1 Medico-legal aspects of Strabismus Lionel Kowal Ocular Motility, RVEEH

2 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

3 My experience : 30 + cases Defendant Advisor / opinions to legal firms - Plaintiff and Defendant Expert witness L.Kowal 2004

4 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

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 Calvinist or Generous personality supports client’s case The patient responded to my hand signal from across the waiting room …. L.Kowal 2004

6 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

7 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

8 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

9 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

10 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

11 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

12 ? Patch the wrong 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

13 Inferior rectus fibrosis after blocks for cataract surgery * ? 1% occurrence * << 1% troublesome * Alternatives exist *MESSAGE Must mention diplopia with blocks L.Kowal 2004

14 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

15 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

16 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

17 WHO IS AN EXPERT? DECLINE to comment if you are not a genuine expert [eg psychiatrist] Incorrect advice HARMFUL & EXPENSIVE – many cases ‘run’ on 2 nd rate reports then abandoned [eg several days in court] US: Some litigation against pseudo- experts L.Kowal 2004

18 PUBLIC / PRIVATE Pt with total 6 th 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

19 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

20 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

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

22 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