Misdiagnosis of a Nevus by an Optometrist Insured with Another Carrier

By Ryan Bucsi, OMIC Senior Litigation Analyst

Digest, Summer 2010

ALLEGATION: Failure to diagnose choroidal melanoma resulting in patient’s death.

DISPOSITION: The case settled for $1.5 million with an arbitrator apportioning $500,000 of the settlement to an OMIC insured group.

Case Summary

A patient presented to an OMIC insured ophthalmology group for a routine eye examination. The patient was examined by an optometrist who was employed by the group but who maintained separate professional liability insurance with another carrier. During the examination, the optometrist identified a nevus on the patient’s right eye. A diagram of the nevus was drawn in the patient’s chart, and the optometrist instructed the patient to return in one year. The patient returned on an emergency basis about 11 months after the initial exam, complaining of an inability to see out of a portion of the right eye. During this visit, an ophthalmologist examined the patient, diagnosed a choroidal melanoma, and immediately referred the patient to a retinal specialist for a same-day consult. The retinal specialist confirmed the diagnosis and sent the patient to a local specialist for treatment. The melanoma measured 16 x 17 mm with a height of 7 mm. Despite treatment for the melanoma, the patient died approximately three and a half years following the initial examination by the optometrist.

Analysis

The optometrist testified during deposition that although the nevus was not suspicious, she had ordered a fundus photograph. The medical record contained neither a fundus photograph nor a record of a bill for a fundus photograph. Plaintiff experts opined that the optometrist failed to diagnose a suspicious nevus, failed to take a fundus photograph, and failed to advise the patient to return in three months. Plaintiff experts also opined that the group was negligent for failing to properly train and supervise the optometrist. Furthermore, plaintiff experts felt the group fell below the standard of care by not notifying the patient that she was being treated by an optometrist and not an ophthalmologist. There was no formal training program or written protocols at the OMIC insured group office. Physicians there stated that they were comfortable with the competence of the optometrist based on her five years of experience. The defense had trouble finding experts to support the care rendered by the optometrist and the group. In addition, the defendants could not establish a causation argument. Melanoma experts opined that the size of the tumor at the time of diagnosis indicated that it was likely present but missed on the initial exam by the optometrist. Without a fundus photograph, the defense could not argue to the contrary. A settlement of $1.5 million was reached, but OMIC and the other carrier could not agree on how the liability should be apportioned. A binding arbitration was scheduled; the only agreement going into arbitration was that neither carrier would be required to pay over its $1 million policy limit. The arbitrator ruled that the optometrist was 70% liable and OMIC’s insured group was 30% liable. Since 70% of $1.5 million exceeded the co- defendant’s policy limits, the other carrier paid $1 million and OMIC paid the remaining $500,000.

Risk Management Principles

Optometrists and ophthalmologists have different scopes of practice and competencies. While some eye conditions can be managed independently by optometrists, others require consultation with, or management by, an ophthalmologist. Eye conditions that can lead to severe vision loss, systemic disease, or death are best managed in consultation with an ophthalmologist. In this case, the role of the employed optometrist was not well defined by the OMIC insured group and there was no formal training, ongoing evaluation of her competency, or written protocols. The optometrist felt the nevus was non-suspicious so she did not consult with the ophthalmologist during her one and only examination of the patient. As this case demonstrates, communication between a group’s optometrists and ophthalmologists is, at times, critical in order to achieve optimal patient care. Risk management experts at OMIC recommend that the optometrist’s role be defined in writing in terms of what conditions he or she can manage independently, what conditions require consultation with an ophthalmologist, and what conditions require management by an ophthalmologist (see this issue’s Hotline column and “Coordinating Care with Optometrists,” available at www.omic.com, for a more detailed discussion and sample protocol).

Risk Management Issues in Failure to Diagnose Neurologic Illnesses

By Jean Hausheer Ellis, MD, FACS

Digest, Spring, 1994

 Although it occurs infrequently, failure to diagnose ophthalmic-related neurologic diseases exposes the practicing ophthalmologist to significant malpractice risk because neurologic diseases tend to be associated with permanent disability and even death.

