BARRIE COURT FILE NO.: CV-18-983-00 DATE: 20241031 ONTARIO SUPERIOR COURT OF JUSTICE
BETWEEN: LARISSA ABBOTT Plaintiff/Moving Party – and – JACEK KOLENDA and JACEK KOLENDA MEDICINE PROFESSSIONAL CORPORATION Defendants/Responding Parties
William Leslie, for the Plaintiff/Moving Party Kosta Kalogiros and Rachel Chan, for the Defendants/Responding Parties
HEARD: October 17, 2024
REASONS FOR DECISION
Overview
1 This is a medical negligence action arising out of an injury sustained by the Plaintiff during sinus surgery. The action was commenced on June 22, 2018. In January 2021, the Plaintiff brought a motion to amend several paragraphs in the Statement of Claim. The only amendments permitted were those that were unopposed by the Defendants. The motion judge found that the other proposed amendments advanced new causes of action in negligence in respect of procedures and surgery performed by the Defendant, Dr. Kolenda, following the initial surgery that is the subject of the original claim. These new causes of action were found to be statute-barred, and the amendments not permitted on that basis.
2 The Plaintiff has served five liability and causation expert reports, four from otolaryngologist Dr. Brian Rotenberg, and one from ophthalmologist Dr. David Plemel. The Defendants contest the admissibility of portions of these expert opinions on the basis that their reports address the additional causes of action that have been ruled to be statute-barred and do not confine themselves to the issues in the Amended Statement of Claim (the “Amended Claim”).
3 The Plaintiff contends that the opinions advanced by the experts fall within the scope of the Amended Claim.
4 With leave of RSJ Edwards, both parties have served motions for the purpose of seeking clarification of the scope of the Plaintiff’s expert evidence in advance of the trial.
The Motions
5 The Plaintiff’s motion seeks an order that each of the five expert reports be admitted into evidence at the trial.
6 During submissions, Mr. Leslie clarified that he is not requesting a blanket order of admissibility. Rather, his client seeks an order finding that the reports, in their entirety, fall within the scope of the Amended Claim.
7 The Defendants’ motion seeks an order declaring that the expert opinions of Drs. Plemel and Rotenberg are inadmissible to the extent that they concern the endoscopic exploration of the nasal cavity (the “Exploration”) and the orbital wall decompression (the “Decompression”) performed by Dr. Kolenda on June 24, 2016 (together the “Other Procedures”). These are the procedures that were the subject matter of the proposed amendments that were not allowed to be advanced.
8 For clarification, these Reasons do not attempt to rule on matters that would normally be decided on a voir dire held before the trial judge in respect of an expert witness, such as whether the expert is properly qualified.
Reasons of Casullo J.
9 Casullo, J. heard the Plaintiff’s pleading motion in January 2021. Paragraphs 4 through 7 of her Reasons concisely summarize the underlying medical events, the chronology of which does not appear to be in dispute:
4The plaintiff was referred to Dr. Kolenda to address pain in her head, face and sinuses.
5On October 5, 2015, Dr. Kolenda performed endoscopic sinus surgery (the “Sinus Surgery”). At a follow-up appointment on April 28, 2016, Dr. Kolenda determined the plaintiff had recurrent frontal sinusitis and recommended the surgery be repeated.
6On June 24, 2016, Dr. Kolenda performed the revision endoscopic sinus surgery (the “Revision Surgery”). Owing to complications arising therefrom, the plaintiff underwent three additional procedures on June 24, 2016:
a) an endoscopic exploration of the nasal cavity performed by Dr. Kolenda (the “Endoscopic Exploration”);
b) a lateral canthal release performed by a different ophthalmologist; and
c) a decompression of the orbital wall performed by Dr. Kolenda (the “Decompression”).
7It appears the surgeries did not alleviate the plaintiff’s medical concerns. The vision in her left eye became so compromised her eyeball was removed in 2019.
10 The Sinus Surgery is not the subject of the claim.
11 At paragraphs 26 to 28 of her Reasons, Casullo J. reviewed the allegations of negligence from the original pleading and compared them to the proposed amendments, along with new subparagraphs that set out further particulars of the negligence. She concluded, at paragraphs 31 and 33, that the proposed amendments were not simply clarifications or corrections to existing facts, nor an alternative claim for relief arising from the same set of facts, but rather were an attempt to add new tort claims of negligence and informed consent in respect of the Endoscopic Exploration and the Decompression.
