Risk Management

Pseudotumor Cerebri in Young Female

Ryan Bucsi, OMIC Senior Litigation Analyst

Case summary

A 23-year-old female presented to the emergency room with blurred vision and was advised to see the OMIC-insured ophthalmologist the following day for examination. She did not keep the appointment, but five days later called the insured’s office to complain of decreased vision and was advised to come in. On initial examination, the patient’s visual acuity was 20/125 OD and 20/50 OS. The pupils were reactive with trace evidence of an afferent papillary defect. A visual field test was not performed. The OMIC insured’s diagnosis was significant bilateral papilledema likely secondary to pseudotumor. Based on the patient’s size (4’11” and 150 pounds), the insured prescribed 1000 mg of Diamox to be taken daily. He also referred the patient to a neurologist for a lumbar puncture. Upon the advice of the neurologist, the patient did not start the Diamox until after the lumbar puncture. The ophthalmologist advised the patient that the pressure was 36 (normal <25) and instructed her to start the Diamox. Approximately three weeks later, the patient returned to the OMIC insured and his partner, another OMIC-insured ophthalmologist, for an examination. Visual acuity was count fingers OU. A positive finding of afferent papillary defect OD was again noted. A constricted visual field based on a confrontational field test revealed a significantly limited visual field OU. The patient was diagnosed with pseudotumor cerebri and Diamox was increased to 1500 mg daily. The OMIC insureds documented that if no improvement was seen in the next week, the patient would be referred to a neuro-ophthalmologist. The patient did not return to the OMIC insureds after this visit. She self-referred to another ophthalmologist, who referred her on to a neuro-ophthalmologist. The neuro-ophthalmologist suspected that the patient had asymptomatic but uncontrolled bilateral disc edema for much longer than six weeks and that for unclear reasons it went into an accelerated phase resulting in significant loss of vision. The patient underwent two bilateral optic nerve sheath fenestrations, but final visual acuity was hand motion at 1.5 feet OD and 6/200 OS.

Analysis

Plaintiff’s experts opined that both OMIC insureds failed to appropriately diagnose and manage the patient’s pseudotumor cerebri and violated the standard of care by failing to refer the patient to a neuro-ophthalmologist for evaluation of pseudotumor cerebri. Several experts were retained by OMIC to review this case and some common opinions emerged. First, all of the defense experts were concerned that a visual field test was not done during the patient’s initial examination by the insureds. They felt a visual field test was warranted in order to determine the degree of central vision loss. The patient could not see the left part of the visual acuity chart so the experts felt that the extent of the patient’s disease was quite evident during the initial examination. Most of the defense experts opined that upon initial presentation, the patient’s condition was an ophthalmic emergency and “cried out for an immediate referral” to a neuro-ophthalmologist. The two OMIC insureds themselves were not entirely confident in the care they provided to the patient and expressed concern that any neuro-ophthalmologist called to testify would be critical of their care and treatment. As a result of the opinions of our retained experts and the OMIC insureds, the case was settled at mediation on behalf of the two OMIC insureds and their insured corporation for $850,000.

Risk management principles

The insureds made the correct diagnosis in this case but, sadly, delayed aggressive treatment of the pseudotumor cerebri as they did not appreciate that it was an emergency situation. Not only did this patient have a high-risk condition, but her behavior in delaying follow-up treatment for five days after her ER visit made her a high-risk patient. Patients who risk serious vision loss and do not take their condition seriously should be referred early for subspecialist care. Early referral ensures that patients likely to delay care or not follow treatment recommendations receive the most advanced care from the start.