Dr KK Aggarwal , President CMAAO and HCFI
15 years later in a case treated at Maharaja Agrasen Hospital in which a new-born resulted in total blindness of a new-born; the Supreme Court has awarded compensation of Rs 76 lakh to the family.
A bench of Justices U. U. Lalit and Indu Malhotra held the hospital, its paediatrician and ophthalmologist guilty of medical negligence as they failed to carry out the mandatory retinopathy of prematurity (ROP) check on the pre-term baby, which led to his total blindness. The court also slammed the hospital for not sharing the medical records of the child, born in 2005, with his parents for over two years after discharge to enable them to approach other doctors for treatment.
The baby was brought to the hospital for medical examination from time to time for more than three months, but the doctors did not undertake the test.The bench awarded a compensation of Rs 76 lakh out of which Rs 60 lakh was allocated for the child’s education, welfare and sustenance. Rs 15 lakh was allocated to the mother as his caregiver and Rs 1 lakh towards litigation cost.
The court upheld the National Consumer Commission’s order that it was a case of medical negligence.
- Retinopathy of prematurity is a developmental vascular proliferative disorder that occurs in the retina of preterm infants with incomplete retinal vascularization.
- ROP is an important cause of severe visual impairment in childhood.
- Other ophthalmologic disorders that occur frequently in preterm infants include amblyopia, strabismus, and refractive errors.
- Guidelines suggest screening all infants with birth weight (BW) ≤1500 g or gestational age (GA) ≤30 weeks
- One should also screen those with BW between 1500 g and 2000 g or GA >30 weeks whose clinical course places them at increased risk for ROP (as determined by the neonatologist).
- Canadian Paediatric Society suggest screening for infants with birth weight ≤1250 g and infants with GA <31 weeks regardless of BW
- Do we have Asian guidelines?
- Screening for ROP is a labour-intensive process with a relatively low yield; <10 percent of infants who are screened require treatment
- The optimal criteria for screening remain uncertain.
- Research has focused on developing prediction models to identify high-risk infants with the hope of reducing the number of infants requiring ophthalmologic examinations. However, these methods require additional validation in broad populations before changes to the screening recommendations can be made.
- The screening evaluation consists of a comprehensive eye examination performed by an ophthalmologist with expertise in neonatal disorders
- How many paediatric ophthalmologists we have in the country?
- And how many neonatal ophthalmologists we have in the country
- The pupil must be dilated in order to visualize the vitreous and retina.
- The protocol is to use a combination eyedrop (Cyclomydril, which contains weak concentrations of phenylephrine and cyclopentolate) 30 minutes or more before the examination. Both manipulation of the eye and the cycloplegic eyedrops can produce adverse cardiorespiratory and gastrointestinal effects (e.g., bradycardia, arrhythmia, apnoea, desaturation, emesis). Therefore, it is essential to carefully monitor the infant during and after the examination procedure. Topical anaesthetic can be used based on the preference of the examining clinician
- How many centers in India would have this facility?
- The retina is examined by looking through the pupil with an indirect ophthalmoscope with a 20 or 28 diopter condensing lens while the eyelids are retracted with a speculum. ROP is most commonly visualized in the peripheral retina, which often is obscured by the iris. In order to completely view this area, a scleral depressor is used to indent the eye externally.
- Alternatively, telemedicine systems can be used to identify infants with potentially severe ROP.
- How many centers are trained for this?
- Start screening examinations at 30 weeks postmenstrual age (PMA) for infants born at 22 to 26 weeks and at 4 weeks of chronologic age for infants born at ≥27 weeks. Treatable ROP rarely occurs before 31 weeks PMA, most initiate screening at 30 weeks PMA to account for the possibility of errors in dating, examination delays due to medical status, and to permit flexibility in scheduling.
- Additional examinations are performed at intervals of one to three weeks until the retinal vessels have completely grown out to the ora serrata (periphery of the retina). If ROP develops, the eyes are examined more frequently, depending upon the severity of disease and rate of progression.
The Indian Retinopathy of Prematurity (IROP) Society
Established in July 2016. The menace of retinopathy of prematurity blindness had reached alarming proportions in the nation. The number of pre-terms born had crossed 3.5 million annually.Improved neonatal survival, over 700 special neonatal care units (SNCUs), a very low prevalence of ROP screening programs and only a handful of ROP specialists are some of the problems.
With over 20,000 ophthalmologist members of the All India Ophthalmological Society, nearly 2000 are Vitreo-Retinal Society of India members. So less than 1% of ophthalmologists in the country are involved directly in ROP care.
Conclusions: India Ophthalmological Society should have been the party in this case or 10% of all 3.5 million cases of premature delivers will file cases in courts for compensations as 2000 vitreo- retinal specialist cannot take care of this large number.
After ROP it can be a case of missing all congenital heart diseases in the hospital, that amounts of 1% of all births.