12 Casullo J. found that the original claim advanced a cause of action only in respect of the Revision Surgery. At paragraph 34 she stated:
It is abundantly clear on a review of the original pleading that the only causes of action advanced are in respect of the Revision Surgery. The proposed amendments are not clarifications. They seek to widen the net and claim against Dr. Kolenda for all three surgeries he performed on June 24, 2016, not solely the first one.
13 And at paragraph 37:
The facts pleaded in the proposed amendments were within the knowledge of the plaintiff from the outset. The new causes of action are statute-barred, full stop. Hence, any argument that the amendments would not prejudice the defendants need not be considered in respect of this first issue.
The Medical Procedure
14 There are additional aspects to the medical procedure that the Plaintiff underwent on June 24, 2016 that are important for the purposes of this motion. For ease of reference, I will use the same terminology for the procedures that was used by Casullo, J.
15 The Revision Surgery started at 0900 and finished at 0910 according to the nursing notes. Dr. Kolenda admitted at his examination for discovery that he breached the lamina papyracea during the Revision Surgery when he entered into the left orbital space.
16 During the reversal of the anaesthetic following the Revision Surgery, the anaesthesiologist noticed that the Plaintiff’s left eye was swollen and Dr. Kolenda was contacted to return to see the Plaintiff. The Plaintiff’s anaesthetic reversal was stopped, and she was brought back to the operating table for a second procedure performed by Dr. Kolenda.
17 The Endoscopic Exploration started at 0924 and finished at 0932. The Plaintiff was transferred to the recovery room.
18 The ophthalmologist who performed the lateral canthal release was Dr. Adam. This was done at the Plaintiff’s bedside after he was called to consult on the Plaintiff at 1000. He recommended that Dr. Kolenda perform another surgical procedure.
19 Dr. Kolenda performed the Decompression, which took place between 1246 and 1336.
The Position of the Parties
20 The Plaintiff fully acknowledges that the only surgery for which she may advance claims for is the Revision Surgery. The Plaintiff also states that the Amended Claim asserts a claim that Dr. Kolenda breached his duty to follow up with respect to the Revision Surgery.
21 It is the Plaintiff’s position that each of Dr. Rotenberg’s reports focus on the Revision Surgery and the subsequent postoperative care provided by Dr. Kolenda. Similarly, the Plaintiff argues that Dr. Plemel’s report does not opine on negligence or causation with regard to any procedure or event beyond the Revision Surgery and the related post-operative care. To the extent that they discuss the Endoscopic Exploration or the Decompression, this was either in response to comments made about those procedures, an expert report served by the Defendants or addressed Dr. Kolenda’s negligent postoperative care.
22 The Plaintiff argues that to not admit any or all of her expert reports on the basis that they mention actions taken following the completion of the Revision Surgery would ignore the Plaintiff’s claim for negligent post-operative care as set out in paragraph 22(g) of her Amended Statement of Claim. In addition to the pleading, because every medical professional has a duty of postoperative care following surgery, the argument advanced is that the opinions are relevant to a triable issue.
23 The Defendants’ position is that their own reports do not opine on the Other Procedures and are focused only on the Revision Surgery. Any references to the Other Procedures is for context only; no comments are offered with respect to liability or causation in relation to the Other Procedures. To the extent that the Plaintiff’s experts opine on the Other Procedures, they are not relevant or necessary to the determination of a triable issue and thus barred by the test for admissibility of expert evidence.
24 Further, the Defendants take the position that paragraph 22(g) of the Amended Statement of Claim does not address general postoperative care. The Plaintiff is mischaracterizing the pleading at the eleventh hour by arguing that postoperative care is grounded in paragraph 22(g), and that the Other Procedures form part of the postoperative care for the Revision Surgery.
25 The Defendants argue that instead of appealing Casullo, J.’s order, the Plaintiff is attempting to expand her claim indirectly by tendering expert evidence opining on the Other Procedures. Dr. Kolenda has prepared his defence only on the issues that are raised by the Amended Claim, which are the issue of informed consent and his care in respect of the Revision Surgery. This tactic, the Defendants suggest, is a collateral attack on the decision of Casullo, J. and constitutes an abuse of process.
