5 cataract surgeries, 5 people blinded: What went wrong?
The patients were lined up in reclining chairs, waiting their turns. When the surgery center’s anesthesiologist reached her, Kathleen White yelped in pain as he injected a numbing agent into her left eye. An assistant whisked her into the operating room for her scheduled cataract surgery.
The surgery lasted no more than 15 minutes — her surgeon had 45 cases on the schedule that day — and seemed to go smoothly. But at a follow-up appointment the next day, a staffer removed the patch over White’s eye and told her to read the letters on a wall chart.
“I can’t,” White recalls telling her. “Everything is black.’’
White, 65, was one of five patients who had surgery at Cataract & Laser Center West in West Springfield on a May morning in 2014, only to discover the next day that the patients could not see out of the eye that had been operated on.
The injuries have shocked and mystified cataract surgeons, who say even one serious injury is rare, and led specialists who examined the patients to conclude that the anesthesiologist on the cases, Dr. Tzay Chiu, possibly pierced their eyeballs or retinas with his needles, according to the surgery center’s investigative reports submitted to the state. Chiu’s attorney, Rebecca Capozzi in Waltham, declined to comment.
The documents reveal confusion about whether Chiu, who had been sent by an agency and was working his first day at the center, was properly screened. He was placed there by an anesthesiologist “broker’’ that had a contract with the center, a common practice.
Unlike many hospitals, the country’s more than 5,400 independent outpatient surgery centers — including about 60 in Massachusetts — often contract with outside companies to provide anesthesiologists, rather than employ them.
Anesthesiologists who are new to a center or substituting for a vacationing or sick colleague must be properly trained and then brought up to speed swiftly, to keep up with the cataract patients who stream through the center at a rapid clip. And if the center and the anesthesiology group are not working together closely, safety checks can fall through the cracks.
Several doctors said it can be hard to find qualified anesthesiologists well-trained to assist with cataract removal, which is the most-often-performed operation in the United States.
In a report to the Department of Public Health, the Cataract & Laser Center said it reviewed Chiu’s education, training, and experience giving anesthesia for eye surgery — including two letters of reference from colleagues — none of which raised red flags.
The center also said the anesthesiologist who was usually assigned there, Dr. Mario Addabbo, observed Chiu’s first three cases and found he was competent — an assertion Addabbo disputed in a recent deposition. All five injured patients have hired lawyers, and two have filed lawsuits so far.
Addabbo said he was “around the corner’’ prepping and discharging patients when Chiu began his cases. Both doctors had contracts with D&G Associates, a Massachusetts anesthesiologist broker.
The lawyer for the surgery center, Michael Roundy in Springfield, declined to comment.
Chiu was using a type of anesthesia, referred to as an “eye block,’’ that involves injecting the numbing agent into the muscles around the eyeball, immobilizing the eye itself. Experts suggest observing 10 blocks before allowing a new anesthesiologist to work unsupervised, according to the Betsy Lehman Center, a state agency focused on improving patient safety.
As a result of the injuries, the West Springfield surgery center told the health department in one report that it increased the number of required observations to 12.
White arrived at the center early that Tuesday. The surgeon, Dr. John Frangie, was her regular ophthalmologist. She could no longer see well driving at night and he recommended cataract removal. She’d never had surgery before — or even an intravenous line — and she was nervous.
Staff moved White from room to room for different parts of the preparation, an experience that reminded her of an assembly line. When she exclaimed as Chiu slid in the needle about 9 a.m., he responded “I’m bad. I’m bad,’’ she said. Pain can be a sign of a problem with the injection, anesthesiologists said.
The other four patients were injured between 11:10 a.m. and 11:40 a.m., according to surgery center reports submitted to the state. James Craig, 75, said he screamed when the needle went in. Wendell Willis, 58, was reclining in a chair when he heard a yell from a patient he did not know. “I said, ‘Is that going to happen to me?’ A nurse said, ‘No, that is not supposed to happen,’ ’’ he told the Globe.
Marilyn Rondeau, 68, said Chiu seemed confident and skilled.
“It is supposed to be a very simple surgery,’’ she said. “Everybody I talked to said, ‘Oh, it’s nothing.’ ’’
She agreed — until the next day. White, Willis, and Rondeau said they are completely blind in the eye that was operated on. Craig has a crescent-shaped blind spot in the middle of his right eye that severely limits his vision.
“I am absolutely afraid to have the other cataract done,’’ Craig said.
Chiu has reached an agreement with the Board of Registration in Medicine, which licenses Massachusetts doctors, not to perform eye blocks while the board investigates the patient injuries, but he can otherwise practice.
Meanwhile, the injured patients are struggling with new limitations, including problems with depth perception, driving, and spotting details. White quit her jobs as a nursing home and home health care aide because she is no longer comfortable behind the wheel.
She wonders whether the outcome would have been different if doctors at the surgery center had caught the injury immediately. A retina specialist told her that if the anesthesia accidentally injected into her eyeball had been washed out right away, fewer nerves might have been damaged.
Dr. Robert Amrhein, an anesthesiologist at Cape Cod Eye Surgery and Laser Center in Sandwich, said a doctor might or might not know right away if he or she caused an injury. Pain can be a signal, or if the surgeon can’t see the retina clearly during the procedure, it might indicate a hemorrhage.
The cases also raise a broader issue about the reliance in Massachusetts on using eye blocks for cataract surgery, while physicians nationally tend to use less-invasive numbing drops more often. The patients interviewed by the Globe don’t recall discussing options with the doctors.
The Lehman Center, which published a report earlier this year on errors in cataract surgery, recommended that doctors use the least-invasive anesthesia appropriate for the case and do a better job describing the choices to patients. They also advised more rigorous evaluation of new surgeons and anesthesiologists.
In its report to the state, the surgery center said Chiu had done hundreds of eye blocks but also raised the possibility that D&G failed to adequately verify his experience. In the end, though, the business wrote a letter to an injured patient in July 2014 saying the cause of the event could not be determined. The center raised the possibility of an error during anesthesia but said because the anesthesiologist had “extensive prior experience’’ it was determined the “event in this case was not preventable.’’
Dr. John Mandeville, president of the Massachusetts Society of Eye Physicians and Surgeons, agreed injuries are not always preventable. He said it’s important for patients to know that surgery centers generally provide high quality care and accept only anesthesiologists who have considerable experience with eye blocks. But he said observing doctors for a dozen cases might not catch problems.
“We have hired surgeons who look great on paper and interview great. In six months, you realize this person shouldn’t be operating and you let them go,’’ he said. “If the anesthesiologist never did it before and came in and did them unsupervised, then that’s a preventable error.’’
But William Thompson of Lubin & Meyer in Boston, the lawyer for Willis and Rondeau, believes the errors in this case could have been avoided. In an e-mail to D&G Associates, Chiu said he last did eye blocks in July 2013, almost a year before the injuries, Thompson said.
“When one patient ends up blinded, it raises a red flag because it’s such a rare complication,’’ he said. “When five patients are blinded, all on the same day, in the same center, it’s really shocking.”