Complicated Course of Chronic Iritis
By Randy Morris, JD OMIC Claims Associate
Digest, Fall 2001
ALLEGATION Failure to timely treat chronic iritis and scleritis.
DISPOSTION Defense verdict on behalf of OMIC insured.
Case Summary
A 50-year old male patient was seen by the insured on a referral from an optometrist for evaluation and treatment of iritis in the right eye. The patient’s history included a prior episode of iritis with a finding of synechia. Examination showed the presence of a cataract, which the insured suspected was caused by chronic iritis. She prescribed Predforte and Mydriacyl. The patient returned for numerous visits with the insured, while at the same time being treated by a primary care physician and an optometrist. On two occasions, when the primary care physician diagnosed conjunctivitis, the insured injected Celestone and the patient seemed to respond favorably.
During a subsequent visit, the insured diagnosed iris bombe related iritis. On two separate occasions, the insured used a YAG laser on an emergent basis to make a hole in the iris and bring down the intraocular pressure. In both instances, the hold closed off within a matter of weeks and prompted the insured to a perform a sector iridectomy. The iridectomy failed within one month. Although the cataract was potentially contributing to the iris bombe, the insured chose not to perform cataract surgery because of ongoing medical issues with the eye.
The insured referred the patient to an iritis specialist for a second opinion. The specialist’s impression was chronic iritis and scleritis, and he ordered a battery of tests to determine whether various diseases might be causing the chronic iritis. Tests for syphilis, tuberculosis, and rheumatoid arthritis were negative, but the patient continued to have problems with the eye. Throughout the course of treatment, the patient was seen by numerous specialists and prescribed various medications, including oral Prednisone. Despite these efforts to diagnose and treat the cause of the iritis, the patient eventually lost all vision in the right eye.
Analysis
The insured, the primary care physician, and a medical group were all named defendants in the patient’s lawsuit. Plaintiff’s expert criticized the insured for not treating the chronic iritis more aggressively, but he was forced to concede that he could not say to a reasonable medical probability that more aggressive therapy would have prevented that patient’s loss of vision. The defense expert felt strongly that the insured had complied with the standard of care at all times and that the patient appeared to have lost vision in the eye despite the best efforts of all the physicians involved. Specifically, the defense expert supported the insured’s decision to get a second opinion when the patient did not respond to treatment with topical steroids.
Risk Management Principles
This case illustrates how an unfortunate result can lead to a lawsuit, even when the best of case is provided. The patient presented with a complicated chronic condition that failed to respond to a multidisciplinary course of treatment. Fortunately, skilled defense counsel and a very effective expert witness convinced the jury that there was no negligence on the part of the OMIC insured in her care of the patient. The insured’s referral to the iritis specialist was a major factor in her defense and underscores the value of a prompt referral when a patient is not responding to treatment. In post-trial interviews, several jurors said they did not like the plaintiff expert’s criticism of the insured ophthalmologist; conversely, they were impressed with OMIC’s defense expert. The codefendants didn’t fare as well, however, and were hit with a plaintiff verdict. In an interesting twist, they appealed the verdict and were granted a judgment in their favor.
Acute Postoperative Endophthalmitis
Anne M. Menke, RN, PhD, OMIC Risk Manager
Digest, Fall 2003
Several policyholders have called with concerns about protocols they use for endophthalmitis prophylaxis before ocular surgery. They have heard rumors that it is below the standard of care not to use the latest topical fluoroquinolones. Currently, there is no basis for this claim. The fact that prevention and treatment of this rare but devastating complication remains the object of ongoing controversy contributes to the confusion. Two sources of information can help allay concerns and provide direction for sound therapeutic choices: OMIC claims experience and evidence-based studies.
Q What is the source of infection in postoperative endophthalmitis?
A In most cases, the causativeorganism is introduced into the eye at the time of surgery. Studies have identified the eyelids and conjunctiva as the primary source, so prophylactic measures are directed there. Other sources of contamination include secondary infection from sites such as the lacrimal system; contaminated eye drops, surgical instruments, intraocular lenses, or irrigation fluids; other agents introduced into the eye; and major breaches in sterile technique.
