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Cover your bases to avoid malpractice
Some basic testing can avoid missed diagnoses and potential litigation.
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As a so-called expert witness, my analysis of more than 400 cases over the past 4.5 decades reveals that most cases could have been avoided if the malpractice merely covered the bases.
First base
Best corrected visual acuity (BCVA) should be 20/20 in each eye in every patient, and if it is not, the clinician must search for the explanation of the reduced acuity.
If the patient’s BCVA is reduced in one eye, especially in a youngster with a normal-appearing fundus, it is tempting to attribute this reduction in vision to amblyopia, a functional etiology of monocular vision loss. This is an important rule: Do not diagnose amblyopia without an amblyogenic factor, most frequently constant unilateral strabismus or significant anisometropia. It is recommended that the clinician consider amblyopia to be a diagnosis of exclusion. If the media (cornea, lens, vitreous) are clear, and the macula and optic disc appear intact, then optic nerve and visual pathway involvement must be considered.
An appropriate test to perform to rule out optic nerve and visual pathway disease is a visual field test. Normal confrontation visual fields give the doctor and patient a false sense of security. Normal confrontation visual fields were recorded in 10 cases of blindness and even death. Therefore, the clinician should perform an automated visual field test. Even on a youngster, today’s testing algorithms are quite fast, and a threshold-related visual field can be obtained in as little as 2 to 2.5 minutes. Remember to obtain a visual field in each eye, as a field loss in the good eye may be due to a lesion at the chiasm or beyond.
Second base
This base covers IOP. While one might think that checking IOPs is something eye care providers always do, this is not necessarily the case. There are a number of malpractice allegations against ECPs for the failure to detect glaucoma because they did not measure IOPs in a timely manner.
The ECP should measure and document IOPs for all patients, regardless of age. This includes patients who present with symptoms that appear to be unrelated to high IOPs. Children, especially those with BCVA not correctable to 20/20, also deserve tonometry.
Third base
Performing a fundus exam, especially through a dilated pupil, or a dilated fundus exam (DFE) is a crucial part of the comprehensive eye examination, arguably even in an asymptomatic patient. A DFE with binocular indirect ophthalmoscopy (BIO) should also be performed, even if the patient is complaining of what appears to be symptoms associated with an anterior segment disorder.
A red, irritated eye in a diabetic patient can be a sign of neovascular glaucoma from proliferative diabetic retinopathy. If the fundus is not carefully checked because the symptoms appear to originate from the front of the eye, a potential cause of blindness (and malpractice allegation) may be missed.
Home plate
To cover this base, a visual field examination should be performed, preferably an automated visual field, as mentioned previously. Granted, some clinicians are adept at performing gross confrontations – some even use small red match tips instead of large gross targets, like fingers, but most clinicians do not develop this skill. I have not and have missed a large field loss in two patients who minutes later demonstrated giant retinal detachments with DFE and BIO.
In addition, the printed page of results from an automated visual field test contains the patient’s name, date of the test and indication of the findings, providing invaluable evidence if malpractice allegations ever result.
Hitting a home run
To further prevent malpractice allegation, the clinician must “seal the deal” with appropriate communication. One can do the best examination and detect disease, but without the final connection with the patient, via communication and ascertaining that the patient understands, the path is left open for malpractice. Communication is crucial between doctor and patient and to the clinician who is receiving the referral.
If an abnormality that is detected during an examination requires a referral to either another eye doctor or to another health professional, the patient needs to understand why the referral is being made, and this must be documented.
The importance of the follow-up must also be stressed, as some malpractice allegations have resulted from patients who felt that the doctor “told me to see another doctor, but I didn’t get the impression that it was too urgent.” In one case, the optometrist arrived at a serious and correct diagnosis and faxed an interdisciplinary referral form to the internist, but the fax was discovered buried in the patient’s record and was never discovered until a year later.
This is akin to hitting a triple, but in baseball, you cannot win until someone crosses home plate.
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Jerome Sherman, OD, FAAO, is a Distinguished Teaching Professor at the SUNY College of Optometry, in private practice at Omni Eye Surgery in New York and a member of the Primary Care Optometry News Editorial Board. He can be reached at: j.sherman@sunyopt.edu.
Disclosure: Sherman reports no relevant financial disclosures.