Risk Management

Patient’s Finances Alters Evaluation and Treatment of Penetrating Globe Injury

By Ryan Bucsi, OMIC Senior Litigation Analyst, Digest, Winter 2010

ALLEGATION:  Failure to diagnose intraocular foreign body.

DISPOSITION:  Case settled for $210,000.

Case Summary

An uninsured illegal immigrant was examined by the insured ophthalmologist after a nail struck his right eye while hammering. Visual acuity on presentation was 20/50 OD. The insured diagnosed hyphema and a full thickness corneal laceration with a selfsealing wound. An undocumented slit lamp examination “ruled out” the presence of a foreign body. The insured patched the patient’s right eye, prescribed Ciloxan, and asked the patient to return the following day. The next day, the patient’s visual acuity was 20/40 OD with a negative Siedel Test demonstrating no wound leakage. A hyphema and a small selfsealing corneal wound were present. A dilated fundus exam was not performed, so the retina was not visualized. The impression was a corneal scleral laceration with slightly improved vision with no mention of a foreign body. The patient was told to return in four days.

The following day, the patient self-referred to another ophthalmologist with hand motion vision OD and complaints of sharp throbbing pain in the injured eye. The patient was diagnosed with a traumatic vitreous hemorrhage OD, resolving hyphema OD, and a partial thickness corneal laceration OD. An exam during an emergency retinal consult revealed a reflective foreign object in the vitreous space. A CT scan done at the local charity hospital confirmed an intraocular foreign body. Residents there performed lensectomy, vitrectomy, anterior chamber membrane removal, attempted foreign body removal, and administered an intraocular antibiotic for endophthalmitis. During surgery, the foreign body slipped into the membrane temporally and could not be located. Two days later, a pars plana vitrectomy with membrane peeling, retinectomy, and foreign body removal was done. One week later, the patient had an enucleation for uncontrolled endophthalmitis.

Analysis

Experts for both the defense and plaintiff agreed that the insured did not meet the standard of care. Specifically, the experts opined that the insured should have ordered an x-ray or CT scan of the right orbit to rule out the presence of a foreign body. The slit lamp exam that the insured said he performed but did not document was inadequate to rule out the presence of an intraocular foreign body. The experts believed that an immediate referral to a retinal surgeon was warranted. Regarding a potential causation defense, there was a question as to whether the injury may have been serious enough from the outset to require an enucleation. Defense counsel and our experts believed it would be extremely difficult to rebut the fact that the failure to locate the foreign body led to the infection and the eventual enucleation OD. There was also an issue regarding the surgeries performed by the residents at the local charity hospital. Some of the experts were critical of the technique used during these two surgeries. However, defense counsel and experts agreed that any potential criticism of the residents probably would not hold up in light of the severity of the endophthalmitis at the time of the first surgery.

Risk Management Principles

The insured explained that because of the patient’s limited financial resources, he hoped to minimize the cost to the patient by monitoring the situation instead of ordering expensive diagnostic tests. The insured felt justified in doing this because the patient had “good visual acuity and an intact ocular structure.” Due to the nature of the injury, however, the insured’s focus should have been on ruling out the presence of a foreign body. A simple x-ray could have accomplished this at much lower cost than CT imaging. Unfortunately, the patient’s illegal residency status and inability to pay allowed the insured to lose sight of what was best for the patient and altered his diagnostic workup. As a result, tests that would have led to an earlier and more definitive diagnosis were not ordered. Alternately, the insured could have made an immediate referral to the local charity hospital, where evaluation and treatment would have been provided at reduced or no cost to the patient.