Q What standards exist for prophylaxis?
A There are currently no definitive standards. The latest evidence-based study by Drs. Cuilla, Starr, and Masket (Ophthalmology, January 2002) gave no prophylactic technique the highest clinical rating; however, an intermediate rating was given to preoperative preparation of the eyelids and conjunctiva with a 5% povidone-iodine solution just before surgery. Because of weak and conflicting evidence, all other reported prophylactic interventions received the lowest recommendation; of these, postoperative subconjunctival antibiotics had greater supporting evidence than the rest.
Q In the absence of standards for prophylaxis, what should I do?
A Base your treatment protocol on sound medical judgment. Tailor your treatment to the patient by taking into account known risk factors such as diabetes or immunosuppression, as well as the risks and benefits of the proposed treatment. Carefully document discussions with the patient, and provide clear, written instructions for pre- and postoperative care. Stay informed by reading peer-reviewed journals, and keep a risk management file of the articles that form the basis for your infection prevention protocol.
Q What is the greatest malpractice risk associated with endophthalmitis?
A Without exception, OMIC claims experience shows that liability arises from a delay in diagnosis or treatment, including a delay in referring the patient to a retina-vitreous specialist.
Q What can I do to reduce the risk of delay in diagnosis?
A If the surgery was complicated (e.g., capsular tear), took a long time, or required extensive instrumentation, you should have a higher index of suspicion for the development of endophthalmitis. Give all patients written discharge instructions stating the symptoms that warrant contacting you (blurred vision, red eye, pain, photophobia). Educate your staff members who handle telephone calls about the risk of endophthalmitis and train them to always ask patients who have these complaints if they have had eye surgery or trauma. Instruct them to schedule emergent appointments for such patients. Use the same screening criteria yourself when fielding after-hours calls (call OMIC for sample screening guidelines and contact forms). Err on the side of patient safety when deciding to treat over the phone versus examining the patient. Document your decisionmaking process in the medical record, especially when the patient calls with symptoms of a possible infection. Obtain a thorough intervalhistory, and perform and document a careful examination, noting the presence or absence of the signs of endophthalmitis (the cardinal sign is intraocular inflammation greater than expected for that point in the recovery process). If in doubt, consult with and/or refer patients to retina-vitreous specialists for cultureand management.
Q Are there other measures I can take to reduce endophthalmitis liability?
A During the informed consentdiscussion, warn patients about the risk of endophthalmitis and the possibility of vision loss. Emphasize the risk if the patient has diabetes, is immunosuppressed, or is having cataract surgery. Have a prudent follow-up plan, especially in symptomatic patients, and ensure that the patient makes the appointment before leaving your office. Diligently follow up on all patients who miss or cancel appointments, again ensuring that they understand that not receiving appropriate treatment could result in blindness. Carefully instruct patients to call you immediately if vision loss, pain, or other ocular problems develop before their next scheduled visit.
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Ophthalmologists Learn Why Patients Sue
By Linda Radigan
Digest, Fall, 1991
Communicate! That was the message to ophthalmologists who participated in OMIC’s risk management seminar Professional Liability Issues in Ophthalmology in Anaheim, CA, on October 12, 1991.
Unexpected Outcomes Prompt Lawsuits
“Patients sue when they have an unexpected outcome,” said Byron H. Demorest, MD, chairman of OMIC’s Risk Management Committee.
In fact, according to James F. Holzer, JD, OMIC’s chief operating officer, the equation for medical malpractice might be summarized as: bad outcome + bad feelings = a malpractice suit.
Nevertheless, a poor result is not malpractice, nor is doing something different from the way someone else would do it malpractice, said Margaret Holm, Esq., an OMIC defense attorney with the firm of Bonne, Jones, Bridges, Mueller and O’Keefe in Santa Ana, CA, who spoke at the Anaheim seminar.
