Malpractice Management
The Trouble with Floaters
A dissatisfied patient initiates litigation over the care he receives for multiple complaints.

One of the most common issues that causes patients to seek legal action is when there is an apparent or real lack of communication and the patient develops the impression that his eyecare practitioner isn't listening to him. Equally important is how the practitioner conveys his diagnostic findings and therapeutic recommendations to the patient and also how he documents these.

Studies have shown that the way a clinician speaks to a patient and the tone of voice he uses is actually a major contributor (five times likelihood of malpractice) to the patient's eventual decision to initiate legal action against the clinician.

The following case illustrates how communication -- in both directions -- plays a role in optometric malpractice and what you can do to protect yourself from this and other potential problems.

Getting the facts

A.C. was a 52-year-old white male who presented for a general ocular exam at an office where he'd been evaluated in the past. (It had been several years since his last exam at this office and in the interim, he'd seen another doctor because of a change in his insurance coverage.)

His current prescription was two years old and the contact lenses he currently wore were from his last examination.

Revealing current findings

The practitioner recorded A.C.'s chief complaint as redness OD greater than OS associated with blur at distance. A.C. also indicated a longstanding history of "floaters" for which he'd recently seen someone. Additionally, he related a general decline in the comfort of his contact lenses over the last 12 to 18 months. His general health history was noncontributory. Family ocular history was negative.

The physical examination demonstrated visual acuity (VA) of 20/40- OD and 20/25. A.C. was moderately myopic in each eye. External examination revealed equal pupil size and reactivity with no evidence of an afferent defect. Extra-ocular movements were full and smooth, but A.C. claimed an awareness of a white "flash" only in extreme left gaze. Confrontations were unremarkable.

Slit lamp examination revealed mild injection of the conjunctiva with some chemosis. The corneas had punctate staining (OD greater than OS), with a single infiltrate at 10 o'clock OD. A.C.'s manifest refraction was 20/30+ with a change in prescription. OS showed no change from the last examination. A.C. didn't have his contact lenses with him for evaluation. Tensions were 16 mmHg OD and 17 mmHg OS. A 90D examination of the posterior pole showed normal cup-to-disc (c/d) ratios OU with normal macular appearance and vascular distribution.

In that A.C.'s primary complaint was related to his external disease presentation and the associated blur, the practitioner prescribed a topical antibiotic to manage the corneal and conjunctival involvement and gave the patient a copy of his new spectacle prescription. The practitioner requested that the patient return for a dilated exam in the future.

A.C. returns

Several weeks later, A.C. returned to the office complaining of further reduction in VA and an increase in "floaters." He also indicated his dissatisfaction with the treatment he received at the last visit. Another practitioner saw him at this visit and noted A.C. to have VA of 20/400 OD, pinhole no change and 20/25 OS. External exam was unchanged other than that the redness had cleared and the corneal activity had abated. Dilated exam revealed a superior temporal detachment that extended through the macula without evidence of a rhegmatogenous component at the time.

When A.C. learned of the findings of this visit, he was upset and insisted that his original visit was for the floaters and that the red eye wasn't a significant factor at that visit. A vitreo-retinal specialist was contacted while he was at the office and recommended that he see the patient on the following Monday because the detachment was through the macula.

Learning valuable lessons

The specialist saw A.C. on Monday and surgically treated him with a scleral buckling procedure that was successful in re-establishing retinal anatomy but left him with 20/400 acuity and a complaint of distortion and rivalry between the eyes that couldn't be suppressed. This resulted in the initiation of legal action against the practitioner A.C. saw upon first returning to this practice for care.

While on the surface this case seems relatively straightforward, a number of underlying subtle issues make it complex and teach us valuable lessons about clinical practice and patient interaction:

► An important aspect of the case is the initial practitioner's decision to treat the presenting complaint and to address the "incidental" issues at a future exam. It's certainly within the accepted standards of care to approach the case such as A.C.'s in this fashion. The concept of addressing the "chief complaint" is an integral part of medicine and a fundamental element in optometric education. In this particular case, the practitioner appropriately addressed the external disease concerns with antibiotic therapy and decided to schedule the remainder of the exam in the future.

► The issue, which this case pivots around, is that of dilation. How often is it required and what symptoms precipitate the need for an immediate evaluation? Was it reasonable for the managing practitioner to defer the dilation in this case? While it's clear that the standard of care is for the practitioner to dilate the patient at some point in the assessment, what guideline can we use for the minimally symptomatic patient?

The American Optometric Association and American Academy of Optometry preferred practice guidelines both indicate that practitioners see the healthy patient at least once every two years and recommend (not require) dilation. Again, in A.C.'s case, the practitioner decided to defer dilation and treat the primary complaint. Given the duration of the complaint of floaters and the flash in extreme periphery, the corneal involvement to explain vision and the general lack of concern on the part of the patient for this aspect of the encounter, it was within reasonable practice to schedule the patient back for a comprehensive evaluation in the future.

► What occurs when the patient and the practitioner's version of the examination differ and the patient initiates litigation? The medical record is always the clinician's best friend when it comes to documenting patient encounter. It's especially important in triage situations where acute intervention is required to establish the chief complaint. Prioritize and manage additional considerations at a more appropriate time. The practitioner in this case kept well-documented records, which played a pivotal role in supporting his position.

► Is it possible that at the time of initial evaluation A.C. had only a chronic vitreous detachment with atypical persistent flashes? Yes!

While it's typically the case that a patient who has a prolonged history of vitreo-retinal symptoms isn't likely to progress, it's also critical to understand that the patient does need a dilated exam.

The selection of the time frame for when to perform this procedure is the domain of the practitioner, who should decide after taking into consideration such factors as the patient's age, family history, refractive status, duration of symptoms, etc. The key is to document the reason for deferring the dilation and specifically scheduling the event in the future.

A change of heart

The key elements in this case were that the initial practitioner provided appropriate care given the presenting signs and symptoms and his records documented the interaction with the patient, leaving nothing to interpretation.

The case didn't make it to court and resolved without episode. Interestingly, while in the care of the retinal specialist several months after the original detachment and after all practitioners scrupulously examined both eyes on several occasions, A.C. experienced a spontaneous detachment OS in between visits with the surgeon. 

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.