Failure to prescribe correct medication

Presentation

A 45-year-old woman came to the emergency department (ED) reporting pain, blurry vision, and sensitivity to light in the left eye. Examination confirmed a corneal abrasion. The patient was given an antibiotic eye drop and instructions to follow up with the defendant ophthalmologist.

She was seen the next day in the ophthalmologist’s practice. At that time, the history revealed that the patient had not filled the oral antibiotic prescription. She also had not administered the topical ophthalmic antibiotics as instructed by the ED physician.

Physician action

Visual acuity was 20/200 in the left eye. A corneal ulcer with an infiltrate was diagnosed. The defendant started the patient on topical tobramycin and dexamethasone, a combination antibiotic and corticosteroid medication. The patient was instructed to return the next day for repeat evaluation.

At that visit, she reported less discomfort and improved vision. On examination, the visual acuity had improved to 20/80 and the infiltrate was still present but improved. Tobramycin-dexamethasone drops were continued as well as ciprofloxacin that had been prescribed by the ED physician.

A return appointment was made for five days. On the appointment date, the patient came to the same ED and was instructed to see the defendant as scheduled. She did not keep this appointment, but was seen the next day. The patient reported an increasing foreign body sensation in the affected eye.

Visual acuity had decreased to 20/200 and an infiltrate was still noted. A therapeutic bandage contact lens was inserted, and the patient was advised to continue ciprofloxacin, and tobramycin-dexamethasone drops and return in two days.

At this appointment the patient reported increased pain and decreased vision in the left eye. She informed the physician that she thought a piece of asphalt had flown into her eye the first day she went to the ED. Visual acuity was 20/400 and the infiltrate was larger, involving the inferior cornea. The bandage contact lens was exchanged and cefazolin and atropine drops were added to the topical medications.

The patient was seen the next two days (Saturday and Sunday) by the defendant. No improvement was noted. On Sunday, the patient was referred to a corneal specialist. The defendant paged the on-call specialist for the corneal group, and that physician agreed to see the patient on Sunday at a medical center. The patient was examined in the ED and appropriate cultures were done.

On Monday, the corneal specialist recorded a corneal abrasion 4 mm by 6 mm that had not increased from the earlier measurements. Two days later, the abrasion had decreased in size to 3 mm by 5 mm. The final results of the cultures were determined five days later (April 16th), and were positive for a fungal corneal ulcer. Amphotericin B was started, along with dorzolamide and timolol ophthalmic drops for increased intraocular pressure.

A return visit with the corneal specialist on April 21 listed amphotericin B, vancomycin, gentamicin, and dorzolamide and timolol as the medication regimen. Meperidine was also prescribed for pain. The patient reported hand motion vision. Pressure had increased to 42, and the infiltrate was described as light blocking and dense, about 5 mm. The plan was to continue therapy and see the patient in five days.

On April 26 the patient described less pain and vision to count fingers. The impression indicated some improvement in the fungal infection, and an order to decrease the anti-fungal medication to every two hours. A return appointment was scheduled in four days.

From April 30 to June 16, the patient was seen 12 times with the indication that the ulcer was responding to treatment and continued therapy recommended. Amphotericin, dorzolamide and timolol, and atropine were continued.

At an appointment on June 16 with the corneal specialist, his findings indicated increasing pain despite meperidine every three hours, light perception only, pressure of 34, 75% hypopyon, filamentary keratitis, and continued infiltrate. The fusiform ulcer was not responding to medical treatment. Latanoprost was added for pressure reduction. Surgery was scheduled for a corneal graft.

The transplant was done on June 18th. In spite of aggressive follow up and care, the transplant subsequently failed. The patient is legally blind in the left eye.

Allegations

The general ophthalmologist was sued and the plaintiff alleged negligence in prescribing both an antibiotic and steroid concurrently as it helped promote the growth of the infection. The plaintiff further alleged that the defendant should have added other antibiotics and an anti-fungal medication earlier thus causing a delay in treatment and the need for corneal transplant.

Legal implications

Physician consultants for the defense described the ophthalmologist’s care and treatment as reasonable and meeting the standard of care. They felt it was appropriate to treat a mild corneal ulcer without cultures in the beginning. When the patient’s condition did not respond to treatment, an emergent referral on a Sunday demonstrated the defendant’s concern.

The physicians who reviewed this case consistently acknowledged that fungal corneal infections are difficult to detect in their early stages. It was also noted that most ophthalmologists may see only one to two fungal infections in their entire careers.

One reviewer emphasized that there were no apparent signs of fungal infection during the time the defendant treated the patient. He felt strongly that no physician could have identified this infection any sooner, and there was no requirement on the part of the defendant to perform a culture earlier, as alleged by the plaintiff.

With regard to causation, the corneal specialist who cared for the patient stated that upon first examining her, the eye did not appear to have a fungal ulcer present. He also agreed that the type of fungal infection the patient had is rare and very difficult to treat. Fusarium is a particularly nasty strain of fungal ulcer and generally results in the outcome this patient experienced regardless of the treatment.

Disposition

This case was taken to trial, and the jury returned a verdict in favor of the defendant.

Risk management considerations

It is satisfying to present a claim in which the defendant physician is exonerated at trial. The treatment given to the patient over the weekend was well documented and demonstrated the physician’s concern and care. It is also noteworthy to add that none of the physician consultants or experts participating in the review of this claim expressed any criticisms about the defendant’s practice protocols or quality of the medical record.

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