***Please see attached photos of eyes from birth to surgery.***
Pregnancy:
• Mother is 26 years old
• 4 prenatal visits
• 1st pregnancy
• Upon hospital arrival for preterm labor, mother tested positive for amphetamines, cannabinoids, and opiates
• Premature rupture of membranes at approximately 31 weeks gestation
• Mother does not have a hx of glaucoma, entire family history somewhat unknown due to mother being adopted.
Baby:
• Vaginal birth, overall normal besides premature
• Birth weight: 1681 grams
• Birth Length: 42cm
• Birth Head Circumference: 26cm
• Apgar at 1min: 4
• Apgar at 5min: 7
• Infant with heart rate below 100 but over 60 an PPV provided with maximum O2 requirement of 100%. Infant improved heart rate and CPAP provided but developed bradycardia and PPC resumed with improvement. Infant then weaned back to CPAP and remained stable, so FiO2 gradually weaned to 30%. Infant then placed on RAM cannula.
• Eval at birth: eyes open and appear normal, infant meets criteria for screening retinal examination. First examination should occur at about 28-42 days.
• Hyponatremia, jaundice, anemia, RDS – all resolved upon discharge
• Baby off CPAP at day of life 5
• Cranial ultrasound at 1 week old: grade 1 hemorrhage at left caudothalamic groove
• Cranial ultrasound at 25 days old: small grade 1 IVH, no hydrocephalus
• Daily reports state, “Does not meet criteria for eye exam” and pupillary reaction is “normal”.
• Discharged on day of life 33
After coming home:
• New baby wellness exam within 1 week of discharge. No examination of eyes.
• Approx. 2-3 weeks after this exam, an NP mentioned something wrong with the baby’s eyes.
• Baby sees multiple specialists and is dx immediately with severe glaucoma and bilateral detached retinas.
• Put immediately on eye drops for glaucoma, which does help lower the pressure
• Exploratory surgery to attempt retinal reattachment occurs when baby is around 4 months old.
• Retinas are beyond repair and baby is fully blind.
Files:
Q: Need to know year of birth and gestational age.
A: 2021, 31 weeks gestation
Q: Can you provide the gestational age for this baby at birth?
A: 31 weeks
Do you believe there might have been medical error?
The AAP Guidelines for examination for ROP call for examination in infants below 1500 grams or 30 weeks. This infant MIGHT qualify as he was 31 weeks and received oxygen for a period of time of more than a few days. Not clear when this case occurred, but curious why 100% oxygen was used in resuscitation. The guidelines also allow for the opinion of the neonatologist regarding the need for exam. This infant does not appear to have been on oxygen for more than a few days based on the summary, so the opinion of the discharging physician appears reasonable. On follow up at 1 week, the pediatrician likely assessed red reflex. Obviously the NP at subsequent exam had concerns. Sad outcome, but seems within standard of care. The ROP exam is for examining the retina, not to determine whether there is glaucoma.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As above. The AAP ROP Guidelines make recommendations for which neonates should be examined by an ophthalmologist.
What makes you a good expert for this case?
I am a board certified neonatologist with over 39 years experience in tertiary level NICUs.
How often do you encounter cases similar to this one in your practice?
Currently Emeitus Neonatologist. Our NICU which cared for infants of all gestational aged and birth weights had a fairly low incidence of ROP.
Do you believe there might have been medical error?
Part of a normal newborn exam is to check for red reflexes in the eyes In congenital glaucoma it is absent
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Early diagnosis would have led to earlier treatment
What makes you a good expert for this case?
I am a neonatologist with >40 years of experience I have a lot of experience in providing expert testimony
How often do you encounter cases similar to this one in your practice?
This ia a rare condition but all pediatricians a trained to check for red reflexes every time they examine a baby so the condition should have been picked up early
Do you believe there might have been medical error?
According to the American Academy of Ophthalmology https://www.aao.org/education/clinical-statement/screening-examination-of-premature-infants-retinop ROP exam is indicated for preterm infants < 1500g birth weight or GA < 30 weeks. Since this infant is 31 weeks and has a birth weight > 1500, it does not automatically qualify for routine eye screening. Since the oxygen exposure is < 5 days, there is no increased risk for ROP. However, a routine eye pressure exam is not part of a neonatology exam. However, general exams including red reflexes are part of the exam. If there is no documentation of red reflexes and an eye exam, then there is a possibility of medical error,
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The possibility of congenital primary glaucoma, association with congenital infection, etc needs to rule out. H/o cloudy cornea, absent red reflex on exam may give a clue in the early stages
What makes you a good expert for this case?
Practicing neonatology in major academic center LEVEL 4 NICU for more than 10 years
How often do you encounter cases similar to this one in your practice?
very very rare, probably once in a decade
Do you believe there might have been medical error?
It is hard to interpret the eye photos but may be better appreciated by a pediatric ophthalmologist.. If the gestational age was less than 31 weeks then a screening eye exam was indicated prior to discharge from the NICU. If this exam was done the diagnosis would have been established prior to discharge with necessary surgery and preservation of sight.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Answer depends on if there were cloudy corneas, enlarged corneas, or abnormal tearing while the newborn was present in the NICU.. Not sure of associated anomalies but primary congenital glaucoma can be associated with other syndromes whereby genetic sequencing may be diagnostic..
What makes you a good expert for this case?
40 years of neonatal experience. Standard of care expert for proper discharge screening. if infant was born < 31 weeks gestation. A necessary expert would be a pediatric ophthalmologist
How often do you encounter cases similar to this one in your practice?
Very rare condition. I have seen only a few cases in my career.
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Comments from similar speciality or otherwise pertinent to the case may also be accepted.