Deviation in the Standard of Ophthalmologic Care During Lasik Surgery

Evaluate breaches in the standard of care by asking and answering the questions below to determine whether there was a Deviation in the Standard of Ophthalmologic Care During Lasik Surgery

Answer the following questions to find out if the standard of care was followed for your case.

  • With which of the symptoms did the patient present? (Choose all that apply)
    Blurred vision of distant objects
    Distortion of vision
    Eyestrain
    Headache
    Fatigue
    No symptoms
    Not elicited
    Answer unknown
    Why is this important?
    Laser-assisted in situ keratomileusis, LASIK, is now the most commonly performed refractive surgery is an effective treatment for myopia, hyperopia and astigmatism.
    Click here for additional information at ClinicalKey.com

  • With which of the following condition did the patient present? Why is this important?
    Answer this question
    Laser Assisted in Situ Keratomileusis (LASIK) has typically been used to correct up to 15 diopters of myopia, 6 diopters of hyperopia, and up to 6 diopters of astigmatism.
    Click here for additional information at ClinicalKey.com

  • Was a medical history obtained? Why is this important?
    Answer this question
    A complete medical history and carefully focused physical examination serve as the core of the diagnostic process. The information obtained guides the further direction of the patient's examination, enables the clinician to make educated evaluations, and be better equipped to advise the patient.
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  • Was a physical examination including eye examination performed? Why is this important?
    Answer this question
    A complete medical history and carefully focused physical examination serve as the core of the diagnostic process. The information obtained guides the further direction of the patient's evaluation and enables the clinician to make the most judicious use of additional tests.
    Click here for additional information at ClinicalKey.com

  • How old was the patient at the time of surgery? Why is this important?
    Answer this question
    The candidate should be at least 18 years old for undergoing Laser Assisted in Situ Keratomileusis (LASIK) surgery.
    Click here for additional information at ClinicalKey.com

  • Which of the following systemic contraindications did the patient possess? (Choose all that apply) Why is this important?
    Answer this question
    Patients with a history of diabetes mellitus, pregnancy, autoimmune disease, collagen vascular disorders, thyroid disease, or abnormal wound healing may be at risk for poor outcomes post-operatively and should be identified prior to proceeding with surgery.
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  • Which of the following ophthalmic contraindications did the patient possess? (Choose all that apply) Why is this important?
    Answer this question
    Ocular contraindications include: • Sjogren's disease is an absolute contraindication. This disease is known to produce severe xerophthalmia that could become vision threatening. Both Laser Assisted in Situ Keratomileusis (LASIK) and Photorefractive keratectomy (PRK) are known to produce transient (sometimes permanent) xerophthalmia thus aggravating the disease manifestation. • Old, inactive herpes simplex keratitis is not an absolute contraindication; however, it is known that the herpes virus may remain dormant in the corneal stroma for years. Its reactivation may be triggered by stromal surgery or by the steroids prescribed postoperatively. • Corneal scars: depending on the size and location of the scar, judgment should be made as to whether to operate on such an eye. Scar tissue is hyaline or elastic degeneration, which is followed by calcification. The excimer laser is calculated to ablate corneal tissue and the ablation rate of the corneal tissue varies from that of the degenerative tissue. Consequently, the scar may become optically more ‘pronounced’, sometimes inducing worse, irregular astigmatism.
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  • Which of the following medications were not discontinued prior to the surgery? (Choose all that apply) Why is this important?
    Answer this question
    Patients taking isotretinoin (Accutane) or amiodarone (Cordarone) may be at a higher risk of complications with surgery.
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  • Which of the following causes for dry eyes were not elicited? (Choose all that apply) Why is this important?
    Answer this question
    Preoperatively, patients should be evaluated for conditions predisposing to dry eye.
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  • Which of the following treatment options were used to treat dry eyes? (Choose all that apply) Why is this important?
    Answer this question
    It is mandatory that dry eye is addressed before surgery to obtain the best postoperative results and reduce complications.
    Click here for additional information at ClinicalKey.com

  • Was the patient advised to discontinue wearing contact lenses prior to surgery? Why is this important?
    Answer this question
    Rigid Contact Lens (CL) wearers should remove their lenses for 3−4 weeks before examination, and soft contact lens wearers should have 2 weeks without lenses.
    Click here for additional information at ClinicalKey.com

  • Was the refractive stability established? Why is this important?
    Answer this question
    All patients should be instructed to bring old spectacles or prescriptions in order to establish refractive stability. Simple refractive errors usually stabilize between 18 and 21 years of age. A documented stable refraction for at least one year is advisable if to avoid a secondary procedure later in life.
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  • Which of the following were not evaluated pre-operatively? (Choose all that apply) Why is this important?
    Answer this question
    The pre-operative evaluation of the patient must include a slit lamp examination, computerized corneal topography, fundoscopy, dry eye evaluation and measurement of intraocular pressure and corneal thickness.
    (2000) 71 EAORNJ 5 960,963,965-966,968-970,972,975-978,981-983

  • Was patient counseling provided prior to the surgery? Why is this important?
    Answer this question
    Patient counseling is a vital part of pre-operative preparation prior to refractive surgery. Not all patients who meet medical and ophthalmic criteria for refractive surgery are necessarily good candidates for the procedure. Patients with unrealistic expectations are likely to be dissatisfied after surgery.
    Click here for additional information at ClinicalKey.com

  • Was an informed consent obtained? Why is this important?
    Answer this question
    The laws of most states require that clinicians obtain informed consent before providing treatment.
    (2011) 23 EOMSCA 3 475-484

