By Dean C. Brick, MD
[Argus, May, 1996]
Successful diagnosis and management of patients with uveitis requires vigilance and patience. The diagnosis may be difficult and obscure; treatment may be prolonged, marginally effective, and fraught with potential complications or side effects. Often the uveitis, which itself may be visually devastating, is caused by a systemic disease whose diagnosis and treatment cannot be overlooked. These factors create unique risk management problems for the ophthalmologist and underscore the need for proper documentation, thorough informed consent, and use of consultants.
Averting Claims of Failure to Diagnose
Failure to diagnose is one of the most common assertions in uveitis-related claims and lawsuits. Proper documentation of an adequate patient history and physical will help avoid this claim, particularly in cases of severe or recurrent uveitis, which can result in vision loss or other complications.
In these instances, the usual history taken by a technician or a physician is inadequate. Since remembering all the important questions to ask a uveitis patient may be difficult, use a detailed, uveitis-specific questionnaire which the patient can fill out in the waiting area. Using a yes-no format makes it easy for the ophthalmologist to review the questionnaire and pose further questions, and can alert the physician to the need to perform a dermatological exam, serology test for toxocara, or other physical or laboratory examinations.
Then, record an appropriate physical exam, which should include the examination of any other organ systems, if indicated, as well as significant negative findings in the ophthalmological exam. Again, the ophthalmologist may use a uveitis-specific eye examination form, with space for recording a descriptive diagnosis: recurrent, anterior, non-granulomatous iridocyclitis, for example, or focal necrotizing retinochoroiditis. In some instances, a specific diagnosis may be possible, such as Fuch's heterochromic cyclitis.
Next, formulate and record a differential diagnosis list. It need not be exhaustive or necessarily include the ultimate correct diagnosis; however, it demonstrates that the ophthalmologist attempted to formulate a diagnosis and ordered indicated laboratory tests, which helps counter claims of failure to perform a thorough workup.
When laboratory tests are performed, the ophthalmologist should review all results before placing them in the chart. At this point, if the diagnosis remains enigmatic and the potential for visual loss is severe, consider referring the patient to a consultant. This helps prevent claims of delayed referral to a specialist.
Treatment Complications Can Trigger Lawsuits
Uveitis treatment is frequently associated with severe side effects and complications. High doses and prolonged treatment with systemic steroids and strong immunosuppressant drugs can lead to informed consent-related claims. To help counter these claims, document in the chart that the risks and benefits of treatment were discussed and that the patient received medication information handouts. Again, collaborating with an internist or a specialist is valuable in defending a decision to use potentially risky therapy and for monitoring strong or prolonged immunosuppressant drug therapy.
Finally, the interval between examinations should correlate with the severity of the disease and the potential for complications. Following these guidelines and maintaining a caring, supportive attitude for patients will help reduce the risks of treating these difficult cases.
To obtain a copy of a uveitis-specific history form, contact OMIC's Risk Management Depart- ment by fax, 415-771-7087.