A computer search of 3,000 ophthalmology claims in the Physician Insurers Association of America’s (PIAA) data base turned up only 15 closed claims alleging failure of an ophthalmologist to diagnose a neurologically related disease. These 15 claims showed the patients’ conditions to be distributed as follows: tumors of the pituitary gland or other endocrine tumors and surrounding nerves or tissue, 8 claims; tumors of the thyroid gland, 6 claims; tumors of the nerves or tissue surrounding the eye, 1 claim. (See box)

All 15 claims allege that the patient’s condition was not diagnosed during an eye examination. Seven of the 15 resulted in an indemnity payment to the plaintiff. The average indemnity paid in these cases ($221,071) exceeded the average settlement for all ophthalmology claims by more than $100,000.

Nearly one quarter (3 of 13) of OMIC’s large loss payments (payments of over $100,000 to the plaintiff) have resulted from claims related to failure to diagnose an ophthalmic-related neurologic illness. The following lawsuits, culled from OMIC’s closed claim files, are instructive from a risk management standpoint because they illustrate the various ways an ophthalmic-neurologic claim can arise in an ophthalmologist’s practice and the different factors that contribute to these types of malpractice claims.

Case One: Pituitary Chromophobe Adenoma

The first case involved a 50-year-old male, who held two jobs to support his wife and three children. He was referred to an ophthalmologist (Ophthalmologist ##1) after complaining to his family practice physician that he was having difficulty with his vision. Ophthalmologist ##1 found normal vision, but did formal visual fields because of suspected glaucomatous cupping. Although not definitive, the fields were interpreted as possible early glaucoma, and the patient was started on Beta-blocker glaucoma drops. He was followed up one more time, and found to have excellent IOP control with therapy. A year later, the patient left the care of Ophthalmologist ##1 and was referred elsewhere by his family practice physician.

The family practice physician referred the patient to Ophthalmologist ##2 who diagnosed bilateral pterygiae. Because of the previously diagnosed glaucoma, a screening visual field was obtained of the left eye, but the patient was unable to complete the right eye field that same day. There was no chart documentation of visual field interpretation by the ophthalmologist, or discussion of these findings with either the patient or the family practice physician. Previous visual fields were obtained from Ophthalmologist ##1 but no comparisons or record reviews were documented. Formal visual testing OU was repeated several months later by Ophthalmologist ##2, but again the chart reflected only the technician’s notes of the testing. The patient continued using the glaucoma drops, but did not keep all his follow-up appointments because of his work hours.

Six months later, the patient was seen in the emergency room for complaints of severe headaches, for which he was admitted and discharged the same day. These headaches were felt by the ER physician to be migrainous. The next morning, the patient was found unconscious at his home and was taken back to the hospital, where he died the next day from subarachnoid hemorrhage related to a large pituitary chromophobe adenoma.

Lawsuit Targets Two Ophthalmologists

A lawsuit filed by the patient’s wife and three children named the family practice physician, the emergency room physician and the two ophthalmologists. The ER physician settled out of the case and paid nothing based upon a strong causation defense that, by the time the patient came to the ER, it would have been too late to operate anyway since surgery or radiation therapy are only effective before the lesion hemorrhages. The family practice physician settled for approximately $100,000.

The main targets of the lawsuit were the ophthalmologists, primarily Ophthalmologist ##2. Ophthalmologist ##1 paid approximately $100,000 to settle the lawsuit. Ophthalmologist ##2 was felt to have greater exposure than ##1 because he had consecutive visual fields that showed the evolving bitemporal hemianopsia. Expert witnesses and consultants in the case described the visual fields taken as showing “classic” signs of a pituitary tumor. Ophthalmologist ##2 paid more than $750,000 to settle the lawsuit against him. Total settlement by all parties in this case was approximately $1 million.

