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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
glasshouseMelbourne’s a small townYou will see my unhappy ptsI will see your unhappy pts
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My experience : 30+ cases
DefendantAdvisor / opinions to legal firms -
Plaintiff and Defendant Expert witness
L.Kowal 2004
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Is it Lawyers & Doctorsor
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 distortion1% risk becomes 50% riskchoose 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
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It is the lawyers DUTY to… manipulate the truth to help victory encourage an expert to accept distortion1% 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 surgPassion 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. VicNSW more ‘aggressive’ culture than VicMore ‘fishing’More record subpoenasMore 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
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 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!]
MESSAGEProper Cyclo Refraction in all adult hyperopia /
esotropia [mydriacyl not enough!!]
L.Kowal 2004
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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 existMESSAGEMust 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 : diplopiaDiplopia due to progressive skewMESSAGEDocument 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 organicImproved 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/strab20%!! 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 secretaryAdd Glossary
Criticize colleagues in supplementary report
L.Kowal 2004