MALPRACTICE MANAGEMENT: Learn from these real-life cases how to protect yourself.
Juvenile Glaucoma
Preventable blindness results in a multi-million dollar settlement.
By Jerry Sherman, O.D., F.A.A.O.

Those of us who provide care to many infants and children rarely encounter serious pathology in young patients. Although pediatric disorders are rare, many are sight and life threatening. For example, juvenile glaucoma is a rare but potentially serious disorder that we must all be aware of when examining young patients. We'll take a look at what bases to cover when we encounter this condition.

How it all began

Dr. Lumis has a large pediatric practice and has provided care to Jessica from the time she was 3 years old until she was 11. During this time, Dr. Lumis performed routine exams and prescribed glasses on half a dozen different occasions for a minor refractive error.

Dr. Lumis corrected Jessica's visual acuity (VA) to about 20/25 in each eye on the more recent visits and on two occasions he recorded the cup-to-disc ratio as 0.0 in each eye. Dr. Lumis didn't record any findings under ophthalmoscopy on the other visits, and it appears that he didn't obtain intraocular pressure (IOP) measurements until the last visit and never attempted visual fields. He later testified that he routinely performed slit lamp exams, but hadn't recorded the findings because they were all within normal limits.

On Jessica's last visit, Dr. Lumis measured her pressures at about 30 mm Hg in each eye. He testified that all other findings were normal and unchanged from previous exams.

Jessica's parents went else-where for a second opinion. This consultant measured her pressures, which again revealed 30 mm Hg in each eye. But, in contrast to Dr. Lumis's findings, the consulting doctor observed band keratopathy in each eye and judged her discs as pale with a cup-to-disc ratio of 0.9 OU.

The consulting doctor referred Jessica to a pediatric glaucoma specialist who provided medical and surgical treatment to each of her eyes. The specialist concluded that the band keratopathy was secondary to an intermittent iritis of unknown etiology after ruling out juvenile rheumatoid arthritis. Hearing deficits also manifested at about the same time.

Acuity leveled off at 20/400 in each eye with restricted visual fields secondary to end-stage glaucoma. Hence, Jessica became blind in both eyes before her 12th birthday.

The lawsuit

Jessica's family sued Dr. Lumis for not detecting the glaucoma, iritis and band keratopathy and alleged that he was responsible for her blindness. During numerous depositions, experts pointed out that band keratopathy develops slowly and that the iritis must have been present for at least 1 year, but most likely longer. Similarly, the elevated pressures were likely present for years and the type of extensive cupping Jessica exhibited must have developed over years, not days.

Because Dr. Lumis testified that the only abnormal finding was the elevated IOP and that he saw no abnormality or change at Jessica's last visit, his observational abilities became suspect. Furthermore, he couldn't explain why he failed to note the band keratopathy and the extreme cupping that were immediately seen by the doctors who evaluated Jessica within 1 week of Dr. Lumis's last evaluation.

Meeting the standard

Many clinicians now attempt IOP measurements in all patients, regardless of age. Sometimes it's not possible to get the needed cooperation for successful IOP measurements, so if you can't, state that you attempted them but couldn't obtain them and try again on the next visit.

A few studies have shown that you can measure automated fields in children as young as 6 years old. Most kids are so familiar with computers and spend hours in front of video games that the clinician can create yet another challenge while performing automated fields. Although it's often possible to get them, the present standard doesn't include formal fields on children.

Disc assessment is vital for all patients. Blurred disc borders in a child are most commonly a result of buried disc drusen, but you should also consider raised intracranial pressure. It's important to note and investigate cupping or an increase in cupping.

Beyond the standard

Although automated visual fields in youngsters aren't the standard, try to obtain them on everyone. I know of several cases of brain lesions in kids that were picked up by obtaining routine automated fields. Try to improve your confrontation visual field technique and use it on kids. And remember to record normal and abnormal findings. Many a judge will tell a jury, "Work not recorded is work not done."

Consider fundus photos of the posterior pole. It's even possible in kids who have nystagmus because you can freeze the image and analyze it later. A baseline fundus photo is invaluable in many cases because you can identify change by comparing photos taken over several years.

What happened in this case?

Jessica's case never made it to trial and the settlement was reported at nearly $3 million. Jessica was eventually diagnosed with a rare syndrome, of which the glaucoma was a part, but Dr. Lumis could've treated her elevated pressures and consequently, prevented her blindness.

Although juvenile glaucoma is fairly rare, the outcome is often devastating if it's not detected and treated in a timely manner.

What to keep in mind

Diagnosing juvenile glaucoma is perplexing for myriad reasons. First, the level of suspicion is generally low unless you're aware of a strong family history.

Second, both tonometry and visual fields are often difficult because of the age and lack of cooperation of the patient. Even careful optic nerve head assessment may not be possible.

Furthermore, the medical/legal implications are far greater in the case of a youngster than in an adult. When a doctor misses glaucoma in a typical adult, he may only have a life expectancy of 1 decade or so at that point in his life. But in a child, the life expectancy is generally projected at 7 or more decades.

Jurors are usually sympathetic to helpless children who remain blind for the rest of their lives. Jury awards in such cases often run into the millions of dollars. Also, the statute of limitations typically runs for only 2 or 3 years in an adult, but runs for more than 1 decade in most juvenile cases. In other words, a patient can sue a clinician even 10 to 15 years after he provided care to a juvenile at a single visit.

Proceed with caution

This case is a perfect example of why we need to proceed cautiously with young patients whose vision exam results are unusual. Make sure you take the best care of your young patients -- to avoid potential lawsuits such as this one and to build and maintain relationships with these patients and their families based on trust and your going beyond the standard of care.

Normal visual fields in a 5-year-old child.

Abnormal nerve fiber layer in the same 7-year-old patient.

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.