Close review of the formal visual fields show combined arcuate glaucomatous changes and bitemporal hemianopsia, as typically seen with pituitary tumors. The past history of glaucoma may have contributed to the misinterpretation of the visual field changes which, when compared with previous bilateral fields, clearly showed the progression of the bitemporal hemianopsia. While Ophthalmologist ##2 testified that he reviewed the fields and compared them, there was no record or documentation to support his testimony. Nor was there any communication to either the patient or the family physician regarding test results or contemplated follow-up.

Another problem in this case related to the patient being lost to follow-up. No system existed in the ophthalmologist’s practice for tracking patients who missed appointments, such as a recall card, telephone call from a staff member, or other form of communication to the patient or the referring physician, to inform them of the need for return testing and examinations.

Case Two: Giant Cell Temporal Arteritis

The second case involved a 67-year-old female who presented with complaints of extreme fatigue, loss of appetite, nausea, febrile illness, nasal congestion and purulent rhinorrhea. She also complained of migraine-like headaches across the forehead, and bilaterally down her face. She was treated for a viral syndrome and briefly hospitalized by her internist, who noted only slight improvement of the symptoms upon discharge.

The headache, fatigue, loss of appetite and nasal congestion persisted for another month, which the internist attributed to a prolonged viral illness. After experiencing these symptoms for six weeks, the patient went to the emergency room where she was treated for sinusitis, and given instructions to see the internist for follow-up. The patient returned to the internist as instructed with complaints of nausea and vomiting, persistent headache and neck pain as well as shoulder and calf pain. She was admitted to the hospital by the internist the same day for an ENT consultation, which confirmed acute sinusitis. Sinus surgery was scheduled for the next day.

During her hospitalization, the patient complained to her nurse of blurred vision in her left eye and a loss of vision for 2 to 5 minutes on the left side, immediately following the sinus surgery. Neither the patient nor the nurse informed the doctors of the 2 to 5 minute loss of vision and the nursing notes reflected only the persistent complaints of blurred vision and headache throughout the patient’s stay.

A routine ophthalmology consultation was obtained the day after surgery for “blurred vision.” The ophthalmologist took the history of blurred vision in the left eye, and obtained the patient’s description of seeing a “tree” in her left field of vision. No one explained to the ophthalmologist that the patient had been hospitalized at a different facility a month earlier, or that an elevated sed rate measuring 72 had been drawn at that time. Vision was found to be 20/80 in each eye at bedside, with normal IOP OU, and dilated fundus examination showed mild bilateral macular edema, which the ophthalmologist attributed to the recent sinus surgery. He recommended follow-up in his office upon discharge four days later.

Once at home, on the day of discharge, the patient told her husband she could no longer see out of her right eye. They immediately called the ophthalmologist, who instructed them to come in. He correctly diagnosed temporal arteritis.

At first, the patient refused to travel to a neighboring academic facility in another city for treatment. She was immediately started on 80 mg of oral prednisone and photographs were taken to document the fundus findings. The next day, the patient finally agreed to go to the recommended academic facility. Upon arrival there, she was placed in the Trendelenburg position and started on a high dose of I.V. methylprednisolone in an effort to salvage vision. A temporal artery biopsy confirmed the suspected diagnosis of giant cell arteritis.

Treatment was of minimal effect and the patient remains legally blind with Count Fingers vision OU. Unfortunately, there was no communication back to the referring ophthalmologist by anyone at the academic facility, nor did the referring ophthalmologist follow up with the patient.

A lawsuit was filed, naming the ophthalmologist, the primary care physician and the hospital nurse. The nurse settled out of court for $50,000, with the internist mediating for a total of $250,000. The ophthalmologist settled for $100,000, for a total settlement of approximately $400,000.

The nurse in this case was an important party because she claimed she had never heard of temporal arteritis before. At the time, it did not particularly concern her that the patient complained of a temporary loss of vision and continued bilateral blurred vision.