Ms. Holm pointed out that the concept of negligence is very strict under the law. “The vast majority of lawsuits filed are totally without merit under the laws involved. They are the sum of a poor result and poor rapport. Very few really add up to malpractice that someone should pay for.”
Even when someone does pay, it doesn’t mean malpractice was involved. Settlements are not an admission of guilt on the part of the insured ophthalmologist, Ms. Holm explained. They represent a compromise, a resolution, of the disputed claim, she said.
More often than not though, malpractice suits are closed without an indemnity payment. Richard A. Deutsche, MD, a member of the Risk Management Committee, reported that payments were made on only 15 (9%) of the 168 cases closed by OMIC between October, 1987 and September, 1990. (See Digest, Vol. 1, No. 1)
Patient Records Often at the Heart of a Claim
Faulty documentation is often the reason why malpractice cases that should have been won are lost, said Mr. Holzer, who offered the following caveats regarding patient records:
- Don’t wait to chart – avoid relying on recall.
- Don’t chart only conclusions. Document intermediate steps, i.e., your rationale for treatment.
- Avoid making personal remarks about the patient in the chart.
- Don’t chart sloppy notes.
- Be thorough – what you don’t document is just as significant as what you do.
And above all, don’t ever alter or obliterate an entry and don’t make any corrections in the record after it has been subpoenaed. “Once a plaintiff’s attorney can show that you improperly altered a record, it doesn’t matter who’s right or wrong, you’re sunk,” said Dr. Demorest. He advised physicians to be very careful when changing or adding to records any time during treatment of a patient. The correct way to change a patient record is to draw a single line through the incorrect entry, date it and initial it. Do not use correction fluid or cross out the original entry so that it cannot be read through the strike out.
Informed consent is also an area of great concern. The consent form should not be confused with the process of informed consent. The process takes place the moment the patient walks into the physician’s office and a dialogue begins; the form is the written memorialization of that process, explained Mr. Holzer. Rapport is an essential component of informed consent, and consent should represent shared decision making between the patient and his or her physician, he said.
Shared decision making sometimes puts the physician and patient at odds. “The patient has the right to make an ill-advised decision, but as their physician you have the right – and obligation – to explain the implications of that decision,” commented Jerome W. Bettman, Sr., MD, a consulting member of the Risk Management Committee and a guest speaker at the Anaheim seminar. If done properly, informed consent is probably the greatest preventer of claims, said Dr. Bettman, who referenced findings from his research of 775 claims in ophthalmology throughout the seminar.
Before You Say Goodbye
See Terminating the Physician-Patient Relationship for our current recommendations and sample forms.
Digest, Spring, 1992
Although the decision to terminate a doctor-patient relationship should never be taken lightly, unresolvable noncompliance, patient conduct or financial reasons may make a continued relationship impossible. Should you decide that it is in your and the patient’s best interest to end the relationship, OMIC suggests you take the following steps recommended in a publication by the American Medical Association’s Specialty Society Medical
Liability Project. 1
• Notify the patient in writing, preferably by return receipt mail;
• Provide the patient with a reason for the termination;
• Agree to continue as the patient’s treating physician for a reasonable period of time, such as 30 days, while the patient makes arrangements for the services of another physician;
• State clearly the date on which the termination will become effective;
• Provide information about resources, such as the medical society or local medical center, that can aid the patient in identifying other physicians of like specialty; normally, the terminating physician should also offer to recommend other physicians from whom the patient may choose;
• Offer to transfer records to the new physician upon receipt of a signed authorization to do so;
• Offer to see the patient in cases of emergency within a stated period of time after termination;
• Include the above-referenced items in the letter notifying the patient of termination;
• Finally, check with your personal legal counsel regarding specific requirements in your state or jurisdiction for terminating a doctor-patient relationship.
Notes:
1. Risk Management Principles & Commentaries for the Medical Office. American Medical Association/Specialty Society Medical Liability Project, Chicago. 1990: 14-15.
