Page 53 - 21st Century Perspective - Glaucoma Supplement

How Inattentiveness Led to Litigation

One of us (RT) just completed defending a medical malpractice case against one of our colleagues.
The following describes how the lack of clinical attentiveness set the stage for this lawsuit:

A 44-year-old man presented for his first-ever eye examination with incipient presbyopia complaints.
During the encounter, the technician was attempting tonometry, and the patient was slightly
uncooperative. Nonetheless, the technician was able to obtain pressure readings of 23 mm Hg for
the right eye and 18 mm Hg for the left eye. The patient’s examination was fully unremarkable, and
he was easily correctable to 20/20 in each eye at both distance and near with +1.25 readers. The
comprehensive dilated examination was charted to be entirely normal with a C/D ratio of 0.2 in both
eyes. The doctor considered rechecking IOP, but because the technician reported the patient was

somewhat apprehensive and uncooperative, the doctor chose not to repeat tonometry, especially
considering the patient was relatively young with healthy-appearing optic nerves. With such IOP
asymmetry, it would have been wise to at least note in the chart, “no evidence of pigment dispersion
syndrome or pseudoexfoliation syndrome; the patient gives no history of ocular trauma,” as these
are common causes for asymmetric IOPs. However, none of these negative findings were charted.

At the time of this patient’s initial examination, he was unaware that his mother had glaucoma; this
was discovered a couple of years later. In cases in which there is any suspicion for glaucoma at all,
always encourage the glaucoma suspect patient to discuss his or her status with family members
and ask about any relative ocular histories.

Two terrible oversights occurred in the above case:

1. In the electronic health record, the only problems charted were “refractive error/presbyopia,”
and “return in 1 year for an annual examination”; there was no mention whatsoever of the
patient being a glaucoma suspect.

2. The patient was not rescheduled to return in 2 or 3 months for a recheck of the IOPs and to
perform pachymetry, or any other diagnostic testing that might have been deemed
appropriate.

Unfortunately for all, the patient was a “no-show” for his annual exam, despite timely telephone
outreach by the office staff. In retrospect, the patient’s failure to return for his annual visit was the

only positive event that dampened the impact of the ultimate settlement.

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