On May 10, 2024, 57 year old patient presents to ophthalmologist with complaints of cloudy visual acuity in the left eye with black lines and spots that move around for two to three months. He had no known ocular history or procedures. He reported a medical history of high blood pressure and arthritis. No known head or ocular trauma.
Left eye exam was 20/25 uncorrected vision. Anterior segment exam documented to show normal tearfilm; clear conjuctiva; clear cornea; the anterior chamber was noted to be deep and quiet with no inflammation; the iris was round and symmetrical, no XFM and the lens was 1+ NS.
The fundus exam after dilation was documented to show no disc heme; vitrious was PFD; macula was flat with normal foveal contour and no edema. Vessels and periphery were normal. The MD's noted impression was "age related nuclear cataract of both eyes and bilateral PVD. He further documented that the "Patient was asymptomatic at this time. Will continue to monitor". RD precautions were noted to have been discussed. Patient was instructed to return in 12 months.
On May 23, 2024 (13 days later), patient presents to different ophthalmologist with complaints of vision loss in the left eye that began three days prior. Patient stated that his vision in left eye was a black bubble with 99 percent black with a little light. The retinal exam revealed macula off and retinal detachment. The assessment was retinal detachment with retinal break. He was provided an immediate referral to a retina specialist.
Patient was seen the following day, May 24, by the retinal specialist. MD confirmed there to be retinal detachment with single break and macula involvement. More specifically, he noted retinal tear (10:30) and retinal detachment (9:00-2:30) The patient was also noted to have developed a sub-acute hemorrhagic PVD about one month prior with a retinal tear and macula involved RD. MD discussed option of PR/Cryo vs PPV, EL and GAS. He also discussed guarded visual prognosis with patient due to central macular involvement of the retinal detachment. Patient proceeded with PR/CRYO.
At patient's June 7, 2024 visit, MD noted the macula to be attached with residual SRF in the superonasal and superior periphery on exam. No new tears or breaks were seen. Laser barricade was performed to prevent residual SRF from progressing and encroaching into the macula.
The last visit in our records is on August 16, 2024. Patient complained of blurred vision. His vision was wavy in the left eye and was described as "looking through a peephole backwards". Patient also stated that he had to keep his eye closed due to being disoriented.
MD noted that macula remained attached with no progression of peripheral SRF past laser scarring. There were no new holes or detachments despite VA subjectively decreasing. MD explained to patient that he may continue to see distortion going forward due to initial macular involvement. Patient's vision has not changed to date.
Questions:
1. Did the first MD more likely than not breach the standard of care by missing retinal abnormality on exam given the patient's reported findings?
2. Were their treatment options to patient as of May 10, 2024 that more likely than not would have prevented his blindness/distortion in his left eye visual acuity that he now experiences?
Files:
No questions yet!
Do you believe there might have been medical error?
The patient may or may not have had a retinal detachment at the time of his first exam. Typically, patients with retinal detachment report that a portion of their vision is missing, but there is no record of that symptom in this case. More likely is that the patient had a posterior vitreous detachment (PVD) at the time of the initial exam but did not yet have a retinal detachment. Since there was likely no retinal detachment at the time, there is no medical error in missing any diagnosis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Unless there was a retinal tear or retinal detachment that went undetected at the time of the initial exam, then there is no causation. There is not enough evidence in the description above to meet the "more likely than not" burden.
What makes you a good expert for this case?
I am a surgical retina specialist and treat retinal detachment every week in the clinic and operating room.
How often do you encounter cases similar to this one in your practice?
Delayed presentation of retinal detachment is common, even after initially presenting to a doctor with symptoms of a posterior vitreous detachment. I see cases like this one several times a year.
Do you believe there might have been medical error?
I believe the first MD should have had a little closer follow up for the patient following his initial exam. The "cloudy vision with black spots" complaint is very normal. It sounds like a normal exam, aside from mild cataract and PVD. Since the symptoms were present for three months, I think the follow up on one year would be considered, ok, but not ideal. Since the A/P indicated the patient was symptomatic, the patients symptoms must not have been too severe. However, any time we have unilateral symptoms, without good findings that explain the symptoms, a sooner follow up may be warranted. RD warnings were discussed, and since patient presented with macula off RD, he must have not paid attention to the symptoms worsening.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
RD symptoms were discussed, exam was normal, aside from PVD, with good vision. It is possible he missed a retinal tear, but hard to say without finding of blood in vitreous. These types of patients come into the clinic all the time. findings do not fit the symptoms. Perhaps an earlier return visit would have caught the tear/detachment. I personally would have had patient come back in one month, but then also would have missed the RD.
What makes you a good expert for this case?
General ophthalmologist for 24 years, busy practice, seeing 50-100 patients per day. These symptoms are very common, and aside from an earlier f/u (which would have missed the RD as well), I would have done the same thing.
How often do you encounter cases similar to this one in your practice?
Blurred vision with floaters are a daily occurrence. Very rarely do they turn into an RD.
Do you believe there might have been medical error?
The first examination showed an asymptomatic pvd. The back of the eye was examined in no breams or tears were noted. There was no mention of a vitreous hemorrhage. The second examination showed that there was a retinal detachment. sometimes following a posterior of vit detachment a break in the retina may form leading to a detachment. The second examination summary states that there was a hemorrhagic posterior vitreous detachment previously. But the summary of the first records do not state that. There's no way to tell that there was Hemorrhage prior if no Hemorrhage was not documented initially.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It does not appear there was any delay in diagnosis. The diagnosis was made promptly and treatment was given promptly.
What makes you a good expert for this case?
I am a physician and retinal specialist and surgeon at the number one eye institute academic program in the United States and an associate professor in retina performing about 400 retinal procedures for year
How often do you encounter cases similar to this one in your practice?
Al I deal with this type of a diagnosis and condition routinely in my practice.
Do you believe there might have been medical error?
Possible mistake but missed tears and new tears can very likely also be the defense. The surgical procedure offered were appropriate. I feel strongly that you can not prove negligence since both physicians acted within the standard of care . I find no basis for a malpractice lawsuit
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Above Too tough to prove! I woukd not pursue
What makes you a good expert for this case?
I have been doing it most of my life . I even work for and against my own malpractice carrier
How often do you encounter cases similar to this one in your practice?
Every day Missed breaks are very common plus possibility that a new break developed
Do you believe there might have been medical error?
The patient may not have had a tear on examination with the first PVD. There is not a 100% correlation between symptoms of PVD and a tear. That said, it sounds as if there might have been reason to believe the tear was old based on the “subacute hemorrhage” on the second examination. For me to say the tear occurred and then was missed with the first PVD symptoms I would need more information for it to be based upon a reasonable degree of medical certainty. Had there been a tear May 10 that was missed, I'm guessing there would have been treatment options available that would have made it more likely than not that the patient would have preserved visual acuity. However, the Devil is in the details. I do not know why they are losing vision now and I do not know what their vision was originally.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Delayed diagnoses of RD often counterfactually create damages.
What makes you a good expert for this case?
I have been retained in over 100 cases in the last six years and I almost exclusively actively practice vitro-retinal surgery.
How often do you encounter cases similar to this one in your practice?
I see situations similar to this weekly.
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