Risk Management Issues in Glaucoma Diagnosis and Treatment

By E. Randy Craven, MD

Digest, Summer, 1994
Glaucoma-related claims and lawsuits arise relatively infrequently. When they do, however, they are more likely to result in indemnity payments, and those payments are likely to be substantially larger than they are for other types of ophthalmic claims.

Using data collected by the Physician Insurers Association of America (PIAA), whose member companies collectively insure more than 100,000 physicians nationwide, this article will explore the nature of glaucoma-related claims and offer guidelines to avoid or minimize the risks associated with these claims. PIAA has collected data on more than 109,000 medical claims and lawsuits in all specialties since January 1, 1985, making its database the most detailed and comprehensive source of medical malpractice loss data currently available.

By comparison, there are only seven claims arising from treatment of glaucoma patients in OMIC’s claims database. While glaucoma cases represent only 1.5% of all OMIC claims, they account for 6% of the ophthalmic claims in PIAA’s database and 7.8% of the 700 medicolegal cases in ophthalmology reviewed by Jerome W. Bettman, Sr., M.D. (Ophthalmology 1990;97:1379-84). The small percentage of OMIC glaucoma claims is probably a reflection of OMIC’s limited claims experience over a relatively short period of time. Therefore, for purposes of analyzing frequency and severity of glaucoma-related claims, the PIAA database is a more comprehensive and reliable source of statistical information.

Claims Frequency and Severity

Figure I compares claims frequency (number) and severity (indemnity payments) of all medical claims in the PIAA database as of December 31, 1993, with all ophthalmology-related claims, all cataract claims, and all glaucoma claims. As Figure I indicates, half of all glaucoma-related claims result in an indemnity payment, and these payments are almost 20% higher than the average ophthalmology indemnity payment. As the chart also shows, although cataract patients file a third of all claims against ophthalmologists, these claims usually settle without an indemnity payment or with a relatively low payment. To date, OMIC has not paid an indemnity to a claimant or plaintiff in any of its glaucoma-related claims. OMIC’s indemnity rate for all types of claims is 24%.

Analysis of Glaucoma-Related Misadventures

At OMIC’s request, PIAA analyzed 194 claims with a diagnosis of glaucoma to determine the nature of allegations (“medical misadventures” alleged) and, if present, associated issues (e.g., informed consent) which prompted or complicated these claims. OMIC also requested that surgical procedures be sorted from medical procedures to ascertain if one area held greater risk.

Figure II lists the types and percentages of “medical misadventures” (a principal departure from accepted practice) alleged in glaucoma claims. Four types of misadventures account for the majority of allegations: diagnostic error (21.7%), improper performance of care (19.1%), medication error (9.8%), and failure to supervise or monitor the case (8.2%).

The most frequent and second most expensive misadventure is a diagnostic error. The most expensive is failure to refer.

Patients and juries take serious issue to vision loss. When claims arise related to diagnostic errors or failure to refer, it may be difficult to explain to a jury how this frequent cause of blindness was not recognized or suspected by the defendant ophthalmologist. Experts will tell the jury that loss of vision from glaucoma may be prevented through early diagnosis and therapy. It is easy, therefore, for the plaintiff’s attorney to show the relation between the breach of duty (diagnostic error) and the cause of damages (blindness or vision loss).

With glaucoma, claims arising from medical treatment outnumber surgery-related claims by more than 50%, and they are more likely to result in an indemnity payment (54% vs. 44%). The average indemnity paid, however, is about the same for medical and surgical procedures, $142,000. (See Figure III.)

Associated Issues in Glaucoma Claims

A major finding in this review was that claims of abandonment by glaucoma patients result in sizeable indemnity payments. Although abandonment was alleged in only slightly more than 1% of all cases, it accounted for the largest average indemnity payment among claims with an associated issue. It is especially important not to let glaucoma patients “slip through the cracks” and out of the practice. If a “glaucoma suspect” becomes noncompliant, difficult to treat or follow, misses appointments, or does not take prescribed medications, the ophthalmologist may be exposed later to claims of abandonment. This risk may be reduced by proper documentation of the missed visits. A jury will want to know what steps were taken to deal with the patient’s noncompliance. Careful documentation in these cases can make the difference between paying nothing and paying half a million dollars.