The Amended Statement of Claim
26 Paragraph 22 of the pleading sets out the particulars of the Dr. Kolenda’s alleged negligence, as follows:
(a) The Defendant failed in his duty to give sufficient and accurate information to the Plaintiff in order to allow her to give informed consent to proceed with the surgery that was performed on June 24, 2016 (hereafter referred to as “the second surgery”);
(b) The Defendant acted negligently in proceeding with the second surgery given that the first surgery was not successful;
(c) The Defendant failed to do proper pre-surgery work-up of the Plaintiff prior to the second surgery;
(d) The Defendant acted negligently in failing to appropriately document the risks and benefits of the second surgery;
(e) The Defendant failed in his duty to properly examine, assess and evaluate the Plaintiff and give consideration to her personal history prior to electing the second surgery and prior to proceeding with the second surgery;
(f) The Defendant acted negligently in failing to use surgical devices and implements properly and appropriately;
(g) The Defendant acted negligently by not adequately monitoring the condition of the Plaintiff’s positioning prior to, during and immediately following the second surgery;
(h) The Defendant failed in his duty to exercise reasonable care, skill and ability in his care of the Plaintiff;
(i) The Defendant acted negligently and in breach of his duty in failing to follow accepted and reasonable protocols and/or guidelines in his assessment, treatment and surgical performance of the Plaintiff;
(j) The Defendant failed to properly carry out any or adequate risks of the surgery, given the Plaintiff’s clinical history;
(k) The Defendant failed to properly carry out any or adequate tests when he knew or ought to have known of the potential risks of the second surgery, given the Plaintiff’s clinical history;
(l) The Defendant was an incompetent otolaryngologist and ought not to have attempted to provide care, treatment or supervision of the Plaintiff;
(m) Such further and other particulars which may arise through the discovery process and through further investigations.
27 The “Second Surgery” referred to in that paragraph of the Amended Claim is the Revision Surgery.
Analysis
28 I will first deal with the Plaintiff’s argument that she has made a claim for negligent post-operative care as set out in paragraph 22(g) of her Amended Claim. This subparagraph alleges that Dr. Kolenda acted negligently by not adequately monitoring the condition of the Plaintiff’s positioning prior to, during and immediately following the Second Surgery.
29 It is patently obvious on the face of the pleading that this allegation refers only to monitoring of the Plaintiff’s positioning during the time immediately connected to the Revision Surgery, and nothing more. It cannot reasonably be interpreted to extend to all post-operative care.
30 Referencing the first of Dr. Rotenberg’s reports, the Plaintiff’s factum notes that Dr. Rotenberg concludes that the orbital breach that resulted in the hematoma occurred during the [Revision Surgery]. The factum continues:
…As such, by the time the subsequent surgeries were performed, the damage had been done. This means that each action performed by the defendant following the [Revision Surgery] speaks directly to quality of post-operative care provided to the Plaintiff…
31 There is no allegation in the Amended Claim that Dr. Kolenda fell below the standard of care in the post-operative care provided to the Plaintiff. The phrase “post-operative care” does not even appear in the pleading. No quarrel can be taken with the Plaintiff’s argument that post-operative care is part of a surgeon’s duty of care to a patient until the care of the patient is assumed by another physician, as prescribed by the Public Hospitals Act, R.R.O. 1990, Reg. 965, s. 30(1) and recognized by the common law. However, that principle has no application here, because the Plaintiff has not pled any facts to support an allegation of sub-par care following the Revision Surgery. It is trite to say that the pleadings define the issues to be tried. The Amended Claim does not make such a claim.
32 That conclusion having been reached, there is little need to discuss the Plaintiff’s related argument that any discussion in the Plaintiff’s expert reports about Dr. Kolenda’s conduct during the Other Procedures all relate to post-operative care. However, two conclusions are readily reached. First, the Other Procedures are distinct surgical events, each with its own operative record, and could never be characterized as post-operative care. The phrase “post-operative care” does appear anywhere in the Plaintiff’s experts’ reports, when referencing the Other Procedures or even in respect of the Revision Surgery. Second, these Other Procedures have already been determined to be statute-barred and, as such, cannot in any way form part of the subject matter of the Amended Claim.
