Several years ago I experienced something that many surgeons quietly fear but rarely discuss openly: two patients brought a legal claim following refractive lens exchange surgery.
Clinically, both outcomes were excellent. Each patient achieved 6/6 distance vision and N5 near vision. By every conventional surgical metric, the procedures were a success.
Yet the experience forced me to confront something that fifty thousand operations had not prepared me for: in modern medicine, technical excellence alone is no longer sufficient protection.
The years that followed reshaped how I think about surgical practice – not just the surgery itself, but the systems that surround it.
An accidental path into ophthalmology
I had not originally planned to become an ophthalmologist. As a medical student I had arranged an obstetrics and gynaecology elective in Chicago. A visa error at the US embassy meant the trip never happened. So instead I spent five weeks in Professor Stephen Kaye’s ophthalmology clinic in Liverpool. By the end of that placement, I knew I had found the discipline I would spend the rest of my career in.
What I could not have predicted then was that the greatest challenge in modern ophthalmic practice would not be mastering the surgery itself, but in building the systems around it.
Medicine is also a profession in which representation still matters. As one of relatively few Black ophthalmic surgeons practising at consultant level in the United Kingdom, I am often asked by students and junior doctors how they should navigate a career in the specialty. My answer is straightforward: aim to be excellent. In highly competitive specialties like ophthalmology, being merely average is rarely enough, and for those from under-represented backgrounds the margin for error can be even smaller. The standards are high, the scrutiny intense, and success ultimately depends on sustained technical excellence over many years.
The Claim that changed my perspective
The claim made against me was not that the surgery had gone wrong. It was that I had failed to explain the risks and had not offered a reasonable alternative — in their case, orthokeratology contact lenses.
I had sent a detailed pre-operative consultation document; they said they had never received it. They also claimed not to have read the consent form. I had discussed alternatives; they said I had not.
In the absence of a recorded consultation, the medicolegal system treats recollection and documentation as equivalent forms of evidence.
They are not.
A clinic letter is a summary. A conversation is an event. And unless that event is recorded, the summary can always be disputed.
That distinction is the fault line running through modern surgical practice.
The blind spot in a measured specialty
Ophthalmology is one of the most quantified fields in medicine. We measure axial length, keratometry, and anterior chamber depth. We calculate lens power using validated formulas and cross-check with multiple devices. We audit outcomes and benchmark them against national standards.
And yet the consultation — arguably the most consequential hour in the entire patient journey — remains largely undocumented in any verifiable form.
A clinic letter summarizes what was discussed, but it is not a verbatim record of what was said. Operative notes describe what occurred, but they are not evidence that it occurred.
The gap between those two things is where litigation lives.
What I changed
The experience forced me to rethink how my practice operated.
I now record every operation. Every one. This footage creates a verifiable account of the procedure that exists independently of my recollection or my notes. If a patient later claims something occurred intra-operatively that I dispute, the recording settles it.
I also use AI-assisted transcription to document consultations. The conversation is captured, structured, and stored so that what was discussed, recommended, or declined exists as a timestamped record rather than a retrospective summary.
At Blue Fin Vision, patients confirm in writing before surgery is booked that they have read both the clinic letter and the blank consent form outlining all material risks. This is not because we distrust patients, but because “I was never told” should never be a viable claim in contemporary surgical practice.
Transparency must also apply to outcomes. For that reason, I publish four consecutive years of National Ophthalmology Database results on my website. Measurement is not an aspiration; it is the architecture of the system.
None of these interventions are technologically complex. The tools already exist for them to be put in place. The barrier has largely been cultural – the profession’s longstanding belief that good intentions and good notes are sufficient protection.
Increasingly, they are not.
Where this is heading
The changes I have described address the documentation problem. But artificial intelligence is capable of closing the loop between every stage of the clinical process, and that is where the real transformation lies.
The system I am building towards would connect consultation transcripts, diagnostic imaging, biometry data, operative video, and postoperative outcomes into a single evolving record — not merely for storage, but for continuous learning.
Imagine a system that alerts you if you are about to perform a non-LASIK lens calculation on a post-LASIK eye. A system that detects subtle refractive drift in your outcomes before it becomes a pattern. A system that, in time, listens to the consultation, reviews the scans, and proposes a lens recommendation — not to replace clinical judgement but to interrogate it.
Every pilot flies with instruments that check their instruments. Every engineer builds to tolerances that are independently verified. The idea that surgical decision-making should be uniquely exempt from cross-checking is not a defence of expertise. It is a defence of ego.
The profession has a choice
The medicolegal environment is not becoming more forgiving. Patients have access to lawyers, online communities, and other patients who have had different experiences. The standard of proof required to defend a claim is steadily rising, while, in contrast, the standard of documentation across the specialty has remained largely static.
Radical transparency is the appropriate response. Not because it protects the surgeon – though it does – but because it is what a properly functioning clinical system should look like.
Every decision documented.
Every intervention recorded.
Every outcome measured and fed back into the process that produced it.
At Blue Fin Vision I often return to a simple principle: to achieve the immeasurable, you must measure everything.
Looking back, the additional scrutiny that sometimes accompanies being different pushed me to build that system earlier and more rigorously than I otherwise might have done.
The result has been a model of radical transparency that has been transformative for my own practice – and whose elements, I believe, represent an important part of the future of ophthalmology.
