage might result in impairment of vision, including diplopia.
The case was settled for a substantial amount.
- Informed consent must involve an explanation of the role of medical treatment, or no treatment at all, rather than just surgery, in non-life threatening medical conditions. In this case, Mr P’s chronic sinus condition might have been controlled with steroids and antibiotics.
- The consent process must also include details of the consequences of a complication, not just a general mention of possible adverse events.
- This case is a reminder that even in what might be considered simple or straightforward surgery, significant problems or complications can, and still do, occur.
- MPS’s free workshop for members, Mastering Shared Decision Making, shows how the shared decision making model is an effective way to ensure that patients make appropriate and informed choices about the treatment options available to them.