33 The Plaintiff also submits that her expert reports should stand because three of them were drafted in response to the expert reports served by the Defendants, which reference the Other Procedures. The Defendants have served two reports from an otolaryngologist, Dr. Higgins, and two from an ophthalmologist, Dr. Harvey.
34 Both of Dr. Higgins’ reports expressly state that his opinion focuses only on the Revision Surgery, due to his understanding that “the Court has ordered that the exploratory procedure and the decompression procedure that took place after the revision endoscopic sinus surgery are not, and cannot be in dispute.” In accordance with that understanding, his report refers to the Other Procedures only by way of narrative reference. He does not express any opinions concerning the Other Procedures.
35 In Dr. Harvey’s initial report, dated June 23, 2023, he references the Other Procedures when providing an overview of the facts, and in referencing the opinion that sought from him. In the introduction to his report, he wrote:
You have asked me to provide an opinion regarding whether Ms. Abbott’s outcome would have been avoided altogether or materially improved had Dr. Kolenda recognized the breach of Ms. Abbott’s lamina papyracea during the revision endoscopic sinus procedure (between 0900h-0910h), instead of during his endoscopic exploration approximately 14 to 22 minutes later, assuming all subsequent events and interventions unfolded as they did.
Put another way, you have asked for my opinion regarding whether Ms. Abbott’s outcome would have been avoided altogether or materially improved had the canthotomy/cantholysis and decompression been performed 14 to 22 minutes earlier than they ultimately were.
36 In the opinion section of his initial report, Dr. Harvey does reference the Endoscopic Exploration in relation to the Revision Surgery for the purpose of a discussion of timing. His opinion is:
As noted above, it is my opinion that earlier detection of the breach of the lamina payraea, ie. during the initial revision surgery rather than during the exploration 14 to 22 minutes later, would not have avoided Ms. Abbott’s ultimate outcome or materially improved her outcome.
37 The Amended Claim places in issue the timing of the discovery of the laminal breach and whether discovery of it during the Revision Surgery would have prevented or altered the Plaintiff’s injuries. As the Defendants have clarified in their factum, they do not take issue with the Plaintiff’s experts opining on whether the decompression might have taken place sooner (14 – 22 minutes) if the injury had been identified during the Revision Surgery and whether that would have altered the outcome for the Plaintiff. All of this discussion, however, centers on Dr. Kolenda’s failure to recognize the injury during the Revision Surgery.
38 A review of the five expert reports prepared on behalf of the Plaintiff indicates that each of them fails to limit the analysis to the Revision Surgery and the timing of the discovery of the injury. Each contains opinions about Dr. Kolenda having breached the standard of care in relation to the Other Procedures and opine on causal impacts of such breaches.
39 The test for admission of expert evidence is not whether the success of the claim hinges upon it. For expert evidence to be admissible, it must meet the threshold requirements of admissibility, and its probative value must outweigh its prejudicial effect. The four threshold requirements to admissibility are: relevance; necessity in assisting the trier of fact; absence of an exclusionary rule; and a properly qualified expert: R. v. Mohan, [1994] 2 S.C.R. 9, at paras. 20-25; White Burgess Langille Inman v. Abbott and Haliburton Co., 2015 SCC 23, at para. 19.
40 It is plain and obvious that any references to the Other Procedures by the Plaintiff’s experts cannot meet the test for admissibility. To be relevant, expert evidence must have probative value in relation to a material issue: R. v. Abbey, 2009 ONCA 624, at para. 80. To the extent that they opine on liability or causation with respect to anything other than the Revision Surgery, they have no relevance to the issues in this trial and will only serve to distract from the triable claims. Opinions related to the Other Procedures which are found in each of the Plaintiff’s five expert reports about whether different examinations should have been conducted by Dr. Kolenda following the Revision Surgery or whether he should have performed the Other Procedures differently or faster, and whether a different outcome would have resulted, are irrelevant and therefore unnecessary.
41 While this conclusion is sufficient to determine the outcome of these motions, the impugned opinion evidence is also barred by an exclusionary rule. Res judicata is an exclusionary rule of evidence by which the party against whom the suit or issue was decided is estopped from proffering evidence to contradict that result: Sopinka, Lederman & Bryant, The Law of Evidence in Canada, 6th ed. (Toronto: LexisNexis, 2022) at 1558.
