malpractice management
O.D. Flunks Optometry 101
See how skimping on the standard of care can come back to haunt you.

In most cases of optometric malpractice, both the attorney for the plaintiff and the defendant hire so-called experts who often express diametrically opposed expert opinions. On rare occasions, the defense has problems finding an expert to testify.

Such cases typically revolve around such an obvious failure on the part of the defendant to meet the standard of care that no expert can testify that he isn't culpable. The following real case exemplifies the importance of not forgetting the basics you learned in Optometry 101.

We're not talking about getting a question wrong on a test in optometry school -- here, a basic error in optometric practice results in irreversible, but preventable, blindness.

This is a fundus photo of a different patient who has an orbital tumor. Always consider choroidal folds because they're hard to detect even when present.

Meet the patient

A 33-year-old RN presents to an O.D. for the first time with a chief complaint of blurred vision in her right eye both without glasses and with a two-year-old prescription.

Her limited history reveals no other additional information. Uncorrected distance visual acuity (VA) was 20/80 OD and 20/25 OS. Uncorrected near VA was J5 OD and J1 OS. The subjective refraction revealed a -50D sphere error in the right yielding 20/25- VA and plano in the left eye yielding 20/20 VA. Of particular interest was a comment by the optometrist on the record for her right eye refraction: "Vision only to the left."

A funduscopic exam through a dilated pupil resulted in the single notation of .3 cup-to-disc ratios in each eye. Goldmann IOPs were 17 mm Hg OD and 18 mm Hg OS. There were no entries under other tests and under progress check, it read, "at patient request only."

The patient resurfaces

Two years later, the patient sees another optometrist for the first time and complains about decreased vision in her right eye for about 4 years and a pressure sensation in the same eye. Best corrected VA was 20/50 OD and 20/20 OS. However, a right, relative afferent pupillary defect (RAPD) of 4+ was observed as well as abnormal color vision and a grossly constricted visual field in her right eye.

Several days later, she underwent an MRI, which revealed a mass of the right sphenoid wing and optic nerve sheath -- most likely a slow-growing meningioma. Surgery was deemed essential but the visual outcome following surgery was light perception visual acuity OD and no depth perception.

What to do if it's you

Most experts opined that intervention two years earlier, more likely than not, would have resulted in a far better visual outcome. Hence, is the first optometrist culpable of malpractice? From a legal vantage point, if he failed to meet the standard of care and that failure led to blindness (the issue of causation), then the doctor is culpable.

Here's what to do if you encounter a similar case. First, seek an explanation for every patient who has less than 20/20 corrected VA. Without constant unilateral strabismus or significant anisometropia, you can't use lazy eye or amblyopia as the explanation.

With clear media and a normal dilated fundus exam, you must consider and assess optic nerve involvement. This evaluation includes pupillary reflexes, color vision and visual fields. Higher tech devices, such as contrast sensitivity, visual evoked potentials (VEPs) and objective nerve fiber layer measurements are helpful, but beyond the minimal standard of care. Although it is advisable to go beyond the standard, it was not essential in this case because the basic tests were adequate.

	CT scan of a different person who has an orbital mass. Note the resulting proptosis of the left globe, another finding suggestive of an orbital mass.

Reviewing the case

Equally as basic as the unexplained reduced VA is the near VA reduction to J5. If the patient was merely nearsighted in her right eye, then why was her near VA so reduced? Any first-year optometry student should know that a pre-presbyopic half of a diopter myope has normal uncorrected near VA. Also, a half diopter of myopia doesn't reduce VA to 20/80.

Another red flag that failed to lead to further testing was the notation of "vision only to the left" during the right eye subjective examination. Such a comment nearly always signifies a frank visual field defect close to fixation and requires investigating, not ignoring.

How it all panned out

During the doctor's deposition, a second version of the record surfaces, which was never seen by the doctor's attorney. This led to a shouting match between the attorneys about failing to make all of the records available to both sides. At this point, the deposition is abruptly ended by the doctor's attorney, only to be completed weeks later.

Under oath for the second time, the doctor argued that he didn't change his records, but only added several comments for clarification. He admitted that he added the comments two years after seeing the patient but claimed to remember the exam results (e.g., normal pupils, color vision and stereopsis).

Although the defense attorney was highly regarded and experienced, he had little to work with and had difficulty in finding a reputable expert to testify on his client's behalf. The case was eventually settled before trial for an undisclosed amount, but sources close to the case revealed the settlement to be considerably greater than $100,000 but considerably less than $1 million.

Remember the basics

The take home message is to cover your bases. As discussed in previous articles, first base is to ensure 20/20 best corrected VA and if not, investigate until you find an explanation. Although the doctor in this case did cover second and third base (tonometry and a fundus evaluation), he missed home plate by not providing visual fields. In addition to covering your bases, remember the fundamentals from Optometry 101: Myopes have good near VA! 

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