MEDICAL REPORT
ON
John Claimant, Date of Birth xx July 19xx
of 10 Anywhere Avenue, Somewhere, Wirral
OF
SOMDUTT PRASAD
Date: 21 January 2008
Specialist field: Ophthalmology
On behalf of: Mr John Claimant
On the instructions of: Another Solicitor
Subject matter: Liability and Causation
CONTENTS
1 Introduction. 2
1.1 Formal details. 2
1.2 Synopsis. 2
1.3 Instructions. 2
1.4 Disclosure of Interest 2
2 The background to the dispute and the issues. 3
2.1 The relevant parties. 3
2.2 The assumed facts. 3
2.3 The issues to be addressed. 4
2.3.1 The cause of Mr Claimant' anisometropia. 4
2.3.2 The standard of care. 4
3 Enquiry. 4
4 The facts on which the expert’s opinion is based. 5
4.1.1 Opinion. 5
4.1.2 Prognosis. 7
5 Conclusions. 8
Appendix 1: details of my Qualifications, Professional experience and Appointments. 9
Appendix 2: Chronology. 10
Appendix 4: A glossary. 15
Appendix 5: Cross sectional diagram of the eye. 17
REPORT
I, Somdutt Prasad, Consultant Ophthalmic Surgeon, 
of BUPA Murrayfield Hospital, Thingwall, Wirral, CH61 1AY have been instructed to produce this report by Mr A N Other of Another Solicitor Limited regarding Mr John Claimant, date of birth xx July 19xx, of 10 Anywhere Avenue, Somewhere, Wirral.
Mr John Claimant underwent intraocular lens exchange at Town 2 Royal Eye Hospital. The incorrect power of lens was inserted, and he now needs to wear a contact lens to see normally. He alleges negligence in the manner of his treatment.
I have been asked to report on liability and causation.
None known.
Contains details of my Qualifications, Professional experience and Appointments.
Contains a chronology
Contains a list of documents I have considered.
Contains a glossary.
Cross sectional diagram of the eye.
John Claimant - the plaintiff.
Mr Surgeon 1 - Consultant Ophthalmologist, Town 1
Mr KB Surgeon 2 - Consultant Ophthalmologist, Town 2
2.2.9 Surgery was performed on the 21st of October 1997. At surgery it was found that the original intraocular lens of 5 millimetre diameter was in front of the capsule, and had slipped down. This lens was removed through a 7 millimetre corneal section, an anterior vitrectomy was performed and a 7 millimetre, 26 dioptre posterior chamber lens was inserted in the ciliary sulcus. The wound was closed with three nylon sutures and a sub-conjunctival injection of Betnesol and Gentamycin administered.
2.2.11 On the 7th of November 1997, the inflammation had settled, but some macula degeneration was noted. The topical steroid ointments were discontinued from this point.
2.2.14 On the 7th of January 1998 the corneal sutures were removed, and arrangements were made for him to be fitted with a contact lens.
2.2.15 He was seen in the contact lens clinic on the 21st of January 1998 and was found to have a vision wearing the contact lens potentially of 6/5.
I have read the documents supplied but have had no contact with any relevant party.
4.1.1.1 Mr Claimant developed premature cataracts in his late 40's, and it seems likely that this was due to a condition known as Fuch's Heterochromic Cyclitis. He underwent surgery to remove the cataract in late 1994, and it appears that the operation performed by Mr Surgeon 1 was complicated by capsule rupture, given the operative findings in Town 2 Royal Eye Hospital.
4.1.1.2 I have not had sight of case notes from Town 1 and any opinion expressed now must necessarily be provisional.
4.1.1.3 However it seems likely that the operation was complicated by capsule rupture. In addition a 5 millimetre intraocular lens that is designed to be sited within the capsular bag, was inserted into the eye.
4.1.1.4 The capsular bag is the part of the cataract that remains once the contents of the lens capsule have been removed in extra-capsular surgery.
