Risk Management

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.