Malpractice Management
Beyond Malpractice
Sometimes the consequences of not going above the standard are worse than malpractice.
BY JERRY SHERMAN, O.D, F.A.A.O.

Many optometrists tell me that their biggest fear is missing something during an examination and consequently having a patient sue them. Optometrists who have been sued and who have gone through the long process of discovery, depositions and trial can certainly attest to the magnitude of the nightmare.

So ask yourselves this question: Is there anything worse than missing a life-threatening disease and living through the protracted legal process? As I learned fortuitously, I believe the answer is yes. I'll explain.

Sharing in confidence

About one year ago I was in Las Vegas presenting several lectures at Vision Expo West. After presenting a two-hour lecture entitled "Retinal Rounds," an optometrist approached the podium, waiting patiently for others to ask their questions. After the room had cleared out, she shared a case with me alone that I will never forget.

She thanked me for the lecture and admitted to learning from it. Then this optometrist told me about her father who, at the time, was receiving treatment for colorectal cancer that had metastasized to several other organs. His prognosis was extremely poor.

Her dad had been her patient for more than a decade. She described his care as rather mundane: routine eye exams and reading glasses. His visual acuity was always correctable to 20/20 and his intraocular pressures (IOPs) were normal as were the rest of the exams. However, several scattered small dark spots in the mid periphery of each fundus were present. The optometrist thought the pigment spots were just scattered pigment with no clinical significance.

Registering the facts

During my lecture, I covered the differential diagnosis of dark lesions in the fundus and showed fundus images from patients of mine over the years who I'd diagnosed with malignant melano-ma, nevi, congenital hypertrophy of the retinal pigment epithelium (CHRPE) and various infections and inflammations such as retinochoroidal scars caused by toxoplasmosis. When covering CHRPE in my lecture, I mentioned the rare association of CHRPE with colorectal cancer or Gardner's syndrome (colonic polyps and other dental and dermatological lesions associated with familial adenomatous polyposis [FAP]).

During my lecture, this optometrist realized for the first time that the spots in her dying father's fundus, which she had observed and dismissed as unimportant for more than a decade, could've led to a timely systemic workup including colonoscopy and perhaps an early diagnosis and effective treatment before metastasis.

Clinically speaking

At least one recently identified genetic mutation causes FAP. Clinical screenings combined with molecular screenings appears to be a feasible approach to following families that have members with this disorder.

The typical CHRPE or "bear track" lesions, as shown in the OPTOS image (see figure) of another one of my patients without colorectal cancer, rarely change. However, a small number of these lesions can spawn a nodular growth that slowly enlarges and can result in an exudative retinopathy.

Why take the chance?

The important, take-home message here is that patients who have lesions similar to the CHRPE lesions in the image, do have a small risk of colorectal cancer. The more numerous the lesions, both eye involvement and the more irregular the borders, the higher the likelihood. If the patient has a family history of colorectal cancer, then the suggested standard of care is to refer him to a gastroenterologist for colonoscopy.

Regarding this optometrist's situation, her father isn't filing charges against his daughter, but her guilt surely surpasses anything that she could have ever imagined happening to her as an optometrist. If you encounter any patient who has numerous CHRPE lesions, especially in both eyes with irregular borders, even if he doesn't have a family history of colorectal cancer, go the extra mile to rule out this life-threatening disorder.

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.