September 13, 2024

Case Study: Failure to Diagnose Glaucoma in a Child with Idiopathic Arthritis Results in a Seven-Figure Settlement

Facts of the Case

The plaintiff was diagnosed with juvenile idiopathic arthritis (JIA) at one year of age. Her pediatrician promptly referred her to the insured ophthalmologist, who first saw the patient on June 16, 2003, for screening examinations for uveitis and related complications of this condition.

The ophthalmologist performed screening examinations every three months until the late summer of 2005 when the patient presented with her first episode of iritis, an inflammation of the anterior uvea in the right eye. She was 3.5 years old. She showed a normal bilateral cup-to-disc ratio. Cup-to-disc ratio is the ratio of the diameter of the cup to the diameter of the optic disc or nerve head. A normal cup-to-disc ratio is around 0.3, and a large cup-to-disc ratio can indicate glaucoma or other pathology. She was treated with topical steroids and was followed at one- to two-week intervals to adjust her medication. Over the following five months, the child showed clinical improvement. By early spring of 2006, she was able to discontinue the use of topical steroids.

Over the next two years, the patient exhibited persistent, intermittent episodes of bilateral iritis. She was treated with tapering dosages of Pred Forte. During this time, her best corrected visual acuity in the right eye was 20/30. Her left eye was 20/20. She also had been intermittently treated with methotrexate for her arthritis. Her cup-to-disc ratio remained constant until the spring of 2008. At that time, the ratio had increased to 0.5 in the right eye and remained at 0.3 in the left. There were clinical signs of iritis only in the left eye. She remained on topical steroids and methotrexate with intermittent improvement and had a complete resolution of the iritis by the autumn of 2008. No ocular pressure readings were taken.

By early January 2009, at age 7, the child’s globes were soft to palpation. Based on that, the ophthalmologist was satisfied that she was not developing glaucoma. However, he did not obtain ocular pressure readings. Nor did he discuss with or recommend to her parents that she undergo an examination under anesthesia because he believed the likelihood of finding glaucoma was lower than her risk of undergoing an examination under anesthesia. His diagnostic impression was juvenile rheumatoid arthritis without inflammation, which had been in remission since October 2008. He continued to prescribe the steroid drops for her on a tapering schedule.

The child had no further inflammation until mid-summer 2009, when she was 7.5 years old. At that time, her visual acuity became markedly reduced to hand motion in the right eye and 20/30 vision in the left without correction. Pinhole testing improved her vision to 20/70 in the right and 20/20 in the left. A pupillary examination was abnormal, and she had elevated intraocular pressures at 26 mm Hg in both eyes. Most notably, her cup-to-disc ratio had increased to 0.9 in both eyes. However, the ophthalmologist still did not initiate treatment for the pressure elevations at this time, electing instead to confirm these findings on reevaluation of the patient.

She was seen two weeks later. Her intraocular pressures were still elevated, and she had clinical signs of iritis. He prescribed medications to lower her pressure and referred her to a pediatric glaucoma specialist who started the patient on Diamox. The specialist believed that the patient’s glaucoma was secondary to chronic inflammation. He performed goniotomy surgery on both eyes one week apart. Both surgeries were uncomplicated and achieved good results. Her bilateral intraocular pressures were markedly lowered to 9 mm Hg in each eye.

The patient was then followed by a different ophthalmologist who performed frequent intraocular pressure monitoring, optic nerve examinations and visual field testing. Subsequently, a repeat goniotomy was performed on her right eye. The surgery was uncomplicated, and she had good ocular pressure postoperatively. The patient was seen regularly, and her intraocular pressures remained consistently at 13 millimeters Hg in the right eye and 14 millimeters Hg in the left eye. Unfortunately, she had sustained permanent loss of her peripheral vision with central vision of hand motion in her right eye and 20/30 vision in her left eye.

The Lawsuit

The parents of the child commenced a lawsuit alleging that the original pediatric ophthalmologist deviated from the standard of care in failing to diagnose and treat secondary uveitic glaucoma in a 7-year-old female child with chronic uveitis, which was associated with JIA.

The plaintiff further alleged that the pediatric ophthalmologist deviated from the standard of care in failing to perform routine intraocular pressure checks at every visit. In addition, if the patient is uncooperative, the ophthalmologist must make every possible effort to obtain accurate readings, including, if necessary, performing an examination under anesthesia. The defendant had never checked the infant plaintiff’s intraocular pressure by reliable means, even though glaucoma was a well-recognized complication of iritis secondary to JIA. The plaintiff alleged that if this defendant had checked the child’s intraocular pressures, he would have detected elevated pressures in a timely manner and instituted treatment with pressure-lowering eye drops. This treatment would have effectively prevented glaucomatous optic nerve damage or at least prompted early surgical referral to a specialist prior to the plaintiff sustaining permanent damage. The plaintiff also alleged that the defendant failed to seek an appropriate and timely consultation from a glaucoma specialist.

Expert Analysis

Glaucoma, by its nature, is a difficult condition to diagnose. Making the diagnosis is dependent upon documenting optic nerve damage as a result of an internal pressure of the eye that exceeds what the microcirculation of the optic nerve can tolerate. What makes it more difficult is that redness, pain, visual changes or other signs or symptoms are nonexistent in this disease. The key to making the correct diagnosis rests solely with the physician, who must suspect its presence and direct an investigation to rule out this condition.

Unfortunately, as in this case, when the patient is a small child, serially measuring intraocular pressures, scanning and photographing the optic nerve and assessing the peripheral vision may all be impossible in the office setting. However, under general anesthesia, the pressure can be properly measured, and the optic nerve can be photographed and scanned. The physician who treated this child initially over a space of more than six years chose not to perform such examinations.