The controversial clinical issue in this case was the elevated sed rate. Expert opinions noted that a slightly elevated sed rate perhaps one in the 20’s or 30’s could be expected in anyone recovering from influenza. It was felt that the patient’s original sed rate of 72 probably would have been found to be elevated to 115 by the time of her second hospital admission, had it been repeated. Elevated sed rates should be followed and repeated to evaluate their rise and fall, to clinically correlate their course and to evaluate their suspected cause.

A second point of contention in this case concerned the role of the consulting ophthalmologist, who was expected to evaluate the overall clinical picture as well as the specific reason for being called in to see the patient. In addition to evaluating an ophthalmologist’s specialty training in the diagnosis and treatment of diseases of the eye, juries will consider whether a defendant-ophthalmologist’s overall training as a physician (i.e., medical school and internship) was applied to treating and assessing the causes of the patient’s ophthalmic illness.

Risk Management Suggestions

Both cases raise several liability issues and point out steps an ophthalmologist can take to reduce liability exposure to these types of claims. These measures include:

• Have a system for reviewing incoming records and making notations in the chart. Consider reviewing incoming records in detail and outlining the crucial elements, making comparisons with your own records. Document that you did so in the patient record.
• Always record interpreted visual fields in the patient record. Consider calling the patient back with the test results, or send a quick note. Include follow-up and medication schedules. Send the results to the referring physician.
• Develop a system for follow-up of missed appointments, making sure that all “no shows” are brought to the physician’s attention. All follow-up efforts should be documented in the patient’s medical record.
• Set aside all patient charts from the day’s appointments for quick review at the end of each day. Flag charts that you want to take a closer look at or to discuss with your partner or colleague. This is a good time to review missed appointments and prescription refills for that day.
• When in doubt about a clinical finding, consider bringing the patient back for a “second look” when you are able to set aside time for an extended appointment to review the situation in greater depth.
• Establish and maintain good patient communication skills. If a problem does develop, keep in contact with the patient and referring physicians. Be as caring, concerned and compassionate s possible. Do not give false assurances or guarantees, but take the time to be a good listener.

Conclusion

As observed in the above cited cases, the ophthalmic neurologic claim can be fairly complex and difficult to anticipate, and can arise in a variety of settings and circumstances. These patients could have entered any practicing ophthalmologist’s care. Although, in retrospect it may be easy to identify the problem areas contributing to these claims, neuro-ophthalmic diagnosis and correct management often remains an enigma. Unfortunately, the consequences of delay are uniformly severe.

Headaches, Jaw Pain and Missed Thrills

By Sharon Kuritzky, MD

Digest, Winter 1998

Sudden loss of vision, headache and a painful temporal artery in an elderly patient – bells ring! Temporal arteritis? But first ask yourself, what has this patient been experiencing in the weeks leading up to this crisis? She hasn’t felt like herself; she has headaches; she has lost weight; she thinks her dentures need repair since her jaws hurt; and she calls her ophthalmologist’s office for an appointment because, “My vision is funny. I see double sometimes and it gets blurry.”

At this point, consider the following risk scenarios:

Scenario 1: A scheduling clerk thinks this is a “routine exam” and gives the patient an appointment three weeks from the time of the call.

Scenario 2: The busy ophthalmologist doesn’t find much on exam except cataracts and forgets to ask about jaw claudication and weight loss. His technician notes “headaches” in the patient’s chart.

Scenario 3: The ophthalmologist thinks about the possibility of temporal arteritis and suggests that the patient see an internist. The ophthalmologist dictates a note that is typed and mailed early the following week to an internist who is on vacation.

Scenario 4: The ophthalmologist sees the patient as part of a contracted “vision care” exam and suspects temporal arteritis, but the ophthalmologist is not a participant in the patient’s HMO. He tells the patient that her condition is serious and that it is urgent that she contact her primary care physician. The ophthalmologist does no further follow-up.