42 The attempt to provide opinion evidence about the Other Procedures is an attempt to relitigate the issues previously raised between the same parties and decided by Casullo, J. Any of the three branches of the doctrine of res judicata apply in this case to bar the admission of the impugned evidence: issue estoppel, cause of action estoppel and collateral attack.
43 As the preconditions to admissibility have not been met, opinions as to the Other Procedures must be declared inadmissible.
Order
44 For the preceding reasons, this court orders and declares:
(a) The Plaintiff’s motion is dismissed.
(b) The expert opinions of Drs. Plemel and Rotenberg, to the extent that they provide opinions about the endoscopic exploration of the nasal cavity and the orbital wall decompression performed by Dr. Kolenda on June 24, 2016, are inadmissible at trial.
45 For certainty, those impugned portions of the reports are excerpted in Schedule A to these Reasons.
Costs
46 If the parties are unable to agree upon the issue of costs within 10 working days from the date of these Reasons, they may make submissions in writing. The Defendants’ are due on November 22, 2024, the Plaintiff’s on November 29, 2024 and any reply, if necessary on December 4, 2024. Written submissions are limited to 5 double spaced pages, plus a Costs Outline. Counsel may extend these dates by mutual agreement, with notice to me through BarrieSCJJudAssistants@ontario.ca.
47 All authorities relied on are to be hyperlinked in the document or uploaded to Case Center with a tabbed (i.e., hyperlinked) index.
48 The submissions are to be filed with the court, with a copy emailed to my judicial assistant at BarrieSCJJudAssistants@ontario.ca, in addition to being uploaded to Case Center.
Madam Justice S.E. Healey
Released: October 31, 2024
SCHEDULE "A"
EXPERT REPORT EXCERPTS
- First Rotenberg Report, dated August 23, 2020
Once the anesthesiologist noted the swollen eye and Dr. Kolenda became aware, did his further management meet the standard of care?
Dr. Kolenda’s operative note for the second procedure does not indicate that he sufficiently assessed the eye. He only remarks that the eye was “swollen”. A prudent Otolaryngologist should have made careful notation of colour of skin, quality of bruising, and whether or not the lid was tense, as all of these signs can be relevant to making the determination of severity of the problem and can make the diagnosis of retrobulbar hematoma in the absence of a CT scan.
Although the patient was still anesthetized at this time which would make assessment of pain or vision impossible, the other signs alluded to above would be sufficient to indicate that a severe problem was evolving, and prompt intervention required.
Considering the short timeline between patient leaving the OR at 0942 and Dr. Adam arriving and recognizing the retrobulbar hematoma at 1000, I would have expected that there would be external evidence of the hematoma when the eye first began to swell while patient was still in the operating room during the second procedure. Ecchymosis and a tense lid were visible to Dr. Adam and should have been visible to some extent at least to Dr. Kolenda prior to the patient leaving the operating room.
A sinus surgeon with Dr. Kolenda’s training and experience should have recognized the hematoma during the second exploratory surgery and known that this was an emergency. External evidence of an acute retrobulbar hematoma would be a standard indication for an emergency lateral cantholysis (as was done by Dr. Adam). However, this condition is so severe that time is typically measured in minutes until irreversible damage and loss of vision happens. If the complication had been promptly recognized and the necessary corrective procedure (lateral cantholysis and eventual orbital decompression) performed during the second surgery instead of being delayed by hours, she probably would have had a better outcome.
Dr. Kolenda did not meet the standard of care in this instance by failing to carefully examine the eye, failing to recognize the hematoma, and by failing to perform corrective procedure in the emergency timeframe.
- Second Rotenberg Report, dated March 23, 2023
My opinion on this case remains unchanged. The essence of the problem was that an unrecognized orbital injury took place during the first surgery that Abbott underwent. During this procedure, a breach of the lamina paparycea occurred, orbital fat was exposed, and an orbital bleed began. It was the unrecognized original injury that precipitated all subsequent events leading to the patient’s eventual visual deficit. While I agree with Dr. Higgins that an orbital injury is a known potential risk of sinus surgery, and that causing an orbital injury occur in and of itself does not constitute negligence, my concern instead stems from the fact that neither the injury or its severity were recognized in the first place. Dr. Kolenda’s operative notes do not indicate an awareness of the eye injury during the first procedure, and the clinical documentation of the second procedure does not suggest that he was aware of how severe the problem was. It was during the urgent Ophthalmological review, which took place shortly after Dr. Kolenda’s assessment, wherein corrective therapy was initiated. In the setting of a retrobulbar hematoma, the timeframe is typically considered to be minutes before irreversible injury to the optic nerve occurs, and unfortunately this appears to be what took place here. It is my opinion that a surgeon of Dr. Kolenda’s expertise and training should have recognized the intra-operative injury during the original procedure, and ought to have also considered the potential seriousness of the problem during the subsequent assessment.
