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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

L.Kowal 2004

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My experience : 30+ cases

Defendant

Advisor / 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

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% 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

….

L.Kowal 2004

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NSW c.f. Vic

NSW more ‘aggressive’ culture than VicMore ‘fishing’More record subpoenasMore aggressive questioning in court‘Experts’ more likely to partisan

L.Kowal 2004

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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

L.Kowal 2004

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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

L.Kowal 2004

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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

L.Kowal 2004

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Inferior rectus fibrosis after blocks for cataract surgery

? 1% occurrence << 1% troublesome Alternatives existMESSAGE

Must mention diplopia with blocks

L.Kowal 2004

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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

L.Kowal 2004

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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 skew

MESSAGE

Document pre-op diplopia. Photos for difficult cases. Weird : 2nd opinions

L.Kowal 2004

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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 organic

Improved by neurontin

L.Kowal 2004

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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

L.Kowal 2004

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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

L.Kowal 2004

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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

L.Kowal 2004

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WE ALL LIVE AND WORK IN A GLASSHOUSE

Thank you

L.Kowal 2004

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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