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Treatment of anterior segment disease requires strict adherence to a medical standard of care. If there is injury to the cornea, therapeutic intervention must be timely to prevent loss of vision. Liability claims involving the anterior segment of the eye constitute approximately 25% of lawsuits against optometrists alleging large damages. The most common causes of liability are: • contact lens related corneal abrasions • infection of the cornea (herpes simplex, fungus) • cataract • tumors of the lid or conjunctiva • ocular foreign bodies • anterior uveitis/iritis
Corneal Abrasions • Most liability claims involve abrasions secondary to contact lens wear; however, any significant abrasion must be managed in accordance with a medical standard of care. • For initial treatment, a broad-spectrum antibiotic should be used; if the abrasion is caused by extended wear of contact lenses, a broad-spectrum antibiotic sensitive for Pseudomonas (e.g., ciprofloxacin) should be prescribed.
Corneal Abrasion • Patching and cycloplegia may be necessary to promote comfort and healing; patching of the eye should not be used if the abrasion is secondary to an extended-wear contact lens due to the likelihood of infection by Pseudomonas. • The patient should be re-examined at 24 and 48 hours after initial assessment. • If resolution has not begun within 48 hours, alternative treatment should be considered. • The patient should be re-examined at 3 to 5 days after initial presentation. • If ulceration occurs, a culture must be taken; aggressive antiobiotic therapy will be required. • The patient must be managed for the risk of recurrent corneal erosion when there are deep cuts in the epithelium or the cornea heals with an irregular epithelial surface.
A woman with mildly dry eyes was fitted with extended wear lenses by an optometrist, and on the first evening of overnight wear she awoke at 3:00 AM with extreme pain in one eye. She removed the lens, but the persistent pain prompted her to be examined the next day by the optometrist, who found a significant area of epithelial loss in the affected eye. The optometrist prescribed no medications but provided the patient with artificial tears. When she returned the following day she was still experiencing pain and the area of epithelial compromise did not appear to have changed, so the optometrist referred her to an ophthalmologist, who instituted antibiotic therapy. During the next week she continued to experience pain and ulcerative keratitis developed, causing the ophthalmologist to hospitalize her and order a culture that identified the infection as due to Pseudomonas. She ultimately filed a negligence lawsuit against the optometrist, the ophthalmologist, and the manufacturer of the lenses. Her claim against the optometrist alleged that he had failed to conform to the standard of care by not instituting appropriate antibiotic therapy immediately.
Corneal Infection • The most common error of diagnosis is failure to recognize herpes simplex keratitis. • Dendritic keratitis of the epithelium may initially present as a focal punctate keratitis, which gradually evolves into a dendritic lesion. • The use of rose bengal assists in the differentiation of dendritic lesions from abrasions. • Treatment of epithelial herpetic keratitis is with an anti-viral agent [e.g., trifluridine (Viroptic)]. The use of topical steroids is contraindicated, for they will cause the lesion to enlarge.
A young daily wear contact lens patient developed a red, painful, photophobic eye. While examining the eye with a slit lamp, the optometrist detected some corneal stippling and a "depression" at the limbus. He discontinued lens wear, prescribed an antibiotic (an aminoglycoside), and scheduled the patient for a followup examination. During the next week, the "depression" resolved, but the stippling persisted and the patient's acuity dropped from 20/20 to 20/25. The optometrist continued the same regimen, but after 2 more weeks the stippling had not resolved and acuity had further lessened to 20/30. The patient consulted another practitioner, who referred her to a medical center clinic. Cultures revealed that she had a corneal infection caused by herpes simplex, and despite treatment the best corrected acuity obtainable in the eye was ultimately 20/100. She filed a lawsuit against the optometrist, alleging that he had misdiagnosed her condition, failed to institute appropriate care, and failed to recognize the need for alternative treatment.
Corneal Infection • A rare cause of action involves secondary fungal infection of the cornea following traumatic injury. • In such a case, there is inevitably a history of organic material gaining entry to the cornea (e.g., tree branch abrasion of the corneal epithelium). • If a corneal infiltrate appears several days after the successful initiation of broad spectrum antibiotic therapy for the abrasion, a fungal infection should be suspected and appropriate management undertaken.
A worker in an orange grove was struck in the eye by a small branch of a tree, which resulted in a corneal abrasion and the deposition of foreign matter in the eye. The worker consulted his family physician for the injury, who rinsed out the eye and prescribed a broad spectrum antibiotic. After 2 days the eye did not appear to be improved, and the physician referred the patient to an ophthalmologist, who prescribed an antibiotic-corticosteroid combination drug (Maxitrol®). Although the patient's eye did not markedly improve over the next few days, the ophthalmologist continued the regimen; at no time was a culture taken to identify the pathogen. After almost a month of treatment, with a gradual worsening of acuity, the patient was admitted to a hospital for reevaluation and culturing of the affected eye. Although a fungal infection was identified and anti-fungal therapy initiated (Natamycin®), the eye continued its downhill course and ultimately had to be enucleated. The worker filed a lawsuit against the ophthalmologist, alleging negligence; he ultimately received a large settlement in his favor.