4.1.1.5 When a lens is inserted into the capsular bag, it normally has a haptic diameter of about 10 or 11 millimetres.
4.1.1.6 In Mr Claimant's case Mr Surgeon 1 did not insert the lens inside the capsular bag, but rather inserted it to lie in front of the anterior part of the lens capsule, in the so called ciliary sulcus.
4.1.1.7 Normally the lens's designed to be sited in this area have a haptic diametre of 12-13 millimetres.
4.1.1.8 It can be readily appreciated that the lens inserted was too small, causing it to dislocate inferiorly, so that the edge of the lens occupied the visual axis rather than the centre of the lens.
4.1.1.9 In my opinion given the situation the decision to remove the intraocular lens and replace it is entirely appropriate. I therefore have no criticism to make of Mr Surgeon 2 plan to perform such surgery.
4.1.1.10 Furthermore from reading the case notes it appears that the appropriate operation was performed and that the results of surgery were technically satisfactory.
4.1.1.11 It is however clear that the incorrect power of lens was chosen prior to surgery and this has caused a condition of anisometropia, or unequal refraction between the two eyes.
4.1.1.12 Avoidance of anisometropia is central to the planning of cataract surgery, and every attempt is made to match the predicted refraction of the fellow eye with the actual refraction of the first eye.
4.1.1.13 The power of the crystalline lens within the eye is measured in dioptres, as is the refractive power of spectacle lenses.
4.1.1.14 If there is a disparity of spectacle refraction between the two eyes of more than three dioptres, then each eye sees a different size image, causing intractable and intolerable double vision.
4.1.1.15 From Mr Surgeon 2' original notes, it is clear that Mr Claimant had no refractive error in his right eye, which had normal vision.
4.1.1.16 In this circumstance most surgeons would attempt to match the refraction of the operated left eye to that refractive state, and would predict a post-operative refraction for the left eye as either plano or a small myopic error.
4.1.1.17 Given that a posterior chamber intraocular lens were to be inserted, this would mean picking a 19, 19.5 or 20 dioptre intraocular lens.
4.1.1.18 In error, a 26 dioptre intraocular lens was inserted.
4.1.1.19 This error can be traced back to the original cataract management record, when the refraction of the two eyes are recorded. The right eye refraction is recorded as -8.75/+1.25 x 144, rather than plano which it actually was.
4.1.1.20 It is quite clear that this recorded spectacle refraction was not taken from Mr Claimant's glasses.
4.1.1.21 It is easy to see how such a mistake might occur, possibly Mr Claimant had brought somebody else's glasses with him, and the strength of those spectacles were measured and recorded as belonging to Mr Claimant.
4.1.1.22 Alternatively the record from another patient was recorded in Mr Claimant's case notes. No doubt there are equally plausible explanations.
4.1.1.23 In my opinion, this error, however it occurred, was avoidable by the simple expedient of repeating the refraction, or checking his vision actually wearing the glasses.
4.1.1.24 This error indicates a standard of care beneath that which Mr Claimant was reasonably entitled to expect from a reasonably competent ophthalmologist.
4.1.1.25 As a result of this error, Mr Claimant now suffers from anisometropia that requires contact lens wear for its correction.
4.1.1.26 Happily it appears that with the contact lenses he is currently wearing, his visual acuity is not degraded in any way.
Not having examined Mr Claimant I cannot comment meaningfully on prognosis.
I, Somdutt Prasad, declare that:
1) I understand that my primary duty in written reports and giving evidence is to the Court, rather than the party who engaged me;
2) I have endeavoured in my reports and in my opinions to be accurate and to cover all relevant issues concerning the matters stated which I have been asked to address;
3) I have endeavoured to include in my report those matters, which I have knowledge of or of which I have been made aware, that might adversely affect the validity of my opinion;
4) I have indicated the sources of all information I have used;
5) 1 have not without forming an independent view included or excluded anything which has been suggested to me by others (in particular my instructing lawyers);
6) I will notify those instructing me immediately and confirm in writing if for any reason my existing report requires any correction or qualification;
7) I understand that;
8) My report, subject to any corrections before swearing as to its correctness, will form the evidence to be given under oath or affirmation;
9) I may be cross-examined on my report by a cross-examiner assisted by an expert;
10) I am likely to be the subject of public adverse criticism by the judge if the Court concludes that I have not taken reasonable care in trying to meet the standards set out above.
