Risk Management

Failure to Diagnose Bilateral Acanthamoeba Keratitis

By Randy Morris, JD

OMIC Claims/Litigation Associate

Digest, Summer 1999

ALLEGATION  Failure to diagnose acanthamoeba keratitis in a timely manner.

DISPOSITION  Defense verdict at trial.

Case Summary

A 35-year-old woman was seen by the insured ophthalmologist on an emergency referral from an optometrist. The patient had been in a car accident and reported that her contact lenses had broken in both eyes and were causing her irritation and pain. The optometrist had placed the patient on Vira-A ointment, Viroptic, and Tobrex. The insured diagnosed bilateral keratitis, discontinued the Viroptic and Tobrex, and started the patient Blephamide ointment.

The patient returned two days later and was seen by another optometrist in the insured’s office. The optometrist diagnosed bilateral keratitis with unknown etiology and asked the insured to confirm the diagnosis. The insured confirmed the diagnosis and continued the Blephamide. The patient returned three days later with diffuse keratitis in the right eye as noted by the optometrist. The insured instructed the optometrist to dilate OU with Hyoscine and patch the right eye with Maxitrol ointment. The patient was to continue using Blephamide in the left eye.

The patient returned the next day complaining that her right eye was very painful and that she was having difficulty driving. The optometrist spoke with the insured’s partner about taking a culture, but the partner did not feel it was appropriate and recommended that all medications be stopped. Two days later, the insured’s partner saw the patient and diagnosed bilateral keratitis deteriorating in spite of treatment. He referred the patient to a nearby university, where specialists diagnosed bilateral acanthamoeba keratitis. The patient eventually underwent two corneal transplants and a cataract operation.


Defense experts argued that acanthamoeba keratitis is a very difficult diagnosis to make and can often masquerade as another type of infection. Most cases are not diagnosed for several months so they felt the minimal delay in this case was acceptable. They pointed out that the insured attempted several treatment approaches and, when there was no improvement, appropriately referred the patient to specialists.

The plaintiff’s expert countered that steroids are contraindicated in the absence of a specific diagnosis and that the insured should have cultured the eye sooner. The defense was able to call into question the credibility of this expert because he had never been involved in the study of acanthamoeba nor was he familiar with the disease process.

Risk Management Principles

This case was well positioned for trial with excellent defense experts, relatively low damages, and a 70 percent probability of prevailing, but there remained a potentially significant complication. The insured was quite emotional about being the target of a lawsuit and defense counsel was concerned that he might appear uncomfortable and nervous in front of the jury. To make matters worse, the plaintiff was an attractive likable woman who could easily win the jury’s sympathy.

OMIC assigned a skilled witness preparation coach, who worked with counsel to help the insured rein in his emotions at trial and come across as a competent physician. When the insured took the stand, he appeared patient and was able to explain the situation to the jury in layman’s terms. The jury understood what the insured said and believed in his ability as a physician. In the end, the jury delivered a verdict in his favor.

While being the defendant in a medical malpractice lawsuit is never a pleasant experience, this case illustrates the importance of not letting the emotional stress of the situation impact the defense of the case. It is important to remember that a physician’s demeanor and appearance often are the factors that “make or break” a case in the eyes of the jury. Patience, reason, and dedication to the defense of one’s care are not simply helpful platitudes. They are absolute necessities to a successful outcome in a medical malpractice action.


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