Failure to diagnose an eye infection in a timely manner

Presentation and physician action

On October 4, a 65-year-old man visited Ophthalmologist A for a diabetic macular edema treatment. The patient received an intravitreal injection of bevacizumab in both eyes.

Immediately after the injection on the right side, the patient reported sharp pain. Ophthalmologist A left after administering the injections. The patient reported continuing pain, but since Ophthalmologist A had already left the office, the patient went home after the treatment.

The next day, the patient called Ophthalmologist A’s office with reports of persistent pain throughout the night, partial loss of vision, and red and watering right eye. Ophthalmologist A suggested artificial tear drops and a cool compress for treatment of dry eye until their next scheduled appointment in two days. Ophthalmologist A later testified that he was not told of any vision loss.

On October 7, the patient returned with symptoms of throbbing and pressure, tearing, weakness, and pain in his right eye. Ophthalmologist A diagnosed post-operative sterile inflammation and hypopyon over 25 percent of the right eye, and prescribed several ophthalmic drops including bimatoprost 0.01%, prednisolone acetate 1%, brimonidine 0.2%, ketorolac tromethamine 0.5% and ciprofloxacin 0.3%.

Two days later, the patient returned showing improvement in the hypopyon. Since the pain was still present, Ophthalmologist A discussed the possibility of surgery but elected to continue the medication regimen and follow up in two days.

On October 11, the patient returned with reports of vision loss on the right side, pain, and worsening hypopyon, which now covered majority of the eye. Ophthalmologist A referred the patient to the retina center for vitrectomy and washout.

At the retina center, the patient was diagnosed with endophthalmitis by Ophthalmologist B. The hypopyon now covered 90 percent of the eye. He was given intravitreal injections of ceftazidime and vancomycin.

The patient was seen for follow-up visits over the next three days. The eye was noted to look worse during the second visit, so the patient underwent vitrectomy and washout and repeat intravitreal injection of ceftazidime and vancomycin. The patient continued to be treated for infection by Ophthalmologist B at the retina center.

The patient never recovered meaningful vision out of his right eye and later had it removed and replaced with a prosthesis.

Allegations

‍A lawsuit was filed against Ophthalmologist A alleging failure to promptly and properly treat infection, which resulted in lost eyesight and ultimate enucleation of the right eye.

Legal implications

Consultants for the defense agreed with plaintiff’s experts that Ophthalmologist A’s actions fell below the standard of care. Development of infectious endophthalmitis after intravitreal bevacizumab treatment is a rare but well-known complication. It can cause severe vision loss if not diagnosed and treated immediately. The patient was not referred for treatment until one week after the injection and two days after Ophthalmologist A considered a diagnosis of endophthalmitis. The delay in treatment increased the likelihood of a poor outcome.

Consultants also noted lapses in Ophthalmologist A’s documentation, specifically the reasoning for treating the patient’s inflammation instead of more proactively diagnosing and treating post-injection endophthalmitis. The patient’s hypopyon was also not documented in the examination section of the record.

Consultants agreed that eye pain, decreased vision, and a hypopyon all pointed to the strong possibility of acute, infectious endophthalmitis. They stated that cases of bacterial endophthalmitis should be treated in a timely manner with injection of intraocular antibiotics. This treatment optimizes the patient’s chances of maintaining vision in the affected eye.

Disposition

The case was settled on behalf of Ophthalmologist A.

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About diagnostic errors

About documentation errors