11) I confirm that I have not entered into any arrangement where the amount or payment of my fees is in any way dependent on the outcome of the case.
Signed
Somdutt Prasad MS FRCSEd FRCOphth FACS Date; 27 January 2008
Appendix 2: Chronology
1993
Left cataract surgery by Mr Surgeon 1 at Town 1 Eye Hospital
20/6/96
Seen by Mr Surgeon 2 in St John St Town 2
Left cataract + IOL Nov 1994, Town 1 Infirmary
Unhappy with vision
Told implant slipped
VA right = 6/6 unaided - refraction plano
Left 6/24 unaided, -3.00/+2.00 = 6/7.5
Illegible
IOL dislocated downwards ++
IOP = 18 mmhg
24/6/96
Letter Mr Surgeon 2 to Admissions officer, Town 2 Royal Eye Hospital
"…list this man for replacement of intraocular lens. GA NHS"
8/7/96
Letter from GP to Admissions officer, ?? centre, agreeing to refer this man to EH as an NHS patient
6/10/97
MREH Listing form,
Replacement of lens, Common pool, Inpatient, General anaesthetic
Undated entry
Left monocular diplopia
Downward displacement of IOL left eye
R eye nuclear sclerosis
20/10/97
Cataract management record
Right VA = 6/6 with -8.75/+1.25x144
Left VA = 6/6 with -7.00/+1x74
Intended procedure = secondary IOL
IOL power = 23dioptre, (a-constant 114.70) desired refraction = -6.00
21/10/97
Operation proforma - surgeon illegible
Left lens exchange under local anaesthaesia
7.00 corneal section,
Findings, eliptical PC hole, enough support for sulcus fixation
Previous IOL too small in front of capsule
anterior vitrectomy, removal of original 5 mm IOL
26 dioptre PCIOL inserted
3 x 10/0 nylon sutures
S/conj injection of betnosol and gentamycin
NB, not given AC IOL in view of age and risk of glaucoma. Explained that we have tried sulcus lens -> wait to see how this behave
22/10/97
Wound leak +
AC deep cells +
IOP = 12 mmhg
31/10/97
VA Right = 6/6 unaided, Left = 2/24, pinhole = 6/18
Vision blurred left eye
Wound leak +
AC deep cells +++ no flare
IOP = 10 mmhg
Increased betnosol to 2 hourly
7/11/97
VA Right = 6/6 unaided, Left = 2/60, pinhole = 6/24
Minimal wound leak +
AC quiet and deep
IOP = 16 mmhg
Posterior pole: disc ticked, macular degeneration
Tail off betnosol
19/12/97
right vision unaided = 6/4
refraction = plano
current glasses left eye (3 years old) = -3.00/+2.25x155 = 6/60+1
Left vision unaided = 2/60
Refraction -8.00/+2.00 x 10 = 6/4-2
Near add = + 2.50 = N5
" Gross disparity between focimitry at pre-assesment clinic and glasses brought today
..the focimitry must be wrong"
IOP = 40 mm hg
Asymetry of discs
Impression steroid responder
Stop betnosol, add G Timolol Left eye
7/1/98
IOP = 15
Sutures removed
8/1/98
Letter from Mrs G detailing gross anisometropia
21/1/98
contact lens clinic
vision with lens potentially = 6/5
stellate KP, AC cells ++, IOP = 18 mm hg
diagnosis Fuch's heterochromia
20/5/98
age = 49
vision right = 6/5 unaided, left 6/6 with contact lens
IOP = 16 mmhg
C/D R = 0.7, L = 0.5
V unhappy with CL
appointment to see KBM
10/6/98
unhappy with fit of CL larger diameter ordered
15/6/98
Letter Ms Y
Unhappy with fit of contact lens. A new larger diameter lens has been ordered
24/7/98
VA R = 6/5, unaided, left = 6/6 with contact lens
Happy with contact lens
Lens in situ, AC stable
IOP not measured
Wrong lens inserted
Illegible
30/7/98
Letter Mr Surgeon 2 to Dr E
"… wrong strength lens inserted…left him with significant myopia…"
"…told him that he has had the wrong implant placed in his eye…"
Appendix 3: A list of documents I have considered
Bundle containing photocopies of casenotes from:
Mr KB Surgeon 2, St John St Town 2
Town 2 Royal Eye Hospital
Anterior synechae: adhesion between the iris and cornea. It may result from intraocular inflammation and/or trauma.
