Delving Deeper
You know not to judge a book by its cover. Why assume that the signs and symptoms a patient presents with are all that's wrong with him?
By Jerry Sherman, O.D., F.A.A.O.

A simple clinical pearl to always keep in mind is, "Any one patient can have more than one disease at any one time." Although we teach the rule of parsimony in an attempt to explain all complaints and clinical findings by one disorder, this attempt at simplicity sometimes costs us dearly.

Yet another clinical pearl, "It ain't rare if it's in your chair," reminds us that a rare disease may be present in what looks like a routine clinical encounter. The following case demonstrates these pearls.

Meet the patient

A 63-year-old white male presented for the first time at an O.D.'s office as the last patient on a busy day. The patient had several chief complaints, which the O.D. recorded and one purported complaint that the O.D. didn't document.

The chart revealed the complaint of a couple of weeks' history of reduced vision at both distance and near in the left eye as well as poor depth perception. Not recorded was the purported complaint of distortion in the upper and inner quadrant through the left eye. Other than slightly elevated cholesterol levels, the patient had no eye or health history.

Clinical findings

The patient's visual acuity (VA) with a 5-year-old pair of glasses was 20/20 OD and 20/60 OS through a -2.00D sphere. A pinhole test improved the VA only slightly to 20/50-.

The doctor refracted the patient and improved his VA to 20/40+ OS with a -1.00D-sphere. Externals revealed normal pupils, motility and confrontation visual fields. He then performed Goldmann applanation tonometry, which he recorded as T=18/18 at 6:30p.m. He dilated with one drop of a dilating agent and his slit lamp exam revealed nuclear cataracts OU, which he graded as 1+ OD and 2+ OS. Using a 90-D lens, he performed ophthalmoscopy and found nothing unusual in the fundus.

At this point, the O.D. diagnosed nuclear cataracts (slightly greater OS than OD) and discussed his findings with the patient. He prescribed new glasses and told the patient to return in 1 year or sooner p.r.n. to check on the cataracts.

Revealing the aftermath

About 13 months later, the patient presented to an M.D. for the first time and immediately stated that it was time to remove the cataract in his left eye because his vision was at that point considerably impaired. At the visit, the M.D. measured the patient's corrected VA at 20/20 OD and at 20/200 OS. He judged the cataracts as 2+ nuclear sclerosis in each eye. A dilated fundus exam revealed a large elevated mass in the left eye inferiorly and temporally.

The M.D. referred the patient to a retinal specialist who diagnosed him with a large, lightly pigmented choroidal melanoma that measured 13 mm x 13 mm x 7 mm as estimated with A and B scan ultrasonography. The specialist recommended enucleation of the left eye and the patient followed his advice.

Defending actions

After being fit with a prosthetic eye, the patient sued the O.D. for failing to diagnose the melanoma 1 year earlier when it was smaller and amen-able to treatment modalities that would have saved the eye.

In his deposition, the O.D. revealed several pertinent disclosures. He testified that his view of the patient's fundus was somewhat impaired because of the cataract in the left eye. He also admitted that he did have an adequate view of the disc and an area 30 to 40 degrees around the disc but said nothing about more peripheral fundus.

The O.D. explained that in similar cases, his typical exam always includes an Amsler grid test but that this office didn't have one. He also had no home monitoring Amsler grids to give to the patient and he revealed that the automated perimeter in that office had been broken.

An expert witness speaks

At trial, an expert witness for the plaintiff gave his opinion that only performing confrontation visual fields is inadequate for a patient presenting with a recent onset of reduced vision, poor depth perception and alleged visual distortion. He opined that Amsler grid and automated fields should've been obtained on that visit or shortly afterward because retinal, optic nerve and visual pathway involvement require assessment and this is best accomplished with automated visual fields.

This expert went on to state that the less-than-ideal-view of the fundus was likely caused by the use of a dilating agent instead of the preferred combination of tropicamide and phenylephrine, insufficient dilation time and failure to perform binocular indirect ophthalmoscopy, which is the accepted gold standard in fundus evaluation.

The patient testified that the O.D. didn't ask him to wait for the drops to work, but rather continued with the exam, flowing from one test to the next. Some evidence surfaced that not only was the plaintiff the O.D.'s last patient of the day, but that the doctor had a date after work.

Remarkably, the doctor testified at trial that he would've performed both the Amsler grid and automated perimetry if these two procedures were available to him at the time of the exam. He hadn't considered having the patient come back to one of the other better equipped office where he also worked or referring him to someone else for the tests.

Meeting the standard

With the facts on the table, you could argue that the O.D. met the standard of care because he did dilate and perform some type of visual field exam on the patient. In fact, the American Optometric Association practice guidelines don't require an eyecare provider to perform a specific type of ophthalmoscopy through a dilated pupil and also don't specify what type of visual field is required. In the O.D.'s opinion, the patient's symptoms were fully explainable on the basis of his diagnosis of cataracts.

Beyond the standard

Although the experts at trial disagreed as to whether the O.D. met the standard of care, all agreed that going the extra mile would've afforded him the opportunity to arrive at a more timely diagnosis of the melanoma and perhaps avoid the enucleation.

If a patient presents with a recent onset of several new chief complaints, perform the appropriate diagnostic work up and follow the patient carefully. It's also more appropriate to reevaluate him in 12 weeks than to wait 12 months to check on his eye health status.

The jury weighs in

A jury found the O.D. not culpable of malpractice. He admitted that the experience of being sued amounted to one of his worst experiences, but he surfaced as a much more sophisticated clinician who will likely avoid such pitfalls in the future.

We all can learn from the experiences of this young O.D. and go beyond the minimum standard of care to avoid litigation and to provide better care to our patients. Besides, you'll be a better doctor for it.

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