Glaucoma’s Legal Pressure

Five action steps to protect yourself from litigation

The misdiagnosis of intraocular disease is the main cause of liability claims involving O.D.s, and glaucoma leads (in numbers) of big claims, according to John G. Classé, O.D., J.D., Professor Emeritus, University of Alabama School of Optometry, who conducted a study on this topic.

The thought of being sued may make you want to quit optometry, sell everything, move to the beach and rent jet skis to escape the possible risk. But don’t. Remember: Virtually every activity carries some sort of risk, even renting jet skis. Also, by simply implementing the appropriate protocols, you can significantly reduce your risk of being sued by a glaucoma patient.

Here, I discuss these protocols.


Failure to document often leads to malpractice payouts. It doesn’t matter if we argue we did the testing, educated the patient or tried to follow-up, if we don’t have documentation to back it up. When it comes to glaucoma, ensure we document the patient’s IOPs, VF, cup-to-disc ratio and the fact that we educated him on the risk of vision loss from glaucoma.

While technology is great, we should be aware that some EHR systems have a copy-forward tool that allows the practitioner to bring forward previous exam findings into the current exam template. As a result, it is imperative we make sure data is accurately entered and updated for the current visit. Continuing to copy forward without changes in observations, diagnosis updates and treatment plan can lead to significant legal liability. If we do not document it, then in the eyes of the legal system, we never did it. Also, if the chart is missing information or the information is wrong, this will be used against us in a malpractice suit.

Many practitioners delegate documentation to staff. However, remember we are the ones responsible for the information in the patient’s chart. Therefore, we must have a review and quality assurance protocol to ensure the documentation is done correctly and thoroughly. This is especially important when it comes to verifying that staff made the appropriate updates and additions to patient documentation. Specifically, we must take time to review the chart documentation prior to finalizing. However, it is also good practice to task a staff person with auditing charts for proper documentation — for example, having someone review all or a certain number of glaucoma charts, ensuring the documentation matches the charges. If discrepancies are found, we must then have a process in place to correct the mistakes, if necessary, and ensure it does not happen again. This is part of an entire compliance program that should be part of our offices. We should have an ongoing staff training and chart quality assurance program, so that any deficiencies are caught and remedied quickly.

Glaucoma Litigation Facts

  • A misdiagnosis of intraocular disease — glaucoma, retinal detachment, tumors — is the leading cause of large liability claims involving optometrists.
  • Glaucoma (open-angle/angle-closure) is the No. 1 cause (in numbers) of large claims.
  • Pigmentary glaucoma is the secondary glaucoma that most often causes litigation.

Data come from a study of 150 malpractice claims involving optometrists performed by John G. Classé, O.D., J.D., which was conducted from 1980-2010.


We have the obligation to complete an interpretation and report on all the testing and to sign the report. Again, we should create a protocol that ensures all testing, such as OCT and VFs, is signed by us. In our office, the OCT and VF results are printed for the doctor to review and then scanned into the EHR. When checking the patient out, the front desk staff looks for signatures on the tests prior to scanning, and if they are missing, puts the test in the O.D.’s box. It is good practice to monitor this within the audit process. When checking for documentation the auditor needs to check for signatures and plans as well.


So, that we are not held responsible for lack of follow-up, we should have a protocol in place to ensure glaucoma patients are not lost to follow-up.

Specifically, if a glaucoma patient no-shows or cancels an appointment without rescheduling, the staff should educate the patient on the need to follow-up and then put a note in the patient’s chart stating he was educated. The patient is then placed on a special list that the staff calls weekly to ensure proper follow-up. If unsuccessful in reaching the patient after several attempts, the patient is sent a certified letter encouraging them to follow-up. Processes are not perfect. Therefore, we pull quarterly lists of glaucoma codes to ensure we are following the patient. The key is documenting every attempt to reach the patient.

Preventing loss to follow-up also includes having a specific referral process. For example, when the referral is made, we should have a designated staff member document the appointment and the patient’s awareness of the appointment in the chart. We should keep a list of referrals, and task a staff member with calling the referral doctor to obtain the records. If through due diligence we cannot reschedule the appointment, we should send the patient a certified letter explaining the seriousness of glaucoma and our attempts to reach him, as doing so can protect us from litigation. At the outset of diagnosis, we should consider providing such education and then having the patient sign a written document, attesting to the education.


The only way to protect ourselves is through diligence.

For example, we should make sure tonometry is done and that we look at the findings. That said, also remember that one-third of glaucoma patients have normal IOPs, reports Ophthalmology. Therefore, we must evaluate the optic nerve and if we note anything suspicious, run a VF, or refer the patient out.


Patients do not sue doctors they like. In fact, an article titled “To Be Sued Less, Doctors Should Consider Talking to Patients More” in the June 1, 2015 issue of The New York Times discusses this, pointing to specific studies on this topic. (See .)

Think about you, or one of your family members, and what you want from your doctors. Consider these questions about you and your practice:

  • Does the staff seem competent and focused on me?
  • Does the doctor talk to me and answer my questions in a clear, concise manner, that I understand?
  • Does the doctor provide me written material of my diagnosis or risk for a disease process?
  • Does the doctor have a follow-up process?
  • Am I provided a written follow-up appointment?
  • Is my doctor reachable when I have questions?

To provide an exceptional experience in our practice, we ensure every patient has a card with our personal cell phones that they can call anytime. While many doctors may scoff at this, we find that rarely do we receive frivolous or unnecessary calls.


Let’s go all in on a well-defined and documented process on how all patients will be managed for glaucoma. Once the aforementioned protocols are in place, we reduce our risk of liability, while providing stellar care. OM