Small anterior synechae usually cause no problems, large areas of anterior synechae formation may produce secondary glaucoma.
Anterior vitrectomy: removal of the anterior vitreous from the eye. Ideally performed with the aid of a mechanical cutting device.
Aphakic/aphakia: absence of the crystalline lens.
Astigmatism: differing refractive power in differing meridia of the eye, often due to a difference in the curvature of the cornea in one meridian with respect to another.
Chloramphenicol: an antibiotic used in ophthalmology.
Corneal abrasion: a loss or scraping off of the superficial (epithelium) layer of the cornea.
Corneal epithelium: the superficial outer (surface) layer of the cornea.
Corneal stroma: the middle layer of the cornea.
Dialysis: is a diinsertion of an intraocular structure.
Ectropion: is an out turning of the eyelid in such a way that the lid margin is no longer in contact with the globe.
Exophoria: a constitutional tendency for the eyes to diverge.
Gonioscope: a contact lens for visualisation of the irido-corneal angle.
Hypertropia: a vertical imbalance of the ocular muscles resulting in one eye being elevated with respect to the other.
Hypotropia: a vertical imbalance of the ocular muscles leading to one eye being lower with respect to the other.
Hyphaema: blood in the anterior chamber of the eye.
Irido-corneal angle: the angle between the peripheral iris and cornea, where aqueous humor drains from the eye. Damage to the irido-corneal angle may lead to the development of glaucoma.
Iris recession: cleavage of the irido-corneal angle. Small degrees of iris recession cause no problems; large recession may be associated with secondary glaucoma.
Lens capsule: this is a thin but relatively tough membrane covering the surface of the crystalline lens. Traumatic rupture or perforation of the capsule leads almost inevitably to cataract formation.
Near reading acuity: is a test of an individual's ability to read print of varying typeface sizes. The best acuity is N5 vision: this is the smallest typeface that can be found in any normal text. N6, N8, etc. are larger typefaces.
Parafoveal: adjacent to the fovea.
Posterior capsular thickening: this is an opacification of the posterior capsule of the lens. It may occur following extracapsular cataract extraction, phacoemulsification, or following removal of a traumatic cataract. It results in reduction in the visual acuity.
Posterior synechae: adhesions between the iris and the underlying crystalline lens.
Random dot stereogram: a method of assessing stereoscopic (three-dimensional) vision.
Sulcus fixed: placement of the posterior chamber intraocular lens into the anatomical groove between the iris and ciliary body: the ciliary sulcus, rather than the preferred placement within the capsular bag.
Tarsal plate: this is the fibrous skeleton of the lid.
visual acuity: a measure of the resolving power of the eye. Usually determined by have the subject read letters of various sizes at a standard distance from the test chart. The result is expressed as a fraction. 6/6 is normal vision and means that the subject's eye has the ability to see at a distance of 6 metres the normal eye would see at that distance. 6/9 vision means the subject can see at six meters what a normal individual would see at 9 metres, i.e. reduced vision. Thus, an increase in the denominator indicates a degree of subnormal vision. A reduction in the denominator (e.g. 6/5) equates to better than normal vision.
Yag laser capsulotomy (iridotomy): disruption of the posterior capsule (iris) by the neodymium Yag laser.
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