Medico-legal aspects of Strabismus

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Medico-legal aspects of Strabismus

• Lionel Kowal
• Ocular Motility, RVEEH

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We ALL live and work in a glasshouse

• Melbournes a small town
• You will see my unhappy pts
• I will see your unhappy pts

L.Kowal 2004
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My experience 30 cases

• Defendant
• Advisor / opinions to legal firms - Plaintiff and
  Defendant
• Expert witness

L.Kowal 2004
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Is it Lawyers Doctorsor Lawyers vs. Doctors
?

• WERE VERY DIFFERENT
• Doctors truth, honesty, one- on- one caring
• Lawyers VICTORY for the client

L.Kowal 2004
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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 clients case
• The patient responded to my hand signal from
  across the waiting room .

L.Kowal 2004
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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 clients 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 clients case
• The patient responded to my hand signal from
  across the waiting room .

L.Kowal 2004
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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

L.Kowal 2004
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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

L.Kowal 2004
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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

L.Kowal 2004
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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 doesnt always get
  better

L.Kowal 2004
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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!!

L.Kowal 2004
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? Patch the wrong eye _at_ 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 childs file

L.Kowal 2004
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Inferior rectus fibrosis after blocks for
cataract surgery

• ? 1 occurrence
• ltlt 1 troublesome
• Alternatives exist
• MESSAGE
• Must mention diplopia with blocks

L.Kowal 2004
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Bilateral Browns

• 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 wasnt 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

L.Kowal 2004
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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

L.Kowal 2004
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WHO IS AN EXPERT?

• Weird repetitive eye mvmts after minor head
  injury.
• Several neurologists cant explain it.
  Psychiatrist confirms is malingering.
• David Zee / Peter Savino confirm is organic
• Improved by neurontin

L.Kowal 2004
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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

L.Kowal 2004
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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

L.Kowal 2004
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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 orthoptists surgical recipe!
• Postop diplopia gt2 further Sx e/where
• MESSAGE Dont do strab if you cant

L.Kowal 2004
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WE ALL LIVE AND WORK IN A GLASSHOUSE

• Thank you

L.Kowal 2004
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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

L.Kowal 2004