All of the above scenarios represent missed opportunities for what should be one of the most thrilling events in the practice of ophthalmology: the chance to prevent blindness. And while the giant cell arteritis begins its visual damage, the stage is being set for liability damages for missing or delaying the diagnosis of temporal arteritis before irreversible visual loss occurs. Temporal arteritis claims are costly and difficult to defend; fortunately, they are rare. Less than 1% of all OMIC claims have involved temporal arteritis. Four of these claims were closed without payment. The remaining two involved allegations of delayed treatment resulting in bilateral blindness and failure to diagnose resulting in blindness in one eye. They were settled on behalf of the insured ophthalmologists for indemnities in excess of $100,000.

Nothing Routine About TA

Of the four scenarios mentioned above, the first is the easiest to correct. Everyone answering the phone in a medical office must be trained to recognize the difference between an emergency, an urgent visit and a routine appointment. Since scheduling staff usually already know the urgency of such complaints as vision loss, eye pain and new onset of floaters, it is a simple matter to add patients over the age of 60 complaining of recent headaches to the list of those who should be seen promptly and brought to the attention of the ophthalmologist.

Never Too Busy to Ask

Alertness to subtle complaints and a high index of suspicion on the part of the examining ophthalmologist addresses the problem in the second scenario. A thoughtful, “How have you been?” followed by a brief review of the patient’s general health system by system, including direct questions about headache, jaw ache and weight loss, is imperative for elderly patients with intermittent or vague visual symptoms. Other symptoms to look out for include fever, scalp tenderness, malaise, morning stiffness and muscle pain. Most patients will not recognize a connection between these symptoms and headache or vision problems and will be unlikely to mention them to an ophthalmologist unless specifically asked.

Suspicious Minds Work Fast

Once there is a suspicion of temporal arteritis, a rapid response and preliminary workup is indicated. The ophthalmologist must use clinical judgment to grade her or his level of suspicion. Direct contact by phone, if possible, should be made with the patient’s primary care physician and documented in the chart. An erythrocyte sedimentation rate (ESR) and C-reactive protein should be ordered and drawn on the day of the exam, with copies of results requested for the primary care physician. These two tests, when elevated, along with the symptoms of jaw claudication and neck pain have been shown to have the highest level of correlation with positive temporal artery biopsies (Hayreh et al, AJO, March 1997).

Patients graded as “extremely likely” should be started on corticosteroid treatment immediately after the blood is drawn and a temporal artery biopsy scheduled. Others can wait for treatment and biopsy until after the results of the lab work, but they should be told to call immediately if there is any change in vision.

The physician should document these instructions in the patient’s chart. Patients with normal ESR and C-reactive protein and few symptoms (excluding jaw claudication) can be followed by observation. Patients with elevated ESR and C-reactive protein require temporal artery biopsy, as do patients with a strong clinical picture and normal ESR and C-reactive protein. It is appropriate to refer patients to a primary care physician, rheumatologist or neuro-ophthalmologist to coordinate the workup and treatment as long as this can be done promptly.

Break Through the Gatekeeper

Anecdotal reports abound of delays in evaluation of patients by gatekeeper model HMOs. This could be a major problem in the fourth scenario. Simply advising the patient to contact the primary care physician probably would not be found to be adequate medical care by a jury reviewing the matter. By examining the patient under the “vision care” directive, the ophthalmologist has established a physician-patient relationship and most likely will be held responsible for that patient regardless of any contract. Direct contact must be made with the patient’s primary care physician and documented in the patient’s chart. Contact OMIC’s Risk Management Department for a copy of its managed care referral form for patients (see next page). One copy of this form should be kept in the patient’s chart and another copy faxed to the primary care physician. Finally, a follow-up call should be made to the primary care physician requesting results of the blood work and biopsy, if indicated.

