Risk Management

Orbital Fracture Missed During Eye Exam

By Mary Kasher, MSN, JD

OMIC Claims Manager

Digest, Winter 2002

ALLEGATION  Failure to diagnose orbital fracture in child, resulting in reduced range of motion and double vision.

DISPOSTION  Plaintiff verdict at trial.

Case Summary

A five-year-old boy was referred to the insured ophthalmologist by his pediatrician for a post-trauma eye exam. The child had been fighting with his brother and was pushed to the floor, rubbing his face on the carpet. Examination revealed normal VA in both eyes. The right eye was normal in appearance and movement; the left eye revealed a superficial abrasion to the corneal surface (2+ injection at inner aspect). Palpation elicited no complaints. Observing no restriction of movement, the insured decided not to perform a forced duction test. Antibiotic drops and a firm patch were applied to the left eye, and a follow-up visit was scheduled for the next day.

The following day, the child presented with increased pain and a “pinching” sensation. He would not allow an examination due to the pain. Suspecting a foreign body and wanting to examine the eye carefully, the insured performed an exam under anesthesia. No foreign body was discovered, but a notation was made that the corneal abrasion was healing. The patient continued to improve until five months later when the pediatrician again referred him to the insured because the left eye was not moving properly. The insured confirmed that the left eye did not elevate properly and referred the child to an oculoplastic specialist.

The specialist noted severely restricted movement OS and ordered a CT scan, which showed a fracture of the orbit. On exam, the upward gaze was almost nonexistent and downward gaze was moderately restricted. The eyeball itself was 2 mm depressed. Surgery to release the entrapped muscle was successful, and improvement in both double vision and movement was noted, although the child continued to experience slight double vision in upward and downward gaze. Neither the child nor his parents reported any problems or restrictions in his activities.

Analysis

The central issue in this case was whether the insured’s examination met the standard of care and whether the delay in diagnosing the orbital fracture affected the outcome. The plaintiff expert and three defense experts stated that with the presenting history and symptoms, they would have suspected an orbital fracture and conducted a forced duction test, either at the office visit or under anesthesia. They also felt it was substandard not to order a CT scan or schedule a follow-up visit after the hospital exam. OMIC was able to find one expert who agreed with the insured that the child did not present with characteristics of an orbital fracture because there were no signs of trauma around the eye and no restriction of movement. Also, the child’s persistent pain was more indicative of a corneal abrasion, which the insured diagnosed, than a fracture. This expert further felt it was not unreasonable that the insured did not perform a forced duction exam under anesthesia since his focus was to examine the cornea and retina. Unfortunately, this expert could not say that the delay in treatment had no effect on the final outcome.

Risk Management Principles

OMIC’s Claims Committee recommended a reasonable settlement to avoid what looked to be an almost certain plaintiff verdict; however, the insured insisted on going to trial because he believed his care was appropriate for the child’s presenting symptoms and that the final result was very good given the injury. Unfortunately, the jury did not agree and came back with a plaintiff verdict.

It is important to remember that when a case goes to trial it is not tried before a jury of the physician’s medical peers but before lay people who have little or no medical knowledge or experience. The jury did not appreciate that the child had an excellent overall result and that the measure of damages was very small, or that the insured’s care was reasonable at the time the child presented. The plaintiff attorney, who had the benefit of hindsight, was able to successfully argue that “if only the doctor had done a duction exam or a CT scan, the child would have better sight today.” It created a scenario in the minds of the jurors that was difficult to overcome.