Medical Malpractice Insights: Endophthalmitis – Dorothy, this isn’t conjunctivitis any more!
- Aug 29th, 2019
- Chuck Pilcher
Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.
Chuck Pilcher, MD, FACEP
Editor, Med Mal Insights
Endophthalmitis: Dorothy, this isn’t conjunctivitis any more!
Did an inadequate exam lead to loss of eye?
Facts: A 53-year-old male awakens in Orlando with 7/10 pain, redness, swelling and drainage in his L eye and eyelids. Just before takeoff on a flight to Seattle, he messages these symptoms to his Seattle clinic’s call center at 2:46 PM. On arrival in Seattle after a 5 hour flight, he sees a message sent to him at 2:51 PM from the call center. They ask him to call back immediately. Having arrived in Seattle and feeling even more pain, he instead goes directly to the clinic’s Urgent Care Center (UCC), arriving at 10:25 PM. The chart documents a history of nasal discharge with “pressure” and “throbbing” in his eye. On exam he has redness, discharge, and is “unable to do visual testing due to swelling” of the eyelids, cheek, and eyebrow. Items NOT recorded in the UCC exam include intra-ocular pressure, ciliary flush, pupil size, appearance of anterior chamber, and fundus. He is diagnosed with conjunctivitis “probably secondary to sinusitis” and prescribed Augmentin, Maxitrol drops, and Vicodin for pain. He is advised to see the eye clinic in 3 days. Early the next morning he is able to contact his general ophthalmologist who sees him in the office at 8:00 AM. He is diagnosed with endophthalmitis. He undergoes emergency surgery before noon, but the vision in his eye cannot be saved. An attorney is consulted regarding a possible lawsuit against the UCC physician.
Plaintiff: The doctor in Urgent Care should have known that my problem was not simple conjunctivitis but a far more serious condition. My symptoms were nothing at all like simple conjunctivitis. He didn’t even do an eye exam. If he would have made the correct diagnosis, or even called an eye specialist, I’d still have vision in my eye.
Defense: Endophthalmitis is a rapidly progressive disease; loss of vision can occur in over 50% of cases regardless of treatment. We agree that the diagnosis should have been made earlier, but on a “more probable than not” basis, earlier diagnosis would not have made a difference.
Result: After expert review by both Urgent Care, Emergency, and Ophthalmology experts, the consensus was that:
- the standard of care, especially the exam, at the UCC visit was not met,
- the condition should have been diagnosed, or a severe problem recognized, during that visit, but
- an earlier diagnosis would not have assured any better outcome on a “more probable than not” basis.
No lawsuit was filed.
- If patients have pain, discharge, redness, and swelling so severe that they cannot open the eye and they need opioids for pain, they do not have conjunctivitis. They need to see an ophthalmologist urgently.
- Had an adequate exam been done, pus or at least a cloudy anterior chamber would have likely been found on the first visit.
- Iritis would be a more logical diagnosis than conjunctivitis but is not associated with purulence.
- Both conjunctivitis and iritis are common in outpatient practices. Endophthalmitis is not. Still, the astute clinician should recognize a “hot eye” and feel a sense of unease when confronted with this acute and serious condition.
- In such a case, a thorough exam is the standard of care and will lead one to recognize the need for additional expertise and an emergent ophthalmology consultation.
- For a review of endophthalmitis, see this Medscape eMedicine article. http://emedicine.medscape.com/article/799431-overview
- “Endogenous Bacterial Endophthalmitis” in “Bacterial endophthalmitis.” Durand ML. UpToDate Online, updated Oct 26, 2017. https://www.uptodate.com/contents/bacterial-endophthalmitis?search=endophthalmitis&source=search_result&selectedTitle=1~106&usage_type=default&display_rank=1#H365247411
- Endophthalmitis Highlights. Bright J. emDocs. Jan 12, 2016. http://www.emdocs.net/endophthalmitis/