malpractice management
Learn from these real-life cases how to protect yourself
Coordinated by J. James Thimons, O.D., F.A.A.O.

The Perils of Prescribing
Sometimes it behooves you to think twice before you prescribe something for a patient.
by Ken Roddy, O.D., F.A.A.O.

The following article is based on an actual malpractice case. The names have been omitted and the data changed so as not to release any protected health information. This is not intended to serve as or replace an attorney's legal advice.After hours, Dr. Helpful (not his real name) received a phone call from a patient who voiced a chief complaint of ocular redness and itching, which corresponded to the height of the allergy season for their area. The patient asked if the good doctor would call a prescription in to the pharmacy for the itching.

Dr. Helpful recalled that the patient had successfully worn daily wear soft contact lens for several years without any problems. He questioned the patient about the contact lenses and was convinced that the patient had been on a daily wear schedule, and had used a name brand multipurpose cleaning, rinsing and disinfecting solution correctly, and had been disposing of the lenses every two weeks, but discontinued lens wear one week ago because of itching. Dr. Helpful also obtained a thorough history of present illness including negative responses to pus, mucus, tearing, pain, photophobia, decreased vision or trauma. The patient's review of systems was significant for allergic rhinitis and over-the-counter (OTC) antihistamine use.

The plot thickens

Dr. Helpful considered the situation and decided to first examine the patient's eyes. But there was one small problem: The patient was a minor and had no transportation to the office because his parents weren't home. Dr. Helpful decided to help the patient out and called in a prescription for a mild steroid ophthalmic suspension. The patient agreed to call back if he experienced any symptoms of pain, light sensitivity or blurry vision. Later that day, one of the patient's parents picked up the prescription and gave the patient one drop in each eye before bedtime. The patient never called the doctor back.

The morning after

Dr. Helpful arrived at his office early the next morning and was surprised to find the patient and his parents were already waiting in the first exam room. The patient was in great distress with pain, photophobia and "blindness."

Examination determined that the patient's best corrected vision was hand motion in each eye. A thorough slit lamp examination revealed a central ulcer in the right eye and a paracentral ulcer in the left eye. Both eyes had an infiltrate that spanned over one half of the central cornea and the corneas were obviously thinned. Dr. Helpful also made one other curious discovery: Each eye had a soft contact lens adhered to the cornea. Further questioning revealed that the patient had been wearing his contact lenses for weeks without removing them and only disposed of the lenses "when they were ready."

Taking action

Dr. Helpful suspected bilateral Pseudomonas ulceration and immediately called a corneal specialist. The specialist saw the patient within the hour and agreed with the tentative diagnosis of bilateral Pseudomonas ulceration. He removed the contact lenses and sent them for cultures. The specialist scraped the corneas for smears and cultures, which later confirmed the diagnosis of Pseudomonas.

The corneal specialist prescribed fortified vancomycin hourly and fortified tobramycin hourly and over the next few weeks, the ulcers resolved, leaving the patient with a central leukoma in the right eye and a paracentral leukoma in the left. Both corneas were thinned with neovascularization. Best corrected acuities were decreased in the right eye greater than the left. The patient's parents sued the optometrist for malpractice, alleging a breach in the standard of care, as well as for negligence. There was an asking price of several hundred thousand dollars to settle the case pretrial.

Questioning the standard

Several interesting issues arise in this case. The first is whether the doctor breached the standard of care by prescribing without seeing the patient. Second is whether the doctor breached the standard of care by prescribing steroids. Lastly is whether the doctor's actions were a causative factor in the corneal ulceration and resultant vision loss.

Is it the standard of care to examine a patient's eyes before prescribing any medication? It seems the answer should be a straightforward, "Yes," the doctor should always examine a patient before prescribing. But is it an acceptable community standard to "call something in" for a patient's allergies? I suspect the answer to that question is also "Yes." How many times has a patient called each of us and asked us to call in allergy medications without first being seen?

Nevertheless, it's prudent advice to see a patient before prescribing any medication. In this case, the patient was a minor and had no one to drive him to the doctor's office. It would also not have been appropriate for the doctor to go to the minor's house and take him to the office after hours without a parent or guardian present. Therefore, in this case, it was impossible for our doctor to examine the patient.

What if?

This leads to the next issue: Should Dr. Helpful have prescribed anything -- especially steroids -- without first examining the patient? I think most doctors would agree that prescribing steroids over the phone isn't the standard of care. But in this case, if the doctor had prescribed a topical antihistamine or a mast cell stabilizer, would the outcome have been different?

What if Dr. Helpful had prescribed artificial tears? Could one drop of mild steroid penetrate a contact lens and suppress the immune system to the point that an infection would flourish? Would one drop of an antibiotic penetrate the contact lens sufficiently to eradicate all Pseudomonas organisms and prevent an infection? The answer to these questions is that, with reasonable medical certainty, the patient probably would have still presented with corneal ulcerations (although it would have sounded much better if Dr. Helpful had prescribed something other than a steroid).

Retracing steps

These types of questions are difficult to answer because no well-controlled human studies exist (for moral and ethical reasons) in which to determine how much damage organisms such as Pseudomonas can cause under various circumstances. Expert witnesses are therefore left to answer based on their own clinical experiences. In this case, the treating physician also agreed that Pseudomonas ulceration probably would have occurred regardless of what the optometrist prescribed.

Were the doctor's actions a causative factor in the ulceration and vision loss? A drop from a sterile bottle can't cause an infection. The causative factors were contact lens abuse and contamination, which were conceded by the plaintiff. Did the steroid drop cause vision loss? With a reasonable degree of medical certainty, the answer to this question is "No."

The steroid that the patient used was mild and instilled only once on top of a contact lens. Pseudomonas by itself can cause the type of destruction that was seen the following day, especially if it's a virulent strain. We can find evidence that the immune response wasn't suppressed in the extensive infiltrate present on day one. Another causative factor in the vision loss was the time lapse between the onset of symptoms and when the patient contacted Dr. Helpful. The plaintiff admitted that he and his parents didn't call the doctor a second time when symptoms of pain, photophobia and vision loss occurred.

Play it safe

Did Dr. Helpful breach the standard of care and commit malpractice? The best answer is that he did breach the standard of care by prescribing steroids without seeing the patient, but he's not guilty of malpractice because of the circumstances surrounding the Pseudomonas ulcers in this case.

The actual case was settled before trial and I unfortunately can't disclose the terms and amounts of the settlement. The take-home lesson is: Don't put yourself in the position of having to say you breached the standard of care, but that doing so didn't result in whatever complaint the plaintiff has against you.

Dr. Roddy is a 1986 graduate of the Oklahoma College of Optometry. He completed a post-graduate residency in ocular disease management in 1993 and has been in private practice in Tulsa, Oklahoma, with his wife Denise since then.

Dr. Thimons is a nationally and internationally acclaimed speaker and serves as medical director at Ophthalmic Consultants. He was awarded Optometry's Top Educator in 1999.