Transcript Medico-legal cases in Strabismus

Medico-legal aspects of
Strabismus
Lionel Kowal
Ocular Motility, RVEEH
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We ALL live and
work in a
glasshouse
Melbourne’s a small town
You will see my unhappy pts
I will see your unhappy pts
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My experience :
+
30
cases
Defendant
Advisor / opinions to legal firms Plaintiff and Defendant
Expert witness
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Is it Lawyers & Doctors
or
Lawyers vs. Doctors ?
 WE’RE VERY DIFFERENT
Doctors : truth, honesty, one- on- one caring
Lawyers : VICTORY for the client
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It is the lawyers DUTY to…
 manipulate the truth to help victory
 encourage an expert to accept distortion
1% risk becomes 50% risk
choose an expert whose Calvinist or
Generous personality supports client’s case
The patient responded to my hand signal from
across the waiting room ….
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It is the lawyers DUTY to…
 manipulate the truth to help victory
 encourage an expert to accept distortion
1% risk becomes 50% risk
 choose an expert whose expertise / lack of expertise supports client’s
case [‘Brawn beats brain’]
‘Expert’ in ref surg case with ZERO experience in ref surg
Passion of intellectual or PERSONAL opposition more important than
expertise
 choose an expert whose Calvinist or Generous personality supports
client’s case
The patient responded to my hand signal from across the waiting room ….
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NSW c.f. Vic
NSW more ‘aggressive’ culture than Vic
More ‘fishing’
More record subpoenas
More aggressive questioning in court
‘Experts’ more likely to partisan
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Bar is VERY high for the Dr
Court [on behalf of the community] determines
standard of care
Peer standards of care NOT a defence
Medical board even higher bar
eg Medownick: CANNOT RELY ON HISTORY AS GIVEN BY
PATIENT - must obtain WRITTEN history from previous Drs
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Chapel & Hart paraphrased
If the case is unusual &
If you the treating doctor know that there is someone
else who has particular expertise in this sort of
case then
Part of the informed consent process must involve
you telling the patient about this other doctor &
letting the patient choose between you & the other
doctor
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Diplopia after adult squint
surgery #1
Adult XT. No diplopia by history or during exam.
Uneventful LR recess: lat incomitance →
persisting lat gaze diplopia.
MESSAGE
1: Diplopia always possible
2: Iatrogenic incomitance doesn’t always get
better
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Diplopia after adult squint
surgery
#2
30 yo WCM
i/mitt ET esp when tired
UCV 6/6. +2 : 6/6. Cyclo +6! [+4 latent hyperopia]
Demands ET surgery : Accomm spasm for suture
adjustment  poor result [→ multiple surgeries
inc hyperopic Lasik!]
MESSAGE
Proper Cyclo Refraction in all adult hyperopia /
esotropia [mydriacyl not enough!!]
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? Patch the wrong eye @ age 10
months for 11 days
Several subsequent ophthals / surgeries →
6/9,6/36; spectacle dependent; ET; poor self
image; poor school results → litigation
15 years later : files from visit not available: case
difficult to defend!
Other Drs not joined
MESSAGE: NEVER discard child’s file
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Inferior rectus fibrosis after
blocks for cataract surgery
 ? 1% occurrence
 << 1% troublesome
 Alternatives exist
MESSAGE
Must mention diplopia with blocks
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Bilateral Brown’s
Parents seek Rx for AHP - tip up [photo 30 °]
Post Sx: diplopia complaints++
NO MEC / clumsiness / objective signs of diplopia
Now: “Why did you operate ? He wasn’t that bad”.
MESSAGE:
Good pre-op documentation of indications for
unusual surgery. Can show parents the pre-op
photos they had brought and transcript of phrases
they had used
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Cerebellar atrophy
DBN  oscillopsia / blur
fixed with tip-up AHP
also skew deviation with diplopia
IR Rc : temp better. re-Rc : diplopia
Diplopia due to progressive skew
MESSAGE
Document pre-op diplopia. Photos for difficult cases.
Weird :  2nd opinions
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WHO IS AN EXPERT?
Weird repetitive eye mvmts after minor head
injury.
Several neurologists can’t explain it. Psychiatrist
‘confirms’ is malingering.
David Zee / Peter Savino confirm is organic
Improved by neurontin
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WHO IS AN EXPERT?
DECLINE to comment if you are not a genuine
expert [eg psychiatrist]
Incorrect advice HARMFUL & EXPENSIVE –
many cases ‘run’ on 2nd rate reports then
abandoned [eg several days in court]
US: Some litigation against pseudo- experts
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PUBLIC / PRIVATE
Pt with total 6th told ‘not fixable’ in public clinic. Pt
sees Dr X [head of same public clinic] privately
and is fixed!
Pt explores action for costs against public clinic and
joins Dr X as head of clinic!
Recent MMC gyne case: Private gyne refers pt to
public clinic with which he has no association and
is joined in action when result is bad
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Acquired XT after refractive
lensectomy
Female , 50. Wears +5. Cyclo refraction +7 =
surgical target → 6/6 OU.
2 DS latent hyperopia → loss of accomm conv used
to control unrecognised exo → troublesome XT
Kushner / Kowal Archives ’03 : 28 pts ref surg/strab
20%!! monovision pts have abnormal binoc vision
MESSAGE: Stratify ref Sx pts into high/ med / low
risk groups & evaluate appropriately
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Role of the Orthoptist
 Historically : Ophthal delegates intellectual
understanding of strabismus to the orthoptist
Case: Alphabet / oblique dysfunction waiting in
OR for orthoptist’s surgical recipe!
Postop diplopia >2 further Sx e/where
MESSAGE: Don’t do strab if you can’t
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WE ALL LIVE AND WORK
IN A GLASSHOUSE
Thank you
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WRITING REPORTS
Emphasise relevance in CV
Disability :American MA 4th & 5th Editions (NOT
RANZCO!)
Report should be understandable to your secretary
Add Glossary
Criticize colleagues in supplementary report
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