- Third Rotenberg Report, dated April 12, 2023
It is more likely than not that the failure of recognition of the original injury, and subsequent delayed treatment, was the cause of what followed for the patient, up to and including the enucleation. There may have been other factors that occurred over years following the event that could have contributed to the severity of this eventual highly adverse outcome. However, I do not think it likely that any of that would ever have happened in the first place had it not been for the initial unrecognized injury and delayed intervention.
- Fourth Rotenberg Report, dated September 28, 2023
The question you have posed is to address the matter of causation in terms of what took place in the original procedure, and also address the standard of care expected of an Otolaryngology - Head and Neck surgeon in managing a suspected orbital hematoma. To perform the review, I have once again carefully studied the original source material provided to me by your office as well as the various materials pertaining to the case and also reviewed the opinions submitted from the medical experts as listed above.
Based on the case time notations, the initial injury took place at some point between 0900 and 0910, meaning that lateral cantholysis did not happen until at least one hour after that, and the orbital decompression did not happen until after three hours after the injury and bleed began. The notes do not show clear documentation of a sense of urgency from Dr. Kolenda regarding the situation, or an indication that Dr. Kolenda understood the severity of the problem.
In reviewing this case it is important to ensure that the standard of care that Dr. Kolenda be expected to meet is that of an Otolaryngology - Head and Neck surgeon, not an Oculoplastic Surgeon. Bailey’s Textbook of Otolaryngology Head and Neck Surgery, 5th edition (c2014), pp 650-655, is the most widely cited textbook in the field, and is considered a definitive reference source for competency in the specialty. This is the book that trainees in the specialty use as a main study reference, and is the source of many Royal College certification exam questions. In this section of the book, the chapter author clearly indicates that an arterial bleed needs a decompression within 30 minutes, and a venous bleed in the 60-minute time frame. Similar timeframes are described in KJ Lee Essential Otolaryngology 12th edition (c2019) pp584-585, and in the textbook on Endoscopic Sinus Surgery by Professor PJ Wormald, 2nd edition (c2008), pp 174-175 which is authored by the world’s pre-eminent sinus surgeon. Based on the chronology of events in Abbot’s case, the treatment time to cantholysis, let alone to orbital decompression, was severely delayed, and well outside of the timeframe described in all of these standard and specialty references. In this case Dr. Kolenda’s treatment of the orbital injury did not meet the standard expected of an Otolaryngology - Head and Neck Surgeon.
The essence of the problem was that an unrecognized orbital injury took place during the first surgery that Abbott underwent. It was the original injury as causative event that precipitated all subsequent events leading to the patient’s eventual visual deficit. My concern stems from the fact that neither the injury or its severity was recognized in the first place, possibly due to the speed of the initial procedure. It is difficult to imagine how a complete bilateral ethmoidectomy and frontal sinus exploration could take place in 10 minutes with appropriate prudence and attention to detail and safety. It is my opinion that a surgeon of Dr. Kolenda’s expertise and training should have identified the serious nature of the injury during the initial procedure, or failing that then he ought to have recognized the dire nature of the problem during the second sinus exploration, and then taken the expected steps to resolve the matter as expeditiously as possible. Causation in this case was the injury which took place in the first procedure. Failure to recognize the injury, and the subsequent lengthy delay in management, are more likely than not to be the source of the eventual damage to Abbot’s eye.
