malpractice management: Learn from these real-life cases how to protect yourself
Undetected Maculopathy
See how going beyond the standard -- even by a little -- can save you frustration and grief.

A 29-year-old white female presented at her O.D.'s office with visual complaints that she associated only with "lots of computer work." She complained about computer glare in the office and about the lines on the computer screen "jumping." She also complained about her vision fluctuating and a possible vision decrease. She reported that her "health is good" and denied taking any medications.

Her unaided visual acuity (VA) was 20/60 OD and 20/40+ OS. A subjective refraction revealed -1.25 sphere OD with 20/20 VA and -1.00 sphere OS with 20/20 VA. Phorias behind a phoropter and near point tests including negative relative accommodation and positive relative accommodation were unremarkable.

Large choroidal neovascularization membrane in a different patient.

The initial diagnosis

An external exam included a normal slit lamp exam revealing 4+ anterior chamber depths and intraocular pressures of 10 mm Hg OU. A fundus exam through an undilated pupil revealed optic nerve heads that were labeled as pink and well defined OU as well as a good foveal reflex OU.

The doctor diagnosed "focusing spasms and accommodative in facility." He prescribed +0.50 and +0.75 spheres for near work and accommodative rock exercises for home. He documented recommending that the patient return in 1 month for a progress check, but she never did.

The real problem surfaces

Three months later, the patient's internist referred her to an ophthalmologist because of injected eyes. Uncorrected VA was 20/100 OD and 20/25 OS. The external exam revealed 2+ to 3+ conjunctival injection in both eyes. The M.D. observed no cells or flair deferred tonometry. He prescribed Ocuflox for the "severe conjunctivitis," along with warm compresses. He told the patient to return in a month or two for a full exam.

A week later, the patient called the M.D. and complained that she couldn't see with her right eye. He told her to come in at once. The exam revealed choroidal neovascularization in the right macula. A referral to a retinal specialist revealed best corrected VA of 20/80-2 OD and a neurosensory macular detachment with a crescent-shaped area of subretinal blood at the fovea and an area of presumed choroidal neovascularization (CNV) just extending infratemporal to that. Color fundus photography and fluorescein angio graphy confirmed the findings.

Weighing the pros and cons

The retinal specialist discussed the risks and benefits of the various treatment options. He didn't recommend laser because the lesion was subfoveal. He didn't recommend surgical removal of the lesion either, but he did mention a relatively new procedure, photodynamic therapy (PDT).

The patient's vision worsened to below 20/400 OD and an untreatable macular scar resulted. The patient sued the O.D. for failure to detect the macular lesion at a stage when her VA was still 20/20 and treatment would likely have prevented vision loss. She didn't sue the M.D. who treated her for the conjunctivitis.

	Disciform scar following CNV.

Establishing the standard

As the expert for the defense, I argued unsuccessfully that the O.D. met the standard of care regardless of whether he dilated. I noted that the patient's presenting symptoms weren't localized to one eye, that her VA was correctable to 20/20 OU and that the O.D. recorded findings of a normal posterior pole OU.

Anyone can argue that the view of the disc and macula in a 29-year-old is generally adequate without dilation. Plus the treatment plan included a re-evaluation in 1 month and if the patient had returned as instructed, it's probable that the O.D. would've been able to identify the macular lesion as it worsened. Furthermore, it's possible that the patient had no macular pathology when seen by the optometrist.

Idiopathic CNV is uncom-mon. If the patient had signs of presumed ocular histoplasmosis, traumatic choroidal rupture, angioid streaks, pathological myopia or macula drusen, then the O.D. should've considered CNV along with dilating the patient and using the Amsler grid, which also would've been clearly indicated. But this patient had 20/20 VA and no risk factors for CNV.

The precedent for dilation and use of a binocular indirect ophthalmoscope (BIO) [Keir vs. US] relates to a peripheral retinal mass that clearly would've been far simpler to detect through a dilated pupil and the use of a BIO. It's unclear whether this often-quoted precedent would apply in a case such as this.

Going beyond the standard

In most patients, the view through a dilated pupil is superior to that without dilation. If the macular lesion were present at the first visit, then a dilated fundus exam would have in-creased the probability that the O.D. would've detected it. Dilating patients routinely may go beyond the standard of care, but it does reduce the risk of malpractice allegations and results in improved patient care.

Automated visual fields, although not the standard in the routine exam of a 29 year old, occasionally reveals disorders that otherwise go undetected. An Amsler grid, although also not the standard in routine cases, could have led to the detection of metamorphopsia and hence the macular lesion in this case.

Central disciform scar with a progressing CNV membrane temporal to the scar along with hemorrhage.

Outcome

The attorney for the O.D.'s insurance company concluded that they could lose the case at trial and agreed on a settlement before the trial date for approximately $400,000. Although the settlement cost him nothing directly, the O.D. is now inquiring as to how to answer the question, "Have you ever been sued for malpractice?" on applications for insurance panels.

Think ahead

This is yet another case of how going beyond the standard of care is the best way to prevent malpractice litigations. If the O.D. in this case had performed a dilation and some form of central fields and found nothing unusual, the case against him would've been much weaker.

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