Sight is a precious gift, so surgery in such a delicate area can cause apprehension; when these cases go wrong, or not as expected, the patient may decide to take matters to court. Jane Olver has extensive, specialised experience behind cosmetic eye surgery and speaks to us on how she helps when things go wrong.
What are the most common cases you deal with in cosmetic eye surgery instructions?
I most often see clients who are dissatisfied with their cosmetic eyelid surgery, either because it had not met their expectations, or had left them with a noticeable disfigurement such as visible scar, asymmetry, eyelid or canthal contour change.
Very often the client will tell me that they went to see their surgeon for one particular problem and they were “talked into” having some surgery they did not go to see their surgeon for; when that surgery then goes wrong, or does not give them the expected result they become unhappy. When they express that unhappiness to their surgeon, this often leads to a breakdown of the professional relation, as the surgeon cannot always see what their patient sees. What the patient really wants is for the surgeon to say is “I made a mistake”, or “Would you like to ask someone else to see you?”. They want their surgeon to know that they did a bad surgery, below the standard they would have reasonably expected from a competent surgeon of similar grade. As that often does not happen and the surgeon effectively rejects them, they decide to bring a legal claim for negligence.
Avoidable complications of eyelid surgery:
- Rounding lateral canthus
- Lower lid sag
- Incomplete eyelid closure
- Dry eye
- Irritated red eyes
- Wrong operation performed
A proper way to avoid the above is for the surgeon to have first done a thorough pre-operative assessment, with measurements of the eyelids and their function, with examining for eyelid laxity, for dry eye. They should ask to see pictures of the patient when they were younger, and identify the patients’ expectations, only offering surgery which is both within those expectations and also within the skills of the surgeon.
In cases of professional negligence, how long can it commonly take to complete an investigation in the field of ophthalmology?
It usually takes about 12 to 18 months. Once I have done the claimants consultation assessment then the report is usually prepared within four to six weeks. After that it is up to the solicitors and the courts. I may be asked to provide a supplementary report if there are queries or new material provided, and to do a joint conference with the other expert.
At the assessment, I will make photographic documentation, measure visual fields, examine osmolarity of the tears for dryness, the eye pressure and examine the eyelids and eyes on the biomicroscope called the slit lamp. This allows me to put in fluorescein eye drops and see if there are surface problems related to the cosmetic eyelid surgery, or an existing pathology which should have been detected by the surgeon before the surgery and could have enabled them to advice their patient differently or tailor their surgery appropriately. This is where being an ophthalmologist is so important as it helps examine the eyelids and eyes, remembering that the function of the eyelids are not just to look beautiful, but also primarily to protect the eye through proper blinking and closing.
How difficult is it to produce a thorough analysis of a claim, and does this often depend on the patient/claimant? Are there many variables?
For a medical expert, the main thing about a potential claim is thoroughly reading the instructions and if possible examining the claimant in order to provide an independent medical opinion. One important variable is the condition of the medical material presented to me: if it is well indexed and paginated then my job is made much easier. If it is presented digitally it is easier to scan through. Often though I will request both digital and paper versions.
As an expert witness in eye surgery, to what extent do you get to engage the full capacity of your expertise?
Fully. With 20 years as a consultant and over ten years training prior to that, and still being in mainstream practice, I am able to draw on my considerable expertise and knowledge in order to be a medical expert. I think having the maturity and reputation helps me provide a sound and considered opinion.
How often is your critical analysis the game-changer in a claim, and what are the consequences for surgeons found to be liable for further eye problems?
This is a very difficult area. In such a small field as eye surgery I am likely to know most of the surgeons, either by name, or have worked with them professionally. In Oculoplastics I will know most of the British Oculoplastic Surgery Society (BOPSS) members. Therefore, I have to declare any potential conflict of interest and I do identify the capacity in which I know the surgeon. Many plastic and maxillofacial and even otolaryngology and head and neck surgeons often carry out eyelid surgery as it is within their training curriculum, but they may not always have the vast experience of an oculoplastic surgeon who only operates on eyelids, and may not have kept as up to date, so many of the claims I see are against surgeons who do not habitually carry out a large number of said surgeries.
Sometimes I may find that the claimant does not have a legitimate claim and that there has not been a breach of duty, and I must say so. My report is for the court and is impartial.
Professionally, I may find that one of my colleagues has made a breach of duty and I have to remain impartially critical, based on the facts having examined the claimant, read the clinical notes and done the literature search. It is not for me to predict what the outcome of the case will be, only to provide my opinion within the framework of my specialist field. I think most surgeons are professionally mature enough to realise that a medical expert is reporting on their observations and it is not a personal criticism of them.
What do you believe would be warmly welcomed by UK ophthalmologists in terms of legal reform in medicine and in your specialist areas?
I do think that UK ophthalmologists must be more transparent about how often we do various surgeries and our complication rates. This will help patients understand that there is no such thing as 100% successful surgery and that they can expect possible scarring, asymmetries, tear flow problems. This may reduce the number of claims, as realistic expectations are paramount. It can be through our yearly appraisal but there should also be an obligation through Care Quality Commission for private practice cosmetic surgery to be properly recorded, inspected and published.
Continued training and evidence of continued learning is also essential.
Currently, higher surgical training includes very little cosmetic surgery so the work being done between the Cosmetic Surgery Interspecialty Committee, the GMC and the Royal Colleges is paramount to laying the foundation for training and producing competent future cosmetic surgeons.