Risk Management



Noncompliance Puts Patient and Physician at Risk in Glaucoma Cases

Digest, Summer, 1994


Allegation

Plaintiff alleged that insured ophthalmologist negligently performed unnecessary peripheral iridectomy, resulting in decreased visual acuity in plaintiff’s left eye.


Disposition

Prelitigation screening panel concluded the claim was without merit. Plaintiff did not pursue the case in civil court.


Background

Several states now use prelitigation screening panels to review the merits of a medical malpractice claim before the case can be pursued in civil court. Often these panels include a physician who specializes in the area of medicine involved in the claim. This type of review process can be extremely beneficial to defendant ophthalmologists who can support their treatment choices with sound medical reasoning. If the review panel renders an opinion favorable to the defendant and the plaintiff chooses to continue to pursue the case in court, the favorable panel decision is admissible evidence when permitted by state law. This creates an additional obstacle for the plaintiff to overcome in proving his or her case and can induce the plaintiff to drop the claim short of litigation.


Case Summary

A 60-year-old female presented to the insured and reported symptoms of headache, eyeache, nausea, vomiting, and blurred and foggy vision three days previously. The insured examined the patient and concluded she had experienced an episode of acute angle closure glaucoma which had spontaneously resolved. The insured ophthalmologist recommended laser peripheral iridectomies OU to avoid another acute episode, as well as a course of treatment for chronic glaucoma. The patient left the insured’s office indicating she would consider the procedure.

Unbeknownst to the insured, the patient sought a second opinion from another ophthalmologist who did not believe the iridectomies were necessary but who advised the patient to be followed for chronic glaucoma. Despite a documented telephone call to the patient and a letter from the insured ophthalmologist urging her to have regular examinations to follow her glaucoma, the patient did not consult another eye professional until two years later. She then returned to the insured for an examination because she felt she needed new glasses. She reported no additional episodes of acute angle closure. The insured reiterated his recommendations for prophylactic surgery and this time the patient agreed.

An iridectomy OD was performed without complications and with good results. After the peripheral iridectomy OS, the patient’s eyes burned, the iris was dilated, and her VA decreased from 20/25 to 20/50. During postoperative visits, the insured noted elevated pressure, vitreous condensation, adherence of the iris to the cornea OS, and increased disc cupping. After two postoperative visits, the patient never returned and subsequently sought eye care from optometrists. Dissatisfied with her decrease in visual acuity OS, the patient filed a written complaint with the Board of Medical Examiners. This complaint prompted a review by the prelitigation screening panel in her state.


Outcome

The litigation screening panel agreed that surgery was an option in 1988 when the insured first recommended it. However, in the absence of intervening problems, the ophthalmologist on the panel did not believe surgery was clearly warranted based on clinical findings alone when the patient returned two years later. In the end, it was the patient’s demonstrated noncompliance in “disappearing” for two years which convinced the panelists that the insured’s treatment plan was justified nonetheless. Documentation by the insured and subsequent treaters specifically indicated that the patient was noncompliant in keeping appointments and taking medications. This documentation laid a firm foundation for the defense’s arguments that it was probably the patient’s own negligence which caused her reduced visual acuity.


Risk Management Principlesand Commentary

The treatment of glaucoma requires vigilance on the part of both the ophthalmologist and the patient. Noncompliant glaucoma patients can jeopardize their own vision and put physicians at risk for litigation. As their condition inevitably worsens, such patients often look for someone else to blame. When it comes to defending a claim, documentation of the patient’s noncompliance and of the physician’s attempts to encourage compliance with medical advice can be as important as documentation of the patient’s clinical progress.

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