Uveitic inflammatory disease in children is often accompanied by concurrent conditions that may pose a greater risk to the child’s loss of vision than the original disorder. When a very young patient has multiple diagnoses, the physician must be very diligent in managing the patient. By choosing not to perform serial examinations under anesthesia or obtain a second opinion from a peer, the physician lost the opportunity to discover the problem in a timely manner because there were no other reasonable tools to make this diagnosis. Whether the physician was uncertain about the patient’s true status or was not aware of his need for increased diligence and appropriate examination is not clear. However, his lack of diligence led directly to the patient’s permanent visual deficits.

To be successful in managing a patient such as this child, a physician must assume that glaucoma is or will be present because the child was being treated with topical steroids and/or the child’s anterior uveitis had compromised the drainage mechanism of the eyes. Therefore, the physician should have presumed glaucoma was present until otherwise proven.

The ophthalmologist had seen very few pediatric glaucoma patients, particularly patients who additionally had a systemic diagnosis such as arthritis. He may have assumed that this patient would not have developed glaucoma due to a lack of expertise with such patients. Unfortunately, his lack of experience led him to inadequately manage the patient partly because he did not have a sufficiently high level of suspicion, which would lead to the extraordinary efforts necessary to make the diagnosis. Because of that, there was serious permanent injury to the child’s vision.

Settlement

The very serious deficits in this physician’s care made the case difficult to defend. Defensibility is further compromised when, as here, the patient is a sympathetic child. As a result, this case was settled with a seven-figure payment.

Legal Analysis

This case involves a malpractice claim about the care rendered to a pediatric patient over the course of several years. The patient, a 1-year-old, was first seen by the pediatric ophthalmologist in 2003. The malpractice suit was commenced in 2009. When a patient is a minor and is receiving continuous treatment for the same condition, the statute of limitations, which governs when malpractice litigation needs to be commenced, can become quite lengthy.

The statute of limitations is a legal doctrine that limits the time in which a plaintiff may bring a lawsuit against a defendant. It is designed to protect defendants against old or stale claims. It is one of the most rigid doctrines in the law, for if the plaintiff fails to commence an action within the required period of time, the plaintiff is forever barred from suing.

The legislature establishes the time limitations that apply to any particular type of lawsuit as to what should be a sufficient amount of time for an individual to bring an action with reasonable diligence. The various time periods specified under New York law depend upon the type of legal action. In a case of medical, dental or podiatric malpractice, the statute of limitations is generally two and a half years “…from the act, omission or failure complained of . . .” CPLR 214-a. This is known as the accrual date. A cause of action for medical malpractice accrues at the time the malpractice was committed, although the accrual date is extended in certain cases. For example, if the injured party is continuously treated by the doctor who committed the malpractice for the “. . . same illness, injury or condition . . .” the statute of limitations is two and a half years from the last date of the continuous treatment. If “. . . an action is based upon the discovery of a foreign object in the body of the patient, the action may be commenced within one year of the date of such discovery of facts which would reasonably lead to such discovery, whichever is earlier.” CPLR 214-a.

There are circumstances that “toll” or extend the date when the statute of limitations begins to run. When the statute of limitations is tolled, it has then been legally suspended—in other words, the clock stops running for a certain period of time, affording the plaintiff a longer time to commence suit. One of the most common tolling provisions applies when the plaintiff is legally an “infant.” CPLR 208(a). Where a medical, dental or podiatric malpractice claim involves a person under the age of 18 years, the statute of limitations is tolled during the period of infancy. The suit must be commenced within ten years of the accrual date or within two and a half years after the minor reaches the age of 18 years, whichever is earlier. In other words, the maximum time limit to sue is ten years. CPLR 208(a).

Assessing when the statute of limitations runs out on a potential malpractice claim is not always a simple matter. Determining the accrual date and calculating the appropriate time period depends on the specific facts of each case. Since the doctrine is so strict, it is one of the first and most important issues analyzed on behalf of the defendant in a malpractice case. In this particular case, the lawsuit commenced in a timely manner within the statute of limitations.

From a purely risk management perspective, several quality-of-care issues impacted the decision to settle this case.

Although the physician was a pediatric ophthalmologist, he lacked the experience necessary to respond to the complexities of the plaintiff’s multiple medical conditions. This was evident throughout his management of the patient over an extended period of time. Because of this lack of familiarity, he should have consulted with a pediatric glaucoma specialist at the beginning of her care to obtain the advice and information he required for her future assessment and treatment. He also should have referred this patient for a second opinion, which might have helped him to defend this lawsuit.

One of the most glaring deficits in the care of this child was that the physician employed inadequate examination techniques to determine whether the child was developing glaucoma. Yet, he was well aware that glaucoma was a serious risk for her. If he had discussed with her parents the risks, benefits and alternatives of an examination under anesthesia, and they had then refused to have their child undergo such an examination, he should have documented this discussion and their decision. His failure to perform an examination under anesthesia would then have been based upon their refusal to consent and not his failure to perform appropriate testing. However, he failed to even discuss this option with the parents. His decision to make this without providing informed consent was a substantial factor in settling this lawsuit.

In summary, when treating a minor under the age of 18, it is important to be aware of the longer statute of limitations that are applicable. Further, parents must be involved in important decisions, and physicians must adequately document consent to recommended procedures and treatments. Finally, when treating a patient with complex comorbidities, it is crucial to consider obtaining and referring the patient for a second opinion. This is important from a risk management perspective since it benefits both the patient and the physician.

Additional information regarding MLMIC Insurance Company can be found here.

Sources

CPLR Section214-a
CPLR Section 208

This document is for general purposes only and should not be construed as medical or legal advice. This document is not comprehensive and does not cover all possible factual circumstances. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors for any questions related to legal, medical or professional obligations, the applicable state or federal laws or other professional questions.