MALPRACTICE MANAGEMENT
Learn from these real-life cases how to protect yourself.

Too Little, Too Late
Was the spider-like dark spot a sign of a missed retinal detachment?
By Jerome Sherman, O.D., F.A.A.O., New York, N.Y.

A 60-year-old white male had been under the care of the same optometrist for more than 10 years and wore contact lenses successfully to correct for 6.00D of myopia in each eye. He called his optometrist early one morning complaining of a "spider-like dark spot" in his left eye that he noticed several days earlier. The doctor fit the man in for a 15-minute exam just before noon.

Findings

Upon examination, the patient's corrected visual acuity was 20/20 in each eye, the slit lamp exam was unremarkable and a non-dilated fundus evaluation with a Volk super-field lens revealed a posterior vitreal detachment OS without evidence of any other abnormality.

Over the previous 10 years, the O.D. had dilated the patient on three occasions but on several other occasions he refused dilation. The O.D. later testified that on this particular visit, he had an adequate view of the fundus with the Volk super-field without dilation and that he didn't have adequate time to dilate the patient anyway because he was just squeezed in that morning.

The doctor explained his finding of a posterior vitreal detachment to the patient and advised him to return to the office if he began seeing flashes of light or an increased number of floaters.

The diagnosis

The patient eventually returned to his O.D.'s office about 1 month later without an appointment and still complaining of the spider-like dark spot. The optometrist had no time to examine the man and referred him to his primary care physician to get a retinal consult.

The next day, a prominent retinal surgeon evaluated the patient and diagnosed him with several retinal tears and a retinal detachment in the left eye and extensive lattice degeneration in both eyes. He performed a scleral buckle procedure for the retinal detachment the following day. He also applied laser treatment to the extensive areas of lattice degeneration in both eyes.

The outcome

The surgery went well and the patient's visual acuity improved to 20/30 in the left eye. However, diplopia, a rather common complication of scleral buckle procedures, resulted. The retinal specialist referred the patient to a strabismologist for the sympto-matic diplopia and he performed a left inferior rectus recession to eliminate the double vision in primary gaze. The patient was still somewhat symptomatic in his peripheral vision.

Visual acuity after the second surgical procedure was 20/25 in the right eye and 20/30 in the left eye, which underwent the two surgical procedures.

The patient filed a lawsuit against his O.D. contending that he missed the retinal detachment because he was negligent and caused the patient to undergo two unnecessary surgeries. The plaintiff still suffers from blurred vision, eye pain and diplopia.

Expert opinions

In his deposition, the retinal surgeon testified that even if the patient had been referred a month earlier, he most likely would've needed the same scleral buckle procedure because of the extensive lattice degeneration with holes in the left eye.

Other experts testified that diplopia after a scleral buckle procedure is common and not attributable to any fault of the retinal surgeon.

Still other experts testified that if the retinal detachment were present on the first visit, the optometrist would have seen it with the Volk super-field lens even without dilation. On the plaintiff's side, one expert expressed his opinion that the optometrist should've dilated the patient on the first visit or immediately referred him to another clinician capable of dilating and assessing the peripheral retina.

Standard of care

According to the American Optometric Association's (AOA's) Optometric Clinical Practice Guidelines: Care of Patients with Retinal Detachment and Related Peripheral Vitreo-retinal Disease, binocular indirect ophthalmoscopy (BIO) with pupillary dilation is generally necessary to diagnose a peripheral retinal break or detachment. But does the introduction of new technology change the guideline?

A new laser system for viewing the fundus without dilation, the Optos Panoramic 200, has been shown in one preliminary study to be as effective as dilation with BIO. So is the Volk super-field lens without dilation adequate to rule out peripheral detachments and breaks?

In this particular case, you could argue that because the optometrist didn't record the presence of extensive lattice degeneration, he may not have been able to visualize the peripheral fundus as well as he thought and perhaps missed a retinal tear or even the detachment.

Going beyond the standard

You could argue about whether the O.D. met the standard on the first visit when he had no time to perform a dilated fundus exam, but keep in mind that he could've asked the patient back in a day or two when he had time for the exam.

The AOA's guideline states that you should follow any patient who has a symptomatic posterior vitreous detachment (PVD) at least every 2 to 3 weeks until the symptoms resolve. By having the patient return sooner for a dilated fundus exam, preferably in a day or two, the O.D. could've reduced his risk of alleged malpractice and perhaps made a more timely diagnosis.

Going beyond the standard is often your best protection to avoid litigation. This particular case was recently settled before going to a jury trial for an undisclosed amount of money. 

Dr. Sherman practices at the Eye Institute and Laser Center in Manhattan and is a distinguished teaching professor at the State University of New York College of Optometry.