- Plemel Report, dated April 16, 2024
From Dr Adams’ note (“indicating that he had an intraoperative complication during endoscopic sinus surgery leading to retrobulbar hemorrhage”), it appears that Dr Kolenda understood that the lid swelling was caused by a retrobulbar hemorrhage. Records would suggest that it was a fast retrobulbar hemorrhage as the findings developed at an early stage (Dr Lee noticing a swollen lid 0-14 minutes after the original surgery and, within a short period of time, Drs Calafeti and Adams documenting periocular bruising, tense lids, a left afferent pupillary defect, and an intraocular pressure that was high to palpation). However, the operative report for the endoscopic exploration nasal cavity for suspected left orbital injury surgery does not show Dr Kolenda assessing for the clinical findings that would necessitate emergent surgical management. The operating report indicates that the bleeding vessel(s) was (were) not identified, medical management (Cyklokapron, blood pressure lowering, and the placement of ice) was initiated, and the medial orbital wall was not decompressed.
Dr Kolenda does not recognize damage to the lamina papyracea during the original bilateral revision of ethmoidectomy and frontal sinusotomy utilizing the image guidance system surgery. I agree with Dr Harvey (June 23, 2023) wherein he opines that such damage to the lamina papyracea can be difficult to recognize and that the damage to the lamina papyracea is itself not the cause vision loss. Lamina papyracea damage caused by surgery is not routinely repaired and no management is needed unless there is a complication caused by it. And, as Dr Harvey points out, it is in fact not the break to the lamina papyracea that results in vision loss but the retrobulbar hemorrhage caused by the break to the lamina papyracea that results in vision loss. Of course, damage to the lamina papyracea is not the only endonasal complication that can cause retrobulbar hemorrhage and resultant vision loss. Therefore, it is not the recognition of the break in the lamina papyracea that is important to this case but recognizing and appropriately managing a surgically induced retrobulbar hemorrhage that resulted from the break in the lamina papyracea. It is for this reason that, although I agree with many statements made in Dr Harvey’s report, I disagree with his conclusion. Dr Harvey focused on whether the outcome of the case would have been changed had Dr Kolenda recognized the break in the lamina papyracea earlier. However, it was that Dr Kolenda recognized a retrobulbar hemorrhage but failed to assess for its severity or treat as if the least favourable outcome was likely that may have contributed to the unfortunate outcome.
Dr Kolenda understood that there was a retrobulbar hematoma as he soon referred to Dr Adams for the same. But Dr Kolenda does not document the severity of the bleed, nor does he provide definitive management. Definitive surgical management might have been provided at the time of endoscopic exploration nasal cavity for suspected left orbital injury surgery had Dr Kolenda evaluated for other clinical signs and the severity of the bleed was appreciated, or if Dr Kolenda had utilized the approach where in all sinus surgery related retrobulbar hematomas are treated as if the least favourable outcome is likely.
Dr Harvey assumes that, had Dr Kolenda observed a breach of the lamina papyracea during the initial surgery, he would have monitored or observed the patient for signs of bleed (such as swelling). Dr Harvey further opinions that the resulting interventions would also have occurred on the same timeline as they did and therefore earlier recognition of the breach of the lamina papyracea would have resulted in the same outcome. However, as Dr Harvey has pointed out above, it is not the damage to the lamina papyracea itself that causes vision loss but the retrobulbar hemorrhage caused by the damage to the lamina papyracea that causes that leads to the eventual damage. It is immaterial whether Dr Kolenda recognizes the lamina papyracea at the initial surgery or not. What is important is that Dr Kolenda recognizes that there is a retrobulbar hemorrhage secondary to a break in the lamina papyracea but fails to treat it as if the least favourable outcome is likely or assess the severity so that he can decide whether the medical management he provided is sufficient or whether definitive surgical management is needed.
Endoscopic exploration nasal cavity for suspected left orbital injury surgery was performed was performed at 0924 - 0932 (14-22 minutes after the end of the first surgery) which was well within the 2- hour window suggested by clinical experience or 100 minutes suggested by animal models to provide better outcomes. But, definitive canthotomy +/- cantholysis or medial wall decompression was not provided at this time. Had Dr Kolenda treated as if the least favourable outcome is likely, or assessed for clinical signs, he might have decreased the likelihood of vision loss.
In summary, there was a complication during the bilateral revision of ethmoidectomy and frontal sinusotomy utilizing the image guidance system surgery wherein the lamina papyracea was damaged. The damage to the lamina papyracea led to a retrobulbar hemorrhage that was recognized but not adequately assessed or managed as if the least favourable outcome is likely during the endoscopic exploration nasal cavity for suspected left orbital injury surgery. In the end, this led to the unfortunate outcome of vision loss and contributed to the eventual enucleation of Ms. Abbott.