Presentation
In February 2012, a 77-year-old woman came to a new ophthalmology group and was seen by Ophthalmologist A.
The patient’s history included a trabeculectomy in August 2003; a left-eye cataract surgery with insertion of a lens implant in December 2007; a left-eye YAG laser capsulotomy in July 2011. She also had a history of open angle glaucoma, chronic open angle glaucoma, cataract, and posterior capsule opacification.
Physician action
During her first visit with Ophthalmologist A, the patient’s intraocular eye pressures (IOP) were 17 mm Hg in the right and 16 mm Hg in the left. Normal range is 12 to 22 mm Hg.
On March 20, Ophthalmologist A performed a phacoemulsification cataract extraction with intraocular lens implanted in the right eye. The patient returned the next day and was seen by Optometrist A, who handled care for Ophthalmologist A’s post-surgical patients.
The patient reported a mild, dull pain, and reported that she was seeing through a milky film. The patient confirmed that she was on moxifloxacin, nepafenac, and difluprednate drops, and stated that she had not applied the drops before coming to the office that day. She also confirmed that she was taking timolol in both eyes at night.
The patient’s visual acuity was 20/50 +2 with an IOP of 31 mm Hg in both eyes. A slit lamp exam indicated trace inflammation. Optometrist A’s impression was history of chronic open angle glaucoma and IOPs slightly elevated. He told the patient to return in one week.
The patient’s follow-up appointment was scheduled for April 2, 11 days after her appointment with Optometrist A. The patient — who was seen by Optometrist B — reported that she was “not happy with the condition of right eye” and was experiencing “poor quality vision.” Her visual acuity was 20/60 and her IOP in the right eye was 40 mm Hg. Optometrist B referred her to Ophthalmologist A, who saw the patient that day.
When seen by Optometrist B, the patient’s IOP was measured multiple times, once showing 35 to 36 mm Hg and a second time at 32 mm Hg. Ophthalmologist A prescribed brimonidine three times daily and increased the timolol to twice daily.
The patient returned two days later and reported no improvement in her vision. Her IOP was 33 mm Hg. Ophthalmologist A prescribed acetazolamide and dorzolamide/ timolol, and told the patient to discontinue the difluprednate and timolol.
Ophthalmologist A saw the patient three more times in April and May. The patient’s IOPs remained in the upper teens, and she continued to report hazy vision in the right eye.
On July 1, the patient was referred to a glaucoma specialist, who performed a laser trabeculoplasty and a YAG laser capsulotomy. The patient never returned to Ophthalmologist A, but subsequent testing with another ophthalmologist showed the patient’s right eye had only a central island of remaining vision.
Allegations
The patient filed a lawsuit against Ophthalmologist A, Optometrist A, and their group. The patient claimed that she suffered permanent peripheral vision loss because Ophthalmologist A’s staff failed to schedule her eye exam within seven days, as directed by Optometrist A. This delay allowed her IOPs to remain elevated and caused her vision loss.
Legal implications
Consultants and experts who reviewed this case — both for the plaintiffs and for the defendants — stated that because the patient’s IOP was 31 mm Hg at the visit on March 20, she should have been seen again within 24 to 48 hours. This would have allowed Optometrist A to make sure the patient’s pressures were monitored and controlled. Although it was expected that she would experience an increase in IOP postoperatively, 11 days without monitoring was too long.
Optometrist A, Ophthalmologist A, and an expert reviewing the case for the defense agreed that the plan for follow up within seven days was reasonable. Optometrist A testified that he wrote a note stating that he wanted to see the patient in seven days, but that he did not know why staff did not schedule the appointment within that time. Open appointments were available, but there were no records and no one could recall why the appointment was not scheduled within seven days.
The patient testified that she was never told about her elevated IOPs. She further stated that if she had known that she needed to be seen within seven days, she would have made sure she was seen.
Disposition
Given the issues related to the appointment scheduling, the case against the ophthalmology group was settled. The case against Ophthalmologist A and Optometrist A was dropped.
Risk management considerations
The lack of attention to detail and accuracy in scheduling the follow-up appointments was the most apparent issue in this case. Every practice needs a protocol for prioritizing appointments to assure continuity of care. When patient care protocols are in place, staff members may be asked to read, sign, and date them to indicate their understanding and acknowledgement of the practice’s policies.
Another risk management issue identified in this case involved lack of communication with the patient regarding timely follow up. It is recommended that patients be told about their conditions, along with the reason for follow-up appointments. Enlisting patients as partners in their own care can help avoid allegations of failure to follow up.
Document patient communication in the record, including changes to the treatment plan, participants in the discussion, issues discussed, decisions, and referrals made. Include the date, location, and time.
