MALPRACTICE QUIZ

Temporary Vision Loss Was No ‘Red Flag’

Jerome S. Sherman, O.D.

A 20-year-old white male presented with chief complaints of frequent headaches and difficulty seeing. The patient reported distance blurred vision, temporary loss of vision, headaches and red eyes. The doctor at this visit apparently asked no additional questions on the headaches and the temporary loss of vision.

With -4.00 spheres, vision was correctable to 20/20 O.U. The slit-lamp exam, pupils, pressures and fundus exam were documented as unremarkable. Color vision and fields were not obtained. The patient was fit with contacts and returned in a week, reporting no problems. Evidently no follow-up visit was scheduled.

The patient returned a year later. The record states “contact lens exam,” but apparently no history was obtained. Best-corrected V.A. was 20/25+ O.U. with a slight increase in myopia. Color vision and fields were not obtained, but slit lamp, pupillary and fundus exams were unremarkable. New soft lenses were dispensed and the patient was told to return “PRN.” A month later, the patient returned complaining of trouble focusing. Noting a film on the lenses and recording that the reduction in vision was due to pollen, the doctor re- corded VA as 20/20- O.U., changed the lens solution and told the patient to return if a problem persisted.
Eight months later the patient returned to the same office but was examined by another doctor. The complaint was “blurred vision.” Best-corrected vision was 20/25 O.D. and 20/60 O.S. Keratometry revealed some mire distortion O.S. only. No pinhole testing was done, nor were color vision or fields assessed; the fundus exam was unremarkable. The diagnosis was “corneal distortion O.S.” It’s unclear if the patient was told to return.

About 10 weeks later the patient presented to a different doctor in a different facility. This doctor performed confrontation fields, which were normal. Best-corrected V.A. was 20/25 O.D. and 20/50 O.S. This doctor referred him for a consultation. The consulting doctor measured 20/100 V.A.O.U. but found no media or retinal abnormality. He referred the patient to another doctor in the same facility. Color vision tests revealed 14 of 15 errors in each eye. Visual fields revealed a bitemporal hemianopsia and MRI revealed a 2cm-by-3cm tumor at the chiasm.

To remove the mass (later labeled a craniopharyngioma) the surgeon had to sacrifice the pituitary gland. The post-op V.A. was 20/50 O.D. and no light perception O.S. Visual fields revealed a complete loss of the temporal field O.D. The patient was left with one half field in one eye, the other eye totally blind. He sued the first two doctors for failing to detect the problem years earlier.

Your professional opinion:
1) A complaint of loss of vision and headaches during the first visit should have been a red flag to the doctor.
a) Agree    b) Disagree

2) On comprehensive examinations, some form of visual field evaluation must be included to meet the standard of care.
a) Agree    b) Disagree

3) Confrontation visual fields always uncover a bitemporal field loss if one exists.
a) Agree    b) Disagree

4) Detection and treatment about two years earlier would most likely have led to a better outcome.
a) Agree    b) Disagree

5) The first two doctors are not culpable of malpractice.
a) Agree    b) Disagree

Discussion
I find the first two doctors culpable of malpractice. Temporary loss of vision should always be investigated but was never addressed by the first doctor. Nor were the headaches. AOA practice guidelines call for some form of visual field assessment in a comprehensive exam. Confrontation visual fields probably are adequate in patients with no significant complaints. But even confrontation fields were not done by the first two doctors.

The second doctor believed the V.A. loss was due to corneal distortion. He considered visual pathway involvement but never tested for it. The next doctor obtained confrontation fields but they were normal. Because of the unexplained V.A. loss, this doctor referred for consultation. Automated fields later demonstrated a nearly absolute bitemporal hemianopsia in spite of the normal confrontation fields.

Confrontation fields by a typical clinician in the typical manner appear to be inadequate. Legal experts suggest automated fields, in part because the copy of a field with the patient’s name and date documents that the test was performed.

Chiasmal tumors generally wipe out the temporal fields before decreasing visual acuity. As the tumor grows the macular, then the temporal fibers are compromised. With timely intervention, the absolute bitemporal field loss can return to normal. Without it, the axons die and permanent visual loss occurs.

In most optic neuropathies, color vision is impaired before visual acuity loss. Neither doctor tested color vision. An abnormal color vision result might have led to an earlier diagnosis and a better outcome.

Some visual impairment resulted from the major surgical intervention. A diagnosis months earlier and successful radiation therapy could have prevented the loss of the pituitary gland and the related complications.

The case is pending.

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