MALPRACTICE QUIZ

Challenging the Truisms on Quality of Care

Jerome S. Sherman, O.D.

A 7-year-old white female was evaluated by a pediatric ophthalmologist for a routine exam; both parents were myopic. Unaided visual acuity was 20/20 O.U. and the refractive error was +0.75 spheres O.U. The cover test was orthophoria at distance and near. The fundus exam was normal, with 0.2 cup-to-disc ratios O.U. Like her father, the girl had mild blepharitis, which was not treated.

Two years later the patient presented with a chief complaint of itching. VA was still 20/20 O.U. with no change in refractive error. The cup-to-disc ratio was 0.3 O.U. The doctor diagnosed blepharitis again and prescribed Blephamide (sulfacetamide sodium-prednisolone) eye drops and Naphcon-A (pheniramine) drops.
Three years later the girl presented with itching and red eyes. The refractive error was -0.25 O.U. with acuity slightly subjectively clearer with the minus. VA was 20/20 O.U. Tobradex (tobramycin-dexamethasone) was prescribed Q.I.D. O.U. for the chronic blepharitis. Two years later, V.A.was still 20/20- without glasses but subjectively better with -0.50 O.U. Tobradex QID O.U. was again pre- scribed. The patient declined to wear glasses and so they were not prescribed. An exam a year later revealed no change.

About four months later the patient presented to an O.D at a commercial optical shop. Acuity was correctable to 20/20 with -1.50 spheres and the doctor suggested contact lenses. Noting large cup-to-disc ratios and pressures of 33mm Hg O.U., he suggested discontinuing the Tobradex and treating the newly diagnosed steroid-induced glaucoma. He referred the girl to a general ophthalmologist and a glaucoma specialist.

Fields revealed moderate glaucomatous-type field loss with arcuate scotomas and nasal steps, greater in the right eye than the left. The glaucoma proved difficult to treat with eye drops. Within 10 months, surgical trabeculectomies were performed. The patient now wears contact lenses, has 20/20 visual acuity and pressures are below 20 O.U., but a moderate and permanent field loss is present. The pediatric ophthalmologist was sued for failure to warn of the risks of steroid drops and failure to perform tonometry.

Discussion
I believe the ophthalmologist would be culpable of malpractice. He never obtained routine IOP measurements, which is the standard of care. He prescribed steroids without obtaining a baseline IOP and renewed them for five years without a single IOP measurement.

The quality of care rendered is not predictable from the doctor’s degree, subspecialty, reputation, office location or number of visits. Here, the O.D in an optical shop did the appropriate tests and arrived at the correct diagnosis on the first visit, while the ophthalmologist missed it over five years.
The case is pending.

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