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Purpose To review data on malpractice claims related to refractive surgery to identify common allegations and injuries and financial outcomes. Methods The WestlawNext database was reviewed for all malpractice lawsuits/settlements related to refractive eye surgery. Data evaluated included patient demographics, type of operation performed, plaintiff allegation, nature of injury, and litigation outcomes. Results A total of 167 cases met the inclusion criteria, of which 108 cases (64.7%) were found to be favorable and 59 cases (35.3%) unfavorable to the defendant. A total of 141 cases were tried by a jury with 108 cases (76.4%) favorable and 33 cases (23.6%) unfavorable to the defendant. Laser in situ keratomileusis was performed in 127 cases (76%). The most common allegations were negligence in treatment or surgery in 127 cases (76%) and lack of informed consent in 83 cases (49.7%). For all cases, the need for future surgery (P = 0.0001) and surgery resulting in keratoconus (P = 0.05) were more likely to favor the plaintiff. In jury verdict decisions, cases in which failure to diagnose a preoperative condition was alleged favored the defendant (P = 0.03), whereas machine malfunction (P = 0.05) favored the plaintiff. After adjustment for inflation, the overall mean award was $1,287,872. Jury verdicts and settlements led to mean awards of $1,604,801 and $826,883, respectively. Conclusions Malpractice litigation in refractive surgery tends to favor the defendant. However, large awards and settlements were given in cases that were favorable to the plaintiff. The need for future surgery and surgery leading to keratoconus increased the chance of an unfavorable outcome.

Purpose of review Since their introduction in the mid-1990s, surface ablation techniques have continued to evolve, enabling surgeons to give patients better quality of vision with less postoperative pain. The purpose of this chapter is to discuss that evolution, the common techniques used today, and how to address potential complications. Recent findings Advanced surface ablation techniques offer advantages over laser in situ keratomileusis, including expanded potential patient profiles, reduced haze and pain postoperatively, and increased quality of vision. Haze reduction via preserved epithelial flaps, smoother stromal beds, and introduction of mitomycin-C intraoperatively have all improved safety outcomes of advanced surface ablation. Summary Experience has shown us that virtually all patients who are candidates for laser in situ keratomileusis can be candidates for surface ablation, but patients with specific ocular conditions, such as epithelial basement membrane dystrophy, superficial corneal scars, and previous radial keratotomy will have the best outcomes with surface ablation. Surface ablation and laser in situ keratomileusis are comparable in terms of safety and quality of vision. Wavefront-guided photorefractive keratectomy offers better acuity and less induction of higher order aberrations than wavefront-guided laser in situ keratomileusis.

Purpose To determine the incidence of and risk factors for fungal keratitis and endophthalmitis in patients with a Boston keratoprosthesis (KPro) and to determine whether surveillance cultures were helpful in predicting fungal infection. Methods A retrospective chart review was performed of 182 patients (202 eyes) who received a type 1 (through cornea) or type 2 (through cornea and lid) KPro between March 1, 1990, and December 31, 2004, and who were followed for at least 1 month (range, 1 month to 13 years; mean, 2.84 years). There were 148 eyes with type 1 and 54 eyes with type 2. Beginning in late 1999, many eyes were given a prophylactic topical regimen containing vancomycin, and many eyes with type 1 KPro were given therapeutic contact lenses. Cases of fungal keratitis or endophthalmitis were analyzed. To determine the fungal colonization rate, 70 surveillance cultures of the ocular or lid surface around the KPro optic were obtained of 36 uninfected KPro eyes (35 patients) at random time-points over 1 year (August 2002 to July 2003). Results There were 4 definite and 1 probable fungal infections in 6893 patient-months of follow-up, or 0.009 fungal infections per patient-year. These included 3 cases of definite or probable Candida endophthalmitis (C. parapsilosis, C. glabrata, and C. albicans) and 2 cases of mold keratitis (Alternaria, Fusarium). The rate was higher in eyes receiving a vancomycin-containing topical prophylactic regimen than those with on a non-vancomycin regimen (5 cases/2774 person-months vs. 0 cases/4119 person-months; P = 0.011). In eyes with type 1 KPro, the rate was higher with therapeutic contact lens wear than without (4/1682 vs. 0/3115 person-months; P = 0.015). Surveillance cultures did not predict fungal infection, and none of the 6 surveillance eyes colonized with fungi (all Candida) developed a fungal infection. The prevalence of fungal colonization in KPro eyes had not changed since our 1996 surveillance study (11% vs. 10%, P > 0.05). Conclusion Fungal infections in KPro eyes have appeared since we introduced broad-spectrum antibiotic prophylaxis and therapeutic contact lenses 5 years ago, but the infection rate remains very low in our mostly New England-based patient population. Cleaning or replacing the contact lens on a regular basis and prescribing a short course of topical amphotericin at the first visible signs of fungal colonization may prevent these infections.