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Medico-legal cases in Strabismus

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					Medico-legal aspects of
     Strabismus

       Lionel Kowal



   Ocular Motility, RVEEH



                            1
   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

L.Kowal 2004                  2
   My experience :      30 +   cases

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


L.Kowal 2004                           3
     Is it Lawyers & Doctors
                or
      Lawyers vs. Doctors ?
 WE’RE VERY DIFFERENT

Doctors : truth, honesty, one- on- one caring


Lawyers : VICTORY for the client
L.Kowal 2004                                    4
  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 ….



L.Kowal 2004                                    5
   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 ….




L.Kowal 2004                                                               6
               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                              7
    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                                                8
         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                                        9
     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


L.Kowal 2004                                       10
     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                                     11
 ? 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


L.Kowal 2004                                             12
    Inferior rectus fibrosis after
     blocks for cataract surgery

 ? 1% occurrence
 << 1% troublesome
 Alternatives exist
MESSAGE
Must mention diplopia with blocks


L.Kowal 2004                         13
               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


L.Kowal 2004                                        14
            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                                        15
      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



L.Kowal 2004                                          16
      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                                  17
           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                                                18
    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

                                                       19
         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


L.Kowal 2004                                       20
 WE ALL LIVE AND WORK
   IN A GLASSHOUSE



Thank you

L.Kowal 2004        21
       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                                        22

				
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