The above guidelines do not apply to patients who present with visual loss in one eye from suspected temporal arteritis. This is a bona fide emergency requiring hospitalization and immediate treatment with high dose corticosteroids. In such cases, it is recommended that the general ophthalmologist obtain consultation and general medical support. Confirmation of a diagnosis of temporal arteritis before the patient loses vision is a tribute to the physician’s diagnostic acumen, supremely beneficial to the patient and a relief to the professional liability insurance company.

6 Things an Ophthalmologist Should Know About Malpractice Insurance

Did you know that you will pay nearly half a million dollars in malpractice insurance premiums over the course of your career? Here are some tips when evaluating your insurance policy that could save you tens of thousands of dollars and take full advantage of current and potential benefits you may not have realized are already available to you.

Reward yourself, not others.

Do not underestimate the dividend advantage. While publicly-traded insurance companies are pressured to meet shareholder expectations and to produce consistent quarterly profits for those shareholders, physician-owned carriers tend to operate in service solely for its policyholders, since those policyholders are usually also the “owners” of the company. The return of profits (above which are needed to prudently operate the company) to policyholders through dividend distributions or credits may translate into tens of thousands of dollars over the course of your career. Clearly everything should be considered in concert with everything else, in other words your net base rate must be sufficiently competitive over the long-term (look at a rate history of at least 10-15 years to account for both favorable and unfavorable insurance cycles) for the dividend “advantage” to be a key factor.

Avoid these like the plague.

Be wary of policies that are “assessable.” Under these policies the insurance company charges an initial premium, with the stipulation that it retains the right to charge you additional premiums, even years in the future, if their losses for that particular policy year exceeded the premiums originally collected. Insurance “trusts” are often subject to assessment. Also carefully weigh the requirements associated with “claims-paid” policies, where the policy is not triggered until the claim is paid, as opposed to when the claim was reported to the carrier. These policies may be more restrictive and not allow for switching to a new carrier while a claim is active, which could last for several years.

Be encouraged, not irritated, if your carrier asks a lot of questions.

Ophthalmologists or their administrators sometimes lament “long” insurance application forms, however it is important to remember that insurance is a shared pool of risk assumed by your carrier and the premium you pay is directly related to the collective claims experience of the carrier’s policyholders. In other words, if a carrier has weak underwriting standards that result in higher average payouts, this must be accounted for in higher rates or lower dividends. Applaud a carrier’s conservatism and competency when evaluating risk, as you will ultimately benefit through cumulative savings.

Don’t settle for the sticker price.

Research the ways you can lower your premium. Carriers often give discounts for risk management activities, loss experience, group or network associations, and practice characteristics such as hours per week, types of procedures performed, and length of time in practice. Make sure you’re getting all available discounts to reduce your net premium. Surprisingly, many policyholders never take advantage of the opportunity to reduce premiums by participating in risk management activities even though the time required (usually about an hour) and the credit earned (usually $500 – $2000) is probably a more monetarily “rewarding” event than a typical patient encounter. Education that enhances risk reduction also may be long-term “investment” as poor claim history requiring you to enter a higher cost “non-standard” insurance market could be particularly costly going forward.

Don’t overcompensate.

Don’t automatically assume that higher liability limits are always the best option for your practice. When it comes to insurance this may simply distinguish you as a bigger target. A good rule of thumb is to prepare for the average not the outlier, and choose adequate but not excessive liability limits. There are several ways to determine appropriate liability limits. First, ask your carrier if they can identify the level of coverage maintained by the majority of ophthalmologists in your area. Second, look for required minimum limits in any contracts with hospitals or outpatient facilities, health plans or networks, and even lease or employment agreements. Third, ask your carrier about the frequency of high settlements or verdicts and likelihood of a claim exceeding average limits. Answers to these questions should give you a general sense regarding reasonably adequate limits for your area and specialty.

Be multifunctional.

