Beyond the Standard
Sometimes it's necessary to go the extra mile just to protect yourself against malpractice.
By Jerry Sherman, O.D., F.A.A.O. and Jeffrey M. Roth, O.D.

If you want something done right, do it yourself." This old adage has many different applications in our world today. In this month's case, we'll see why you shouldn't trust anyone -- even a patient -- to convey your findings about his health.

Enter the care-free patient

A 25-year-old white male, whom we'll call Mr. Cross, presented with a chief complaint of a foreign body sensation in his right eye. He'd worn soft contact lenses for several years without significant problems. The optometrist, whom we'll refer to as Dr. Blue, didn't obtain a detailed general health history at this time, but he did measure Mr. Cross's best corrected visual acuity at 20/20+ in each eye with the contact lenses.

A slit lamp evaluation revealed a misdirected lash that had been in contact with the inferior conjunctiva OD. While performing the slit lamp exam, Dr. Blue observed a "limbal iridescence" in each eye. Removal of the lash appeared to alleviate Mr. Cross's symptoms, but Dr. Blue requested that he return in 2 days to be certain that all was well. As instructed, Mr. Cross returned and was evaluated by a different doctor in the same office several days later. Mr. Cross was asymptomatic and his visual acuity was 20/20.

The second doctor, Dr. Adams, also performed a slit lamp exam and noted "crocodile shagreen" and suggested a consultation with a corneal specialist. Mr. Cross never bothered to see the specialist.

The situation in question

Six months later, Mr. Cross presented again to Dr. Blue for a routine contact lens check up. Visual acuity was correctable to better than 20/20 in each eye. A slit lamp exam again revealed a large iridescent ring deep in the cornea near the limbus.

At this visit, Dr. Blue decided to pursue the unusual slit lamp observation. He consulted the Will's Eye Manual in his office and discovered that the rings fit the textbook's description of a Keyser-Fleischer ring, which is most often caused by abnormal copper deposits in Wilson's disease, which is hepatolenticular degeneration.

Upon learning this, Dr. Blue asked Mr. Cross if he had any history of liver problems and Mr. Cross responded that indeed, some of his liver enzymes had been noted as mildly abnormal. He also mentioned that his physician believed that the liver enzyme disorder was caused by the drug isotretinoin (Accutane), which Mr. Cross was taking to treat his acne, and perhaps also brought on by mononucleosis caused by the Epstein-Barr virus for which he'd tested positive.

Dr. Blue faxed a single page inter-professional report listing his observation and the possible association with Wilson's disease to Mr. Cross's internist.

In his deposition, he testified that he did fax the report, gave the original to the patient and told him to check it out. Dr. Blue also retained a copy of the report for his own records. One week later, Mr. Cross returned to Dr. Blue's office because he had lost a contact lens.

Upon questioning, Mr. Cross indicated that he hadn't seen his internist about Dr. Blue's concerns. Dr. Blue made a note on his chart to call the patient's internist, but he never did.

The diagnosis

Over the next year, Mr. Cross's internist saw him several times for various problems including a marked weight gain, but he apparently never mentioned the optometrist's concern about Wilson's disease.

As it happened, the internist never received the fax and was therefore unaware of the optometrist's findings or his concern. Over this period of time, Mr. Cross began to develop psychiatric-type symptoms and was evaluated by two psychiatrists who attributed these problems to the recent divorce of Mr. Cross's parents.

As the disorder worsened over many months, one psychiatrist noted increasing tremors and referred Mr. Cross to a neurologist to rule out Parkinson's disease. After the neurologist noted slurred speech and involuntary hand movements, he performed an MRI, which revealed a copper-type ring at the base of Mr. Cross's brain.

Blood and urine testing confirmed the abnormal copper levels and the neurologist finally made a diagnosis of Wilson's disease and quickly initiated treatment. The neurologist's diagnosis came about approximately 1 1/2 years after Dr. Blue noted the iridescent corneal rings. Although Mr. Cross improved somewhat with treatment, he still suffers from what some doctors have labeled severe neurological dysfunction.

The lawsuit

Family members and friends advised Mr. Cross to see a malpractice attorney, because so many treating doctors appeared to have missed the diagnosis. The attorney recommended that numerous doctors be named in the lawsuit. Drs. Blue and Adams, three physicians in the medical group and the two psychiatrists were all served. None of the ophthalmologists in the medical group who evaluated Mr. Cross over the past 5 years ever considered a diagnosis of Wilson's disease and no eye evaluation was noted through numerous records.

As expected, the attorneys for the insurance company representing the medical group searched for experts in optometry and psychiatry to spread the potential culpability among as many practitioners as possible. (If a patient is willing to settle for, let's say $1.4 million, the seven different insurance companies representing the seven different doctors each only have to shell out $200,000 a piece to meet the patient's demand.)

Standard of care for referrals

Neither Dr. Blue nor Dr. Adams recognized the unusual corneal observation as a Keyser-Fleischer ring initially. This alone doesn't constitute malpractice because most practitioners would similarly fail to recognize this rare and subtle observation as part of a life-threatening systemic disease.

The optometrist who used the term "crocodile shagreen" (Dr. Adams) had the wrong diagnosis but did attempt to refer the patient. Dr. Blue arrived at the correct diagnosis when he consulted the Will's Eye Manual the second time he examined Mr. Cross. Dr. Blue referred him back to his internist to confirm his suspicions but his astute diagnosis and attempt at referral never benefited the patient.

But what's the standard of care with regard to referral? Is informing the patient and faxing a report adequate when you uncover a finding related to a systemic disease with significant morbidity and even eventual mortality if left undiagnosed and untreated?

Little is written in the optometric literature concerning the appropriate standard. John Classe, O.D., J.D., in his book Legal Aspects of Optometry, suggests making the appoint-ment while the patient is in your office and setting up a system to make sure he keeps it.

Patient responsibility

In this case, the patient was told about the rings and the likely connection with Wilson's disease. He was also given the original referral form and knew that it was faxed to the internist. In his deposition, the patient claimed that he didn't think it was a serious problem because the optometrist's voice failed to convey a sense of urgency.

As Mr. Cross began to gain weight and develop psychiatric and neurological symptoms, he never mentioned the O.D.'s findings to any of the specialists he consulted. This fact supports the contention that Mr. Cross was at least partly to blame for the near-tragic outcome, although some will argue that because the condition had already begun causing psychiatric problems, Mr. Cross can't be held culpable.

Going beyond the standard

In retrospect, Dr. Blue should've called Mr. Cross's internist to directly relay his suspicion of Wilson's disease. Fax reports are easy to misplace or lose in a busy practice and even if a staff member puts the fax in the patient's chart, other documents could easily conceal it and the doctor could easily miss it. This case also points out that reliance on the patient to convey important information may not be justified.

Although it's arguable as to whether the optometrist met the existing standard of care, it's still always highly recommended in such a case to go beyond the standard and ensure that the right information gets into the right hands (or ears). Decrease the risk of malpractice litigations dramatically by taking the extra step.

NOTE: Numerous depositions have been taken and the case will be scheduled for trial in the future. Although this case study will be published before an outcome has been determined, two important points justify the early publication:

First, if you observe a corneal abnormality similar to the images seen in this article, confirm or rule out Wilson's disease.

Second, always consider going beyond the standard of care to prevent tragedies and to decrease malpractice allegations.

The names used in this article are fictitious to maintain the anonymity of the actual individuals.

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.

Dr. Roth is a 2002 graduate of SUNY College of Optometry.