Failure to diagnose and treat infection
A 72-year-old woman with a history of diabetes came to the ED due to pain in her left eye.
Presentation and physician action
A 72-year-old woman with a history of diabetes went to the emergency department (ED) of a local hospital due to pain in her left eye. The ED physician suspected orbital cellulitis, but CBC and CT scans were normal. The patient was treated with topical ciprofloxacin and oral amoxicillin for bacterial conjunctivitis.
The next day, April 30, the patient went to see Ophthalmologist A due to worsening pain and decreased vision in the left eye. The patient had a large corneal abrasion and hypopyon (white blood cells in the anterior chamber). With the help of a physician colleague, Ophthalmologist A attempted an anterior chamber (AC) tap, but they were unable to obtain a sufficient sample.
The patient was treated with topical antibiotics and steroids, including oral ciprofloxacin and 80 mg of prednisone. Ophthalmologist A thought the uveitis might be herpetic and prescribed antiviral oral medications two days later. Multiple antiglaucoma medications were also given to the patient to control increased intraocular pressure.
Between April 30 and May 10, the patient saw the ophthalmologist eight times. The patient initially began showing clinical improvement, but her vision remained poor with only light perception. During this time period, Ophthalmologist A and the patient corresponded via text message about the patient's symptoms, prescriptions, and progress.
On May 12, the patient sought a second opinion from Ophthalmologist B, a retina specialist, who diagnosed endophthalmitis. (Ophthalmologist B was a friend of the patient.) The next day, Ophthalmologist B performed a vitrectomy, lensectomy, membrane peeling, and an intravitreal injection with antibiotics and steroids.
The eye culture revealed Streptococcus pneumoniae and coagulase-negative staphylococci. Due to continued pain and the loss of light perception, the patient underwent enucleation of the left eye, and now has a prosthetic eye.
Allegations
A lawsuit was filed against Ophthalmologist A alleging failure to perform an adequate investigation and timely diagnose the cause of the patient’s eye infection. It was further alleged that if the vitrectomy had been completed sooner, the patient would have a functioning left eye.
Legal implications
The biggest issue in this case was that Ophthalmologist A failed to obtain a culture and administer antibiotics early in the treatment. Consultants believed the standard of care required Ophthalmologist A to obtain a culture at the first visit.
Endogenous endophthalmitis occurs more commonly in patients with diabetes. The unsuccessful AC tap did not rule out the diagnosis, and Ophthalmologist A did not send the patient to a specialist.
Defense experts said it was unlikely the patient would have recovered useful vision due to the presence of Streptococcal pneumoniae, which can cause vision loss within one to two days of signs and symptoms. She may have regained 20/400 vision at best. Early intervention may have prevented the enucleation, but not loss of eyesight.
Disposition
This case was settled on behalf of Ophthalmologist A.
More on diagnostic errors.
Disclaimer
This closed claim study is based on an actual malpractice claim from Texas Medical Liability Trust. This case illustrates how action or inaction on the part of the physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. This study has been modified to protect the privacy of the physicians and the patient.
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