By Dr Angelo Appiotti

The professional responsibilities of a doctor

Eye surgery always represents a major decision, requiring the patient to take the time to retrieve information, compare and carefully choose the eye surgeon and clinic most suited to his/her situation. But when the patient hits a certain age and suffers from a severe refractive error or an impairing illness such as a cataract, surgery may and must represent an effective solution to restore his/her autonomy and help him/her live life to the fullest. With patients aged over 70, qualities such as the ability to listen to them and provide them with adequate information, as well as the ability to deal with any unforeseen events in a professional and humble manner, are all the more crucial to achieve a successful outcome and patient satisfaction.

This is the story of Maria, a 73-year-old woman from Trapani, Italy.

Maria suffered from high myopia (less than 10 dioptres) and had a mature cataract in both eyes. She underwent right eye cataract surgery at the hospital, but during the pre-surgery visits she was not: 1) asked whether, after having the cataract removed and her high myopia treated, she wished to remain mildly myopic, therefore needing glasses exclusively to watch TV and drive and not to read, or vice versa;  2) informed of the importance of operating on both eyes within a short time period due to the high anisometropia (difference in vision between the eyes) which would have been a consequence of her first surgery.

For a number of reasons unknown to me, Maria underwent cataract surgery without being adequately informed. As a consequence, the refractive outcome of the right eye was poor to say the least: the wrong intraocular lens implant (IOL) had been placed inside the patient’s eye, resulting in a hyperopia refractive error (+4 dioptres) and significantly impairing both her near and distance vision.

It is worthwhile mentioning that calculation errors in biometrics (measurement of ocular length to create a custom-made IOL) may happen, but generally within 1 dioptre. It is inconceivable to make a mistake of 4 dioptres, also in light of the state-of-the-art equipment doctors are provided with.

During two post-operative check-ups, the patient was told that the outcome was normal since the IOL had yet to settle into the eye, without taking into account that her vision – +4 dioptres in her right eye, myopia (-10 dioptres) and a cataract in her left eye – was seriously compromised. In order to make her discomfort easier to understand, let’s imagine the patient walking with one foot bare and the other wearing an 8-inch high heel.

Had the mistake been discovered immediately, Maria would have undergone another surgery, so that she could have the wrong IOL replaced, thus not waiting needlessly for the former to settle into the eye.
One month later, at the following check-up, the head physician finally decided to operate on the woman again: by then, the IOL had settled and was embedded into the tissues and could not be removed without complications such as intraoperative capsular ruptures and vitreous loss occurring, potentially resulting in retinal detachment.
Since this option was no longer viable, she was offered some extreme alternatives, for example adding a new lens in the right eye (the “piggyback” technique) or operating on the left eye to make both eyes equally hyperopic (+4 dioptres). However, the simpler option, that is undergoing laser surgery (potentially performed by a refractive surgeon), was never mentioned.

On top of that, the patient was treated with arrogance, neglected and left unattended, even though she was complaining – and understandably so – of a discomfort she was not responsible for.
However, despite being discouraged and disappointed, Maria decided not to give up and with her granddaughter’s help, she began to search for information, so as to find a solution to her problem. Eventually, she contacted me.

Since the very first visit, I have immediately noticed that her vision could not be improved by glasses or anything else (not even contact lenses could help her, due to the presence of the cataract in the left eye and to her 10-dioptre high myopia).
I put forward a quicker, immediate and painless solution, that is femtosecond (FS) laser-assisted surgery on the right eye and operating on the myopia and cataract in the left eye on the same day, so as to treat her myopia (it is impossible to consider an over-5-dioptre laser treatment on the right eye) and allow her to get rid of distance glasses in favour of reading glasses.

Maria and her granddaughter eventually decided to head back to Sicily. A month later, the patient decided to undergo femtosecond laser-assisted surgery on her right eye and to have an IOL implanted in her left eye. In just one day, Maria had a natural visual acuity of 8-9/10 in both eyes. The remaining -0.50 myopia in both eyes was the result of a specific choice on my part, since it will improve her depth perception in near vision.

Such were Maria’s devastation and bewilderment after the long period of discomfort she had to go through while waiting for a solution to her problem that she did not notice immediately that, right after my operation, she could already see perfectly without her glasses and without pain or annoyances.

This story raises a fundamental issue: each patient wants his/her doctor to be professional, caring, meticulous, and sympathetic. Humility should be the defining trait of a good surgeon, because it is a quality that makes you reconsider your choices and the way you would manage potential complications during a surgery, with the ultimate goal of achieving the desired outcome. Accepting responsibility in difficult situations is what distinguishes a common doctor from a conscientious, highly professional one.