Risk Management

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.