  • Were the laser and microkeratome tested according to manufacturer’s instructions, before the surgery? Why is this important?
    Answer this question
    Before admitting the patient, the excimer laser and the microkeratome have to be tested according to the manufacturer's instructions.
    Click here for additional information at ClinicalKey.com

  • Was an assessment of the surgical instruments and the computer performed? Why is this important?
    Answer this question
    All instrumentation must be checked and calibrated prior to the procedure. It is necessary that the surgeons confirm the identity of the patient, the operative eye and that the parameters are correctly entered into the laser’s computer.
    (2000) 71 EAORNJ 5 960,963,965-966,968-970,972,975-978,981-983

  • Were prophylactic topical antibiotics administered? Why is this important?
    Answer this question
    Just before the Laser Assisted in Situ Keratomileusis (LASIK) surgery, topical broad-spectrum antibiotics may be applied prophylactically.
    Click here for additional information at ClinicalKey.com

  • Which of the following technical steps were allegedly not followed during the LASIK surgery? (Choose all that apply) Why is this important?
    Answer this question
    The Laser Assisted in Situ Keratomileusis (LASIK) surgery protocol has been referred to as a ‘preflight checklist,’ as it represents a series of sequential steps that needs to be performed in an identical fashion for every case, ensuring standardization.
    Click here for additional information at ClinicalKey.com

Evaluate breaches in the standard of care by asking and answering the questions below to determine if there is a Deviation in the Standard of Ophthalmologic Care During Lasik Surgery

Answer the following questions to find out if the standard of care was followed for your case.

  • With which of the following symptoms, along with chronic headache, did the patient present? (Choose all that apply)
    Progressive visual loss/ blurred vision
    Transient visual obscurations
    Intracranial noises/ hearing Loss
    Diplopia
    Nausea and vomiting
    Photophobia
    Symptoms not elicited
    Answer unknown
    Why is this important?
    Pseudotumor cerebri (PTC) is a perplexing syndrome of increased intracranial pressure (ICP) without a space-occupying lesion. Chronic headache, either intermittent or permanent, is a hallmark of pseudotumor cerebri.
    (2004) 22 ENLOGC 1 99-131

  • Which of the following risk factors were elicited from the patient? (Choose all that apply) Why is this important?
    Answer this question
    
The clinician needs to elicit a thorough medical history from the patient. A hereditary link has been suggested for pseudotumor cerebri. There is an increasing incidence of pseudotumor cerebri among adolescents.

    (2007) 52 ESUOPH 6 597-617 



  • Was an ophthalmic evaluation performed on the patient? Why is this important?
    Answer this question
    
Papilledema (optic disc edema caused by increased intracranial pressure) is the cardinal sign. Optic disc edema either directly or indirectly is the cause of visual loss. To accurately assess for papilledema, the clinician must perform an ophthalmic evaluation.

    (2010) 28 ENLOGC 3 593-617 



  • Was a fundus examination performed during the ophthalmic evaluation? Why is this important?
    Answer this question
    
The hallmark of pseudotumor cerebri is papilledema that may be asymmetric.

    (2004) 22 ENLOGC 1 99-131 



  • Was either a contrast enhanced MRI or a magnetic resonance venography performed? Why is this important?
    Answer this question
    
Neuroimaging is mandatory to exclude a space-occupying lesion or ventriculomegaly.

    (2004) 22 ENLOGC 1 99-131 



  • Was cerebrospinal fluid examination performed? Why is this important?
    Answer this question
    
The spinal fluid examination is critical for diagnosing pseudotumor cerebri. No patient should be diagnosed presumptively without a lumbar puncture.

    (2004) 22 ENLOGC 1 99-131 



  • Was the patient’s cerebrospinal spinal fluid pressure elevated? Why is this important?
    Answer this question
    
Elevated cerebrospinal fluid pressure is usually found in pseudotumor cerebri.

    (2004) 22 ENLOGC 1 99-131 



  • Was a cerebrospinal spinal fluid analysis performed? Why is this important?
    Answer this question
    
The diagnostic criteria of pseudotumor cerebri include normal cerebrospinal fluid composition.

    (2004) 22 ENLOGC 1 99-131 



  • Did the clinician refer the patient to a specialist? Why is this important?
    Answer this question
    
Pseudotumor cerebri is best managed using a multi-disciplinary approach.

    (2004) 22 ENLOGC 1 99-131 



  • How severe was the patient’s vision loss? Why is this important?
    Answer this question
    
The treatment strategies differ depending upon the amount and progression of visual loss.

    (2010) 28 ENLOGC 3 593-617 



  • Was weight loss advised by the clinician? Why is this important?
    Answer this question
    
Diet and weight loss generally is advocated for the obese patients. Weight loss has been used to treat IIH for many years.

    (2010) 28 ENLOGC 3 593-617 



  • Which of the following treatment options were initiated? (Choose all that apply) Why is this important?
    Answer this question
    
Medical treatment is aimed at lowering intracranial pressure and treating symptoms directly, such as headache.

    (2010) 28 ENLOGC 3 593-617 



  • Did the clinician recommend follow-up on a periodic basis? Why is this important?
    Answer this question
    
The patient needs to be managed conservatively with careful neuro-ophthalmic follow-up and repeated lumbar punctures.

    (2004) 22 ENLOGC 1 99-131 



  • Was surgery recommended? Why is this important?
    Answer this question
    
Surgery is indicated for moderate to severe visual loss or worsening of vision attributable to papilledema. 

    (2004) 22 ENLOGC 1 99-131