Article Date: 7/1/2001

What you need to know to keep you -- and your patients -- safe.
JEROME SHERMAN, O.D., F.A.A.O., New York, N.Y.

Optometry's scope of practice has dramatically changed over the last 10 to 20 years, and we're in the public's eye now more than ever as the primary providers of eye care. In addition, technological advancements have made it possible to detect ocular conditions earlier, faster and with greater accuracy.

Although these changes serve patients well and advance our profession, we need to be aware that with all of these positives come increased responsibility for properly diagnosing patients and for not missing any sight- or life-threatening conditions. Perhaps the worst experience an optometrist could have in his professional career is to be involved in a lawsuit stemming from alleged malpractice. The nightmare sometimes lasts years, resulting in sleepless nights, feelings of guilt and anger, depression and the inevitable second-guessing. What if I'd dilated? What if I'd performed fields? What if I'd asked about any headaches?

A peripheral retinal fundus photo revealing two retinal tears, which often lead to a total retinal detachment if not treated in a timely fashion. They're often missed without a dilated fundus exam with binocular indirect ophthalmoscopy.

On rare occasions, a major case goes to trial and a jury finds the optometrist culpable, resulting in a well-established practitioner suffering from immediate, irreparable damage.

We all can reduce our risks of malpractice litigation to near zero by covering all our bases and keeping in mind the things most commonly overlooked when caring for patients. To write this article, I pored over nearly 200 cases to identify and report to you the most common triggers of optometric lawsuits. Find out what they are and how you can avoid making these mistakes to keep yourself safe from a potentially devastating malpractice lawsuit.

Covering the bases

The vast majority of malpractice cases fall within three categories of disorders: retinal detachment, glaucoma and tumors. Failure to diagnose choroidal neovascularization and proliferative diabetic retinopathy are important, but are less frequent causes of malpractice litigation.

The simple rule of covering the bases relates to all eye clinicians, and most cases could've been avoided had the clinician done so.

A threshold visual field depicted in a 3D hill of vision plot. This patient had no symptoms in his right eye, 20/20 vision and normal IOPs, but a large, arcuate scotoma and nasal step, which are characteristic of moderate nerve fiber layer loss in glaucoma. Fields are required in any glaucoma suspect.

What's malpractice anyway?

For an optometrist to be culpable of malpractice, three factors must be present.

Case 2: The tumor (hemangioblastoma) that was partially surgically removed 1 year after visual acuity was documented as reduced to 20/60. The teenager lost all light perception in both eyes and the jury awarded nearly $10 million to the patient.

  1. The professional care rendered needs to be below the generally accepted standard of care. The American Optometric Association (AOA) Practice Guidelines are often used as a standard, when applicable. If the standard is somewhat difficult to determine, a judge will often instruct the jury to consider a like practitioner under like circumstance. The like practitioner isn't the Harvard professor, but another clinician who's in a similar setting to the plaintiff.
  2. The patient must suffer a loss. Just because an optometrist failed to perform a fundus exam on Mr. Jones, there's no case unless Mr. Jones suffered some type of loss that was preventable if the doctor had in fact performed the fundus exam. The loss is usually in the form of irreversible loss of vision, but it can occasionally mean loss of life, too.
  3. Some link or connection must exist between what the clinician failed to do and the loss suffered by the patient. If a patient has retinitis pigmentosa and the optometrist failed to diagnose it, the loss of vision isn't related to the missed diagnosis but to the untreatable and progressive degeneration from the disease.
    As a general rule, a clinician isn't held responsible for missing a diagnosis of an untreatable disorder. But if the failure led to vision loss that could've been prevented if he had met the standard of care, the issue of causation has been met and the doctor will likely be found culpable.

What has had the most impact on our standard of care?

Curiously, the standard of care in both optometry and ophthalmology has changed most because of two precedent-setting cases -- not because of standards created by the professions. Here are some cases in point:

With regard to routine automated visual field screening, several major cases that are presently making their ways through the courts could create a new standard requiring routine field screening.

An axial MRI revealing a large, chiasmal tumor in a patient with advanced nuclear cataracts. Fields were never performed and the patient's visual symptoms were all attributed to his cataracts. 

The AOA Practice Guidelines include a visual field evaluation on comprehensive exams but the method of testing was intentionally left vague. Most clinicians interpret this as meaning that confrontation fields are adequate in routine cases.

Putting it all together

I've covered much ground so far, but by now you should have a good idea of the conditions most commonly cited in lawsuits, and about which bases you need to always cover.

Here are a couple of actual cases that illustrate some common trigger points for malpractice lawsuits. See if you can identify what the practitioners should've done to avoid these following lawsuits.

This case also highlights the point that an "iritis" may not be caused by inflammation but instead by compromised, leaky blood vessels as found in patients who have diabetes with rubeosis.

A choroidal malignant melanoma that was previously diagnosed as central serous choroidopathy. When the tumor progressed, the true diagnosis became more obvious.

Learning from others

By following some simple guidelines, such as covering the bases, we can all provide better care to our patients and dramatically reduce our risk of being involved in malpractice litigation.

I hope you'll keep these points in mind when caring for your patients. Look for more true cases of alleged optometric malpractice to learn from next month and in subsequent issues of Optometric Management, which will contain my new column "Malpractice Management."

Dr. Sherman practices at the Eye Institute and Laser Center in Manhattan and is a distinguished teaching professor at the State University of New York College of Optometry.

Optometric Management, Issue: July 2001