Don’t ignore the value of “added” benefits in your policy. Risk management resources not only help lessen your (and your carrier’s) risk for claims and suits but also provide you an opportunity to distribute “ready-made” employee training materials. Look for sample forms, documents, or guidelines that will help your staff work more independently. Often claims are triggered by experiences your patients have with ancillary staff when you are not around. Make sure they know how to handle difficult situations that present in the office. Risk prevention hotlines or consultative services are particularly valuable. Added protection for your medical entities, ancillary staff, or regulatory exposures such as billing errors, privacy violations, premises contracts or licensure, or security breaches could fill coverage gaps and supplement or eliminate the need for other policies.

Noncompliance Puts Patient and Physician at Risk in Glaucoma Cases

Digest, Summer, 1994

Allegation

Plaintiff alleged that insured ophthalmologist negligently performed unnecessary peripheral iridectomy, resulting in decreased visual acuity in plaintiff’s left eye.

Disposition

Prelitigation screening panel concluded the claim was without merit. Plaintiff did not pursue the case in civil court.

Background

Several states now use prelitigation screening panels to review the merits of a medical malpractice claim before the case can be pursued in civil court. Often these panels include a physician who specializes in the area of medicine involved in the claim. This type of review process can be extremely beneficial to defendant ophthalmologists who can support their treatment choices with sound medical reasoning. If the review panel renders an opinion favorable to the defendant and the plaintiff chooses to continue to pursue the case in court, the favorable panel decision is admissible evidence when permitted by state law. This creates an additional obstacle for the plaintiff to overcome in proving his or her case and can induce the plaintiff to drop the claim short of litigation.

Case Summary

A 60-year-old female presented to the insured and reported symptoms of headache, eyeache, nausea, vomiting, and blurred and foggy vision three days previously. The insured examined the patient and concluded she had experienced an episode of acute angle closure glaucoma which had spontaneously resolved. The insured ophthalmologist recommended laser peripheral iridectomies OU to avoid another acute episode, as well as a course of treatment for chronic glaucoma. The patient left the insured’s office indicating she would consider the procedure.

Unbeknownst to the insured, the patient sought a second opinion from another ophthalmologist who did not believe the iridectomies were necessary but who advised the patient to be followed for chronic glaucoma. Despite a documented telephone call to the patient and a letter from the insured ophthalmologist urging her to have regular examinations to follow her glaucoma, the patient did not consult another eye professional until two years later. She then returned to the insured for an examination because she felt she needed new glasses. She reported no additional episodes of acute angle closure. The insured reiterated his recommendations for prophylactic surgery and this time the patient agreed.

An iridectomy OD was performed without complications and with good results. After the peripheral iridectomy OS, the patient’s eyes burned, the iris was dilated, and her VA decreased from 20/25 to 20/50. During postoperative visits, the insured noted elevated pressure, vitreous condensation, adherence of the iris to the cornea OS, and increased disc cupping. After two postoperative visits, the patient never returned and subsequently sought eye care from optometrists. Dissatisfied with her decrease in visual acuity OS, the patient filed a written complaint with the Board of Medical Examiners. This complaint prompted a review by the prelitigation screening panel in her state.

Outcome

The litigation screening panel agreed that surgery was an option in 1988 when the insured first recommended it. However, in the absence of intervening problems, the ophthalmologist on the panel did not believe surgery was clearly warranted based on clinical findings alone when the patient returned two years later. In the end, it was the patient’s demonstrated noncompliance in “disappearing” for two years which convinced the panelists that the insured’s treatment plan was justified nonetheless. Documentation by the insured and subsequent treaters specifically indicated that the patient was noncompliant in keeping appointments and taking medications. This documentation laid a firm foundation for the defense’s arguments that it was probably the patient’s own negligence which caused her reduced visual acuity.

Risk Management Principlesand Commentary

The treatment of glaucoma requires vigilance on the part of both the ophthalmologist and the patient. Noncompliant glaucoma patients can jeopardize their own vision and put physicians at risk for litigation. As their condition inevitably worsens, such patients often look for someone else to blame. When it comes to defending a claim, documentation of the patient’s noncompliance and of the physician’s attempts to encourage compliance with medical advice can be as important as documentation of the patient’s clinical progress.