Detection of glaucoma entails a complete eye examination, including measurement of intraocular pressures, gonioscopy, evaluation of the optic nerve, and visual field testing. Results of these examinations should be recorded in the patient’s chart each time they are performed. Glaucoma suspects should be flagged for more frequent examinations to monitor for changes and informed of the factors that put them at risk for developing glaucoma. They should be told that failure to comply with treatment can result in vision loss. If educational brochures are offered to glaucoma patients, it should be documented in the chart that they received them.

Standardize Record Keeping

The following suggestions may help standardize glaucoma record keeping and management once a patient is diagnosed. First, as previously mentioned, it is important to have a standard way of initially evaluating the patient to establish adequate baseline information. After a complete eye exam, the thought process should shift to the type and stage of the glaucoma.

Once the diagnosis is established, it is necessary to monitor the patient’s progress. This can be done with sequential evaluations of previous office records, but an abbreviated sheet with the glaucoma-pertinent information is also reasonable. In my practice we use a one-page “flow chart” to indicate the date, medications, vision, IOP, gonioscopic findings, optic nerve configuration, and static visual field statistical parameters for each visit. Ten or more visits can be recorded on a single sheet, making it easy to detect changes. (A copy of this flow chart may be obtained by contacting OMIC’s risk management department). The remainder of the examination is documented on the standard SOAP progress record.

Sort Visual Fields Separately for Each Eye

Visual fields should be sorted separately for the right and left eye in reverse chronological order. This allows for a quick comparison of the two eyes, checking for a neurologic defect as well as a progression in an individual eye. A system for documenting the optic nerve shape is necessary to initially stage the level of the glaucoma and to check for progression of the disease.

The type of equipment used for following glaucoma is an important consideration. Mostglaucoma specialists use static perimetry for their initial evaluation and for following the course of the disease. Goldmann perimetry can be helpful for advanced cases. Most ophthalmologists use an estimate of the optic nerve head anatomy based on a drawing or ratio estimate. Some ophthalmologists use photographs to help follow up on cup progression. Newer computerized nerve head analyzers may be helpful but have not yet been accepted as a modality for detecting changes in the nerve.

Establish Treatment Goals

Establishing initial and subsequent treatment goals can be difficult in glaucoma cases. Experience is invaluable in estimating a treatment intraocular pressure goal. If progression occurs, the treatment goal should be reevaluated. If surgery is an option, the patient mustclearly understand the purpose of the surgery and the outcome that can reasonably be expected. Many patients undergo surgery expecting it to improve their vision; this may not be the case with glaucoma surgery.

Physician-patient rapport requires keeping the patient apprised of the stage of the disease, its course to date, and what can be expected in the future. This type of dialogue with the patient helps reduce an ophthalmologist’s risk since a key trigger in lawsuits is the surprised patient who feels betrayed because he or she finds out more might have been done. Obviously, some cases will progress despite treatment, and this possibility needs to be reinforced with glaucoma patients and carefully documented in their chart.

they are prescribed so the patient will be able to recognize potential problems before they become serious. Patient information sheets on the side effects of specific anti-glaucoma medications are available from the American Academy of Ophthalmology and the American Medical Association.

Risk Management Suggestions

In summary, the data collected by all doctor-owned insurance carriers show that glaucoma-related claims result in an indemnity payment more than 50% of the time. By adhering to the following risk management guidelines, ophthalmologists may avoid becoming another casualty of this statistic:

Begin with a complete diagnostic eye exam.
Develop a system for glaucoma record keeping and management. Keys to this system include using up-to-date equipment and following a standard method for initially and subsequently evaluating glaucoma patients.
Once a patient is diagnosed with glaucoma, establish a specific goal for treatment and use accepted parameters to follow the course of the disease.
Keep glaucoma patients apprised of the progress of their disease. Inform them of the risks and benefits of their treatment, including drug side effects, and document that you did so.