Risk Management



Delayed Diagnosis and Treatment of Glaucoma

Digest, Spring 1997


ALLEGATION

Delayed diagnosis and mismanagement of glaucoma resulting in vision loss in one eye.


DISPOSITION

Claim settled on behalf of insured ophthalmologist.


Case Summary

In July 1990, a 47-year-old female CEO for a regional manufacturing company presented to the office of the insured with complaints of blurred vision and light sensitivity in her right eye over the course of approximately two months. A full eye exam was conducted and all findings were essentially normal. The ophthalmologist diagnosed refractive error in both eyes and successfully corrected the patient’s vision to 20/25 OD and 20/20 OS. The patient was instructed to return in two years unless she experienced a further problem.

A month later, the patient returned with complaints that her right eye had worsened, including light sensitivity and a spot of decreased vision. The Amsler grid test showed a defect in the inferior portion of the visual field of the right eye. The ophthalmologist diagnosed conjunctivitis and corneal abrasion and placed the patient on Vasocidin drops for 10 days. The patient returned after four days, again complaining of blurred vision and irritation from the antibiotic drops. The best corrected vision in her right eye was 20/30-2 and in her left eye 20/20-1. Both funduscopic exams were normal. The antibiotic was changed to Gentacidin and the patient was told to return in a week.

The insured did not hear from the patient again for eight months when she appeared with complaints of blurred vision and light sensitivity in the right eye. Visual acuity with correction was 20/30-2 in the right eye and 20/20 in the left. Tension was 30 in the right eye and 28 in the left. Funduscopic exam revealed abnormal cup to disc ratios in both eyes with the worst being 0.8 in the right eye. Visual fields were abnormal on the right and borderline on the left. A diagnosis of bilateral glaucoma was made and the patient was placed on Betagan and instructed to return in 10 days. When the patient returned in 10 days, she reported that the right eye felt better, although visual acuity was essentially the same. Pressure in the left eye had dropped from 28 to 23 but had risen from 30 to 31 in the right eye. The insured placed the patient on a combination of glaucoma medications, which effectively lowered the intraocular pressure to 19 in the right eye.

For the next several months, the patient’s intraocular pressure vacillated from the mid-20s up to 30. The insured noted that intraocular pressure was elevated at some visits because the patient had forgotten to take the glaucoma drops in the morning, resulting in an elevated pressure when the exam took place in the afternoon. The patient also reportedly failed to have her prescription for eye drops filled for a period of three months. Even though the insured continued to monitor the patient’s pressures and adjust her medication every four to six months, this roller coaster pattern of elevated pressures continued throughout most of the next two years.

In September 1993, the patient presented with decreased vision and a change in the appearance of the optic nerve. The cup to disc ratio had now increased to .89 and VA in the right eye was hand motion only. At this point, the insured referred the patient for surgical evaluation and the patient ultimately underwent a laser trabeculoplasty for advanced loss of vision in the right eye. Vision was stabilized but not recovered. The patient sued the ophthalmologist, alleging that vision loss in her right eye was due to delayed diagnosis and mismanagement of glaucoma. The case was subsequently settled before trial.


Analysis

There were two deficits in record keeping that hampered defense of this case. The first was the failure to document ocular pressures on the patient’s second and third visits. Defense experts pointed out that when the patient presented with consistent symptoms of decreasing vision and light sensitivity in the right eye, failure to check pressures would be considered by most to be below the standard. If the pressures were normal and documented, there would be no question regarding the insured’s approach to treatment; however with no pressures recorded, it was left open for the plaintiff to point out that the glaucoma might have been diagnosed earlier. Although the insured stated that his customary routine would have been to check the pressures and that this patient’s must have been normal, there is no mention of this in the chart.

The second record keeping problem was the lack of documentation of patient noncompliance. Over the two years of reported noncompliance, there were very few notations indicating these problems in the medical record. This became critical when the plaintiff attorney interpreted the medical record as showing that the pressures were “just not monitored well” and “adjustments were not timely made” in the medications. The patient testified that she was a model patient who followed all directions. It was very difficult to argue at that point that the variations in treatment patterns were due primarily to patient noncompliance.


Risk Management Principles and Commentary

In recent years, glaucoma cases have developed a significant presence in medical malpractice litigation. A 1996 study of 383 ophthalmology claims from the Medical Liability Mutual Insurance Company of New York found that 15% of the high loss cases (over $250,000) involved the management of glaucoma. The most common problems to appear in litigation were related to failure to diagnose and/or manage chronic glaucoma.1 An earlier study in 1994 specifically analyzed 194 glaucoma claims from the Physician Insurers Association of America (PIAA) and found that four types of problems account for the majority of allegations in glaucoma claims:2

  • Diagnostic error (21.7%)
  • Improper performance of care (19.1%)
  • Medication error (9.8%)
  • Failure to monitor patient (8.2%)

Not every case involving these allegations is a case of negligence. In many instances, the injury to the patient is the result of a known complication that can be defended provided the legal facts of the case are not complicated by poor record keeping. When a plaintiff attorney searches the medical records for the cause of vision loss in a glaucoma patient, inevitably the search will analyze evidence of (1) a failure or delay in diagnosis and (2) a delayed or improper treatment pattern. Documentation or lack thereof in the medical record can make or break a case for either side.

Notes
  1. Kraushar MF, Robb JH. Ophthalmic Malpractice Lawsuits with Large Monetary Awards. Archives of Ophthalmology. March 1996; 114: 333-337.
  2. Craven RE. Risk Management Issues in Glaucoma Diagnosis and Treatment. Ophthalmic Risk Management Digest. Summer 1994: 3-5.
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