Description of Event or Problem · 1
PT WAS SCHEDULED FOR BILATERAL LASIK IN 2002. BEFORE HER SURGERY, VISION WAS 20/400 IN THE LEFT EYE AND APPROXIMATELY 20/1600 IN THE RIGHT EYE. THE DOCTOR BEGAN BY PERFORMING THE SURGERY ON RIGHT EYE. AFTER PREPARING THE EYE FOR THE SURGERY BY APPLYING NUMBING DROPS AND USING THE WIRE LID SPECULUM, HE USED A 130 MICRON MORIA MICROKERATOME HEAD. HE EXAMINED THE BLADE, PLACED IT INTO THE HEAD OF THE MICROKERATOME, AND THEN SCREWED THE HEAD INTO THE MOTOR. THEN, HE TESTED THE MICROKERATOME ON THE SUCTION RING. ALL OF THE EQUIPMENT, INCLUDING THE MOTOR, APPEARED TO BE IN GOOD WORKING ORDER. HE THEN PLACED THE SUCTION RING ON EYE. ONCE THE PRESSURE WAS ACCEPTABLE, HE ATTACHED THE MICROKERATOME TO THE SUCTION RING AND MADE THE CUT. AFTER HE RETURNED THE MICROKERATOME TO ITS ORIGINAL POSITION, HE REALIZED THAT THE FLAP WAS A BUTTONHOLE. THE DOCTOR THEN INSPECTED THE MICROKERATOME BLADE AND HEAD AND DID NOT FIND ANY DAMAGE. BUT, TO BE SAFE, THE DOCTOR REPLACED THE BLADE AND THE MOTOR. HE AGAIN TESTED ALL OF THE EQUIPMENT BEFORE HE USED THE MICROKERATOME TO CUT THE CORNEAL FLAP ON THE LEFT EYE. THE FLAP IN THE LEFT EYE WAS A BUTTONHOLE AS WELL. HE DID NOT PERFORM LASER TREATMENT ON EITHER EYE. THE DOCTOR SENT PT HOME APPLYING A BANDAGE CONTACT LENS AND PRESCRIBING A REGIMEN OF MEDICATED DROPS. AT THE FIRST POST-OPERATIVE VISIT ON THE NEXT DAY, PT'S VISION WAS CORRECTABLE TO 20/60. FOUR DAYS AFTER THE SURGERY, PTCAME IN FOR A SECOND POST-OPERATIVE VISIT. THE DOCTOR NOTED THAT FLAPS WERE HEALING WELL BUT THAT THE INTERFACE WAS IRREGULAR. PT'SVISION WAS CORRECTABLE TO 20/40 IN THE RIGHT EYE AND 20/80 IN THE LEFT. PT DID NOT VISIT THE PHYSICIAN AFTER THE SECOND POST-OPERATIVE VISIT AND MORIA DOES NOT HAVE ANY ADDITIONAL INFORMATION ABOUT PT'S CONDITION. WHILE THE SURGERY TOOK PLACE IN 2002, MORIA ONLY LEARNED OF THE SURGERY WHEN PT'S COUNSEL RECENTLY CONTACTED MORIA IN CONNECTION WITH LAWSUIT AGAINST THE SURGEON WHO PERFORMED THE LASIK. AFTER REVIEWING THE RECORDS, MORIA DECIDED TO REPORT THIS INCIDENT BECAUSE IT IS AN ADVERSE EVENT CAUSED BY USER ERROR. PT HAD UNUSUALLY STEEP CORNEAS AT 46 DIOPTERS WHICH PUT THEM AT SPECIAL RISK FOR BUTTONHOLES. THE DOCTOR DID NOT PROPERLY ACCOUNT FOR THE STEEPNESS OF PT'S CORNEAS WHEN HE CHOSE A MICROKERATOME HEAD THAT WOULD HAVE YIELDED A THINNER CUT. TO PREVENT BUTTONHOLES, A PHYSICIAN SHOULD USE A MICROKERATOME HEAD THAT WOULD RESULT IN A THICKER FLAP MOREOVER, THE BUTTONHOLE IS NOT CONSISTENT WITH A MALFUNCTIONING MOTOR OR DEFECTIVE BLADE. EITHER OF THOSE PROBLEMS WOULD HAVE LED TO A JAGGED CUT RATHER THAN A BUTTONHOLE.