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Questioning the Standard of Care
The results of this case may prompt you to re-evaluate your follow-up care protocol.
BY JERRY SHERMAN, O.D, F.A.A.O.

It's rare for a malpractice case that's settled before trial to affect the existing standard of care. But this case of a "routine" choroidal nevus may do just that: Create a new standard. Read on and envision yourself as the unfortunate optometrist who provided care to a 43-year-old man presenting for a routine exam.

Serving Sam

Sam, a typical, early myopic presbyope who had a wife and three children, presented for the first time to a female optometrist who worked in a large ophthalmologic practice. He wanted new glasses because he had scratched his old pair. He had no significant symptoms or eye and health history.

As a myope of 30 years, Sam had numerous eye exams, all of which were routine, but he presented this time to a new practice without any previous information, save for the prescription from his scratched lenses.

Examining the patient

Sam's best corrected visual acuity (BCVA) was 20/20 OU at distance and near. His new prescription essentially matched his old one. The external exam was unremarkable and Goldmann pressures were in the mid-teens.

The fundus exam, through a dilated pupil, was essentially within normal limits. However, the optometrist observed a small dark lesion OD. She drew and labeled a one-disc diameter choroidal nevus, which she drew one-disc diameter temporal to the fovea OD. Sam obtained his new glasses and returned one year later as instructed.

Re-evaluating Sam

Although his vision was nearly 20/20 in both eyes, a dilated fundus exam this time revealed a large, light-colored mass beginning slightly temporal to the fovea OD and extending to the far temporal periphery.

The retinal specialist in the practice made a diagnosis of choroidal melanoma and referred Sam to a prestigious eyecare teaching center in a major metropolitan area. The consulting ophthalmic oncologist agreed with the diagnosis. He fully evaluated Sam systemically and noted no other lesions. The consulting doctor recommended proton beam irradiation and later performed the procedure without incident.

On careful follow up by Sam's general oncologist, select liver enzymes worsened and scans of the liver and other abdominal structures were obtained. The oncologist found a small lesion in his liver, which he hadn't seen before. The results from a liver biopsy came back normal, but worsening liver enzymes led to other liver scans and then to a second biopsy. Predictably, this biopsy revealed melanoma cells.

Sam underwent various experimental treatments for the melanoma metastasis. He even traveled to the National Institute of Health in the Washington area for the latest and most promising therapy. Within several years of his diagnosis of a small choroidal nevus, Sam died.

	An OPTOS image through an undilated pupil of a choroidal nevus temporal to the macula OD of a different patient. A small, unrelated lesion even further temporally is pigment hyperplasia. Choroidal nevi, found in at least five percent of the general population, are easily identified with the OPTOS.

Missing documentation

The female doctor and her facility were sued by his surviving wife and children for incorrect diagnosis and improper follow up.

During her deposition, the doctor claimed to have taken fundus photos of the nevus, although the record and billing submission didn't support this claim. The retinal specialist in the practice testified that he never saw any earlier fundus photos and he opined that the O.D. never took the photos.

The issue of the alleged photos became crucial in that the photos could have supported the diagnosis of a small choroidal nevus (or at least the appearance of a small choroidal nevus) or could have proven that a much larger lesion was initially present but was misdiagnosed by the optometrist.

With the help of an experienced plaintiff's malpractice attorney, both parties reached a settlement before a jury trial. The settlement was unofficially reported at close to $2 million.

Rethinking the standard

Although most educators tell you to photograph choroidal nevi and have the patient return in about one year for reassessment, perhaps this case supports the need for much more careful follow up. One of the expert witnesses argued during his deposition that a doctor should immediately document the first time he discovers a small choroidal nevus and re-evaluate the patient in three months. If the doctor doesn't note any change at the three-month follow up, then he should have the patient return in six months. No change over the first three visits then warrants yearly exams.

Of course larger lesions deserve other diagnostic procedures such as B-scan ultrasonography and fluorescein angiography. If still in doubt, obtain a consult from an ophthalmic oncologist.

Go the extra mile

Although the female doctor in this case appeared to meet the existing standard of care, the patient died and litigation against her was successful. As mentioned in previous columns, going beyond the standard is often your best protection from litigation. But will this case result in a new standard?

Dr. Sherman practices at the Eye Institute and Laser Center in Manhattan and is a distinguished teaching professor at the SUNY College of Optometry. To protect the anonymity of the individuals involved in this case, we have not used their real names.