Carola Rozon visited New York ophthalmologic surgeon Edwin Schottenstein, MD, in 2013 to undergo a second eye surgery, according to court documents. As with the previous surgery, Dr. Schottenstein performed phacoemulsification, a technique by which the tip of an ultrasonic machine is inserted into the lens through a small incision in the anterior chamber. The machine’s vibrations break up the hard, inner portion of the nucleus that is affected by the cataract, and the lens is then extracted with irrigation and suction, leaving the capsular bag filled with fluid.
Dr. Schottenstein made a 2.75-mm incision in the anterior chamber and successfully removed most of the nucleus of the cataract lens, according to the appellate decision. However, complications arose during the surgery when the capsular bag tore, and a piece of the lens dropped through the tear into the back of the patient’s eye.
Following the complications, Dr. Schottenstein injected a folded 6-mm intraocular lens (IOL) into the patient’s eye, but it was off center and moved toward the back, according to court documents. He removed it with holding forceps, pulling the unfolded 6-mm IOL through the 2.75-mm incision.
Because it was New Years Eve, Dr. Schottenstein did not immediately seek assistance from a vitreoretinal surgeon. Two days later, on Jan. 2, 2014, the patient was referred to a vitreoretinal surgeon for removal of the dropped lens. The vitreoretinal surgeon reported signs of trauma to the patient’s eye, including corneal edema and blood from a vitreous hemorrhage. Neither the ophthalmologist nor the vitreoretinal surgeon reported any injury to the patient’s iris.
Because of the vitreous hemorrhage, the vitreoretinal surgeon could not visualize the back of the eye. He used a B-scan ultrasound to create an image of the back of the eye to determine whether there were any retinal tears. According to court records, the vitreoretinal surgeon reported that the B-scan did not detect any retinal tears, and the vitreoretinal surgeon scheduled the patient for a follow-up the following week.
On Jan. 9, 2014, there was still blood in the patient’s eye from the hemorrhage. The vitreoretinal surgeon did not perform another B scan and stated that, with a fundoscope, he could see the back of the eye and the piece of fallen lens, according to court documents. No retinal tears were seen. Surgery was scheduled for 6 days later.
During the surgery, the vitreoretinal surgeon noted a choroidal effusion, swelling of the blood vessels that feed the retina. After draining it, he saw a giant retinal tear and retinal detachment at the top of the patient’s eye. Over the course of a year, the vitreoretinal surgeon performed five more surgeries to repair the giant retinal tear, but they were unsuccessful. Ultimately, the patient lost sight in her right eye.
The patient sued Dr. Schottenstein for malpractice in 2016, alleging that, as a result of his negligence, she suffered the retinal tear and is now blind in her right eye. A trial took place in November 2019.