Cataract • Failure to diagnose age-related cataract does not, of itself, create an action for damages, because there is no immediate injury if age-related cataract is not treated. For age-related cataract there is no treatment available to arrest the progression of the disease—other than surgery, which is used when vision is functionally impaired—and thus referral is usually not indicated until acuity is 20/50 to 20/60. A compensable injury can result, however, if the clinician fails to detect co-existing disease.
Cataract • If a cataract has begun to affect the patient's visual acuity, the patient must be warned of the ramifications of the reduced acuity on the patient's ability to operate a motor vehicle or to perform other potentially hazardous undertakings for which reduced acuity poses a risk of injury. • When surgery is indicated, the surgeon must be selected with due care. • If the optometrist performs the post-operative care, it should be in conformance with the co-management protocols established with the surgeon.
A college professor who had been the long-term patient of an optometrist was found to have acuity that slowly decreased from 20/20 to 20/50 over the course of several years, with the decrement being attributed to cataracts. The optometrist had performed non-contact tonometry (NCT) at these examinations but readings had been in the low 20s, which is “high normal” for the NCT. Although the optometrist had looked at the interior of the eye with a direct ophthalmoscope through an undilated pupil, he had not noted the cup-to-disc ratio, instead noting “normal” in the patient’s record for the ophthalmoscopy findings. The effects of the decreased acuity eventually led the optometrist to refer the patient to an ophthalmologist for cataract surgery, but the surgeon found .8 and .9 C/Ds and instituted treatment for primary open-angle glaucoma instead. A lawsuit was filed against the optometrist, and substantial damages were paid.
Lid and Conjunctival Tumors • Basal cell carcinomas of the lid are more prevalent than squamous cell carcinomas by a ratio of as much as 40:1, comprising an estimated 20% of all lid tumors. • The most significant factors for basal cell carcinoma are a fair complexion, chronic exposure to sunlight, and a history of previous basal cell carcinomas.
Lid and Conjunctival Tumors • Nodular basal cell tumors can be mistaken for papillomas or epidermal cysts; they can change in appearance to become ulcerative, eroding to form pearly borders and an ulcerated center. They can also be multicentric, with multiple nodules of tumor. • Metastasis of a basal cell carcinoma is extremely rare, but a suspicious lesion should be referred for assessment and biopsy because it can erode the soft tissue of the lid or orbit, making surgical repair quite difficult.
During the course of a routine examination, an optometrist detected a "blocked oil gland" on a patient's lower lid. The patient was instructed to use warm compresses for a week and to return for further care if the condition worsened. Although the treatment did not resolve the problem, the affected area did not get worse and the patient did not return to the optometrist. Almost two years later the patient was examined by another practitioner, who advised biopsy of the affected area. The patient was found to have a basal cell carcinoma which extended 13 x 5 mm along the lower lid. Two surgeries were required to remove the tumor and effect repair of the lid, which did not completely recover normal function. A lawsuit was filed against the optometrist, alleging that she had failed to diagnose the tumor and that the delay had complicated the effort to repair the lid. Damages were awarded to the patient.
Lid and Conjunctival Tumors • Squamous cell carcinoma is most often found on the scalp, ears, and back of the hands. Rarely, it involves the conjunctiva. • The appearance of squamous cell carcinoma is variable, but characteristically it is an elevated, firm nodule that has a red, scaly surface, which can ulcerate causing bleeding and crusting. • Metastasis of a squamous cell carcinoma from the lid is rare, but a small, erythematous nodule that gradually enlarges and develops a superficial scale or ulcerates, crusts and bleeds should be subjected to biopsy.
A woman in her 30s was examined by an optometrist and found to have a raised lesion on the temporal conjunctiva of one eye. He referred her to an ophthalmologist, even though he believed the lesion was “probably” benign, because there was a large feeder vessel and the patient reported the lesion had grown fairly rapidly. The physician was suspicious that it was squamous cell carcinoma and excised it. A pathologist examined the removed tissue and said it was conjunctival compound nevus rather than tumor. A month after the surgery the ophthalmologist released the patient back to the optometrist, but she did not actually schedule an examination until 5 months later. She received a refraction and spectacles, and the optometrist noted the eye was still red in the area of the excision. About 3 weeks later she returned for another assessment, complaining that her cat had scratched her eye and that she was experiencing “eyelash” foreign body sensation. She also complained that the eye ached and her vision was “foggy”, even though she was correctable to 20/20. The OD examined for injury from the scratch—which was in the same eye and location as the excision—and noted there was both new and resolving hemorrhage, but no open wound. There was also subconjunctival hemorrhage inferiorly. He concluded that the scratch (which had occurred about 3 weeks before the exam) had healed and that the hemorrhage was resorbing. He instructed the patient to return if “anything changes”. She did not return until 6 months later, however, and at that time she had an obvious elevated conjunctival lesion in the same eye, located where the inferior subconjunctival hemorrhage had been. She was also found to have 3.75 D of astigmatism in the eye and 20/25 acuity. The optometrist again referred her to the ophthalmologist, and again the lesion was excised. The pathologist’s report this time, however, was that the tissue was malignant melanoma. The eye was eventually removed, but subsequently the melanoma was found to have metastasized. The woman sued the optometrist for negligence. She received damages but subsequently died.
Ocular Foreign Bodies • If the history of injury indicates the likelihood of a penetrating injury to the cornea, perform adequate testing to rule out this possibility: slit lamp examination (with fluorescein), tonometry, ophthalmoscopy and fundus biomicroscopy. In suspicious cases, order specialized testing such as radiographs, ultrasonography, or CT scans. • When examining a patient with an ocular foreign body, it is important to obtain an accurate visual acuity, to evert the lid to look for trapped debris, to perform a careful slit lamp examination (with fluorescein), and to inspect the interior of the eye (including the periphery) for evidence of penetration. Escaping aqueous from a penetrating wound may be detected with fluorescein (Seidel's sign). Tonometry may also be of use in detecting hypotony.
Ocular Foreign Bodies • If a corneal foreign body is removed, antibiotic therapy will be necessary for the compromised epithelium; a broad-spectrum agent is the initial drug of choice. • To facilitate healing, a pressure patch may be used. A cycloplegic and an analgesic may be needed to reduce patient discomfort and pain. • Patients should be seen at 1 day, 2 days, and 3 to 5 days after the injury to ensure that corneal healing has been achieved.
A worker hammering some metal was struck in the eye by a foreign body. He went to the emergency room of a nearby hospital, where a physician removed a small metal fragment that was embedded in his cornea. After a week's treatment with a topical antibiotic, the eye healed without incident. Five months later, however, the worker began to exhibit the symptoms of siderosis, and an intraocular examination revealed the presence of a metallic foreign body. Although surgery was performed to remove the object, the worker suffered a significant loss of vision from the siderosis. He filed a lawsuit against the hospital, alleging that the physician had been negligent for failing to examine the interior of the eye. He received damages.
Anterior Uveitis/Iritis • Non-traumatic anterior uveitis results from underlying systemic disease. Patients must receive a diagnostic evaluation for the underlying disease in addition to treatment for the anterior uveitis/iritis. • Symptoms of eye pain and photophobia and signs of paralimbal conjunctival injection, miosis and cells and flare in the anterior chamber indicate the presence of inflammation.
Anterior Uveitis/Iritis • Most cases of anterior uveitis involve the ciliary body (iridocyclitis); treatment should involve cycloplegia of the ciliary body and, if appropriate, the use of topical corticosteroids to suppress the inflammation. • Systemic steroids should not be used for the treatment of anterior uveitis/iritis unless a topical route of administration has been shown to be or clearly is inadvisable.
Anterior Uveitis/Iritis • Evaluation of a patient with recurrent, bilateral and/or granulomatous anterior uveitis requires determination of the underlying disease; clinical laboratory testing will be needed to detect (among other causes): • ankylosing spondylitis • sarcoidosis • syphilis • tuberculosis • rheumatoid arthritis • Lyme disease • multiple sclerosis
Example case: recurrent uveitis • Woman in her 20s presented with a 2 year history of recurrent red eye OS • Conjunctivitis was diagnosed and treated, but there were 2 more episodes over 1 ½ years before iritis was diagnosed • Clinical laboratory tests were ordered but the results were negative • Afterwards, another episode resulted in greatly reduced acuity in the eye
Observe how the lawyer creates the impression that because lab testing resulted in negative results the optometrist didn’t know what else to do, thereby contributing to subsequent vision loss.
CLAP traps • If there is recurrent red eye, especially bilaterally, uveitis resulting from underlying systemic disease must be ruled out • If initial clinical laboratory testing is negative, a plan for further evaluation of suspected systemic causes should be discussed with the patient and implemented • Referral for clinical testing is appropriate, whereas failure to order tests is not
