Found 22 Results Sorted by Case Date
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Florida – Ophthalmology – Persistent Pain And Inflammation In The Right Eye Following Cataract Surgery



On 12/4/2013, a 78-year-old female presented to an ophthalmologist for phacoemulsification with posterior chamber implant (“cataract surgery”) on her right eye.

During the cataract surgery, the patient experienced a posterior capsule tear, a known complication and an accepted risk associated with cataract surgeries.

On 2/3/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted inflammation in the patient’s operative eye.

On 3/27/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted inflammation in the patient’s operative eye.

On 4/8/2014, the patient presented to the ophthalmologist for an examination, and the ophthalmologist noted that the patient experienced post-operative chronic iritis in her operative eye.

On 5/6/2014, the patient presented to the ophthalmologist for a follow-up examination of her operative eye.

On 8/14/2014, the patient presented to the ophthalmologist for a follow-up examination of her operative eye.

On 9/18/2014, the patient presented to the ophthalmologist and reported throbbing pain in her operative eye.

Despite knowing that the patient experienced a complicated cataract surgery, followed by persistent inflammation in her operative eye, the ophthalmologist did not perform a dilated examination until 9/18/2014.

Despite knowing the patient experienced a complicated cataract surgery, followed by persistent inflammation in her operative eye, the ophthalmologist did not refer her to a retina specialist.

The Board judged the ophthalmologist’s conduct to be below the minimum standard of competence given his failure to perform a dilated examination on the patient’s operative eye to investigate the causes of persistent post-operative inflammation within a reasonable time after the cataract surgery.  The ophthalmologist also failed to refer the patient to a retina specialist to investigate the causes of persistent post-operative inflammation within a reasonable time after cataract surgery.

The Board ordered that the ophthalmologist pay a fine of $2,500 against his license and that the ophthalmologist pay reimbursement costs for the case for a minimum of $4,634.56 but not to exceed $6.634.56.  The Board also ordered that the ophthalmologist complete five hours of continuing medical education in post-operative care and complete one hour of continuing medical education in “Risk Management.”

State: Florida


Date: November 2017


Specialty: Ophthalmology


Symptom: Head/Neck Pain, Swelling


Diagnosis: Post-operative/Operative Complication, Ocular Disease


Medical Error: Failure to examine or evaluate patient properly, Referral failure to hospital or specialist


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Ophthalmology – Lack Of Diagnostic And Preoperative Testing To Assess An Epiretinal Membrane



From 8/12/2015 to 4/1/2016, (“treatment period”) a 69-year-old male presented to an ophthalmologist with complaints of blurred vision in his eyes.

During the treatment period, the ophthalmologist diagnosed the patient with a mature cataract in his right eye, and complicated cataract, proliferative diabetic retinopathy, and epiretinal membrane (“ERM”) in his left eye.

During the treatment period, the ophthalmologist did not perform or document performing the appropriate objective preoperative diagnostic testing, such as an Optical Coherence Tomography (“OCT”), of the retina to adequately assess the ERM in the patient’s left eye.

During the treatment period, the ophthalmologist did not thoroughly examine or document a thorough examination of the patient’s eyes by performing objective preoperative testing and imaging, such as fundus photos documenting the ERM, an Amsier grid showing distortion of the patient’s vision, an Amsier grid on either eye, or showing the patient’s retina and irregularities in the retina to support the epiretinal membrane peel in the patient’s left eye.

During the treatment period, the medical records maintained by the ophthalmologist did not clearly document any indication of the ERM on the patient’s left eye preoperatively.

During the treatment period, the ophthalmologist did not perform or document performing, objective preoperative testing and imaging studies, such as an OCT of the retina, an Amsier grid showing distortion or metamorphopsia, taking fundus photos, or a fluorescein angiogram to justify his course of treatment