Risk Management

Failure to diagnose a RD by a comprehensive ophthalmologist

RYAN M BUCSI, OMIC Claims Manager

A 57-year-old corrections officer presented to an OMIC insured comprehensive ophthalmologist on referral from the emergency department. The patient reported a fall at work where he struck the left side of his head, face, and hip. He explained that his vision became blurred after the fall. His vision was 20/40 OU with bilateral cataracts. The IOP OS was 9, which was low compared to the IOP OD. The insured referred the patient back to his primary care physician. One month later, the patient returned to the insured’s office and the insured noted a decrease in visual acuity to 20/125 OS; the IOP was still 9. The insured attributed the worsening vision to progressive cataracts OS>OD and referred the patient to a colleague for surgery, which was performed two months later. On postoperative day 3, the patient’s vision had further decreased to 20/150 OS. The insured diagnosed a retinal detachment and emergently referred the patient to a retina specialist. The following day, the retinal specialist performed a pars plana vitrectomy with laser to reattach the retina. Subsequently, the patient had two recurrent retinal detachments with scar tissue requiring two additional surgeries, a gas bubble injection and the placement of silicone oil. The retina specialist noted that any return of vision OS was unlikely. The patient’s final visual acuity was HM.

Analysis

Plaintiff expert’s theory was that the patient suffered a traumatic tear of a portion of his retina OS as a result of the fall and that the initial OMIC insured failed to diagnose this detachment despite it becoming progressively more severe during the time he saw the patient. As a result of this delay in diagnosis, the ability to re-attach the retina, once the detachment was diagnosed, was significantly lessened and was a substantial factor in bringing about the permanent loss of sight OS. The plaintiff experts were critical of the first OMIC insured since the patient associated the blurry vision OS with the fall from the moment it happened; the discrepancy in IOP between the right and left eyes with the left eye pressure being much lower after the fall than for the many years preceding it; the worsening visual acuity during the first month after the traumatic incident as further evidence of continued retinal detachment; and a rather superficial initial examination and lack of a dilated and funduscopic examination. Unfortunately, our defense experts agreed with plaintiff expert’s opinions on this case. Our experts believed that the second insured (the cataract surgeon) could also potentially be criticized for not performing a dilated examination prior to the performance of the cataract surgery. The plaintiff’s case was strengthened when the retina specialist testified at his deposition that the patient suffered a traumatically induced retinal detachment as a result of the fall. The retina surgeon declared that the detachment progressively worsened over the next few months. Due to the retina specialist’s impartial position in the case and his firm statements, he became the best expert for the plaintiff. Defense counsel estimated the likelihood of a plaintiff verdict at 80%. As a result, mediation was scheduled and the case settled for $475,000 on behalf of the fist insured, as he essentially took the blame for the substandard care, thus prompting plaintiff to dismiss the second insured and the group.

Risk management principles

The first insured performed only a cursory examination. He did not appear to take the recent fall into account when evaluating the vision loss. The diagnosis of cataracts could potentially explain the blurry vision, but the reason for the asymmetrical lower IOP was not explored. According to all experts in this case, the sudden vision loss and asymmetrical IOPS should have set off alarm bells. However, the insured did not appreciate or explore other explanations for the visual complaints once he diagnosed bilateral cataracts. Furthermore, the insured did not perform a dilated examination, which was indicated based on the patient’s presenting complaints and recent history of trauma. Had this been done it is more than likely that the insured would have discovered a retinal detachment, which would have increased the odds of all or some vision being saved OS. In addition, the lack of a dilated exam prior to cataract surgery represents another missed opportunity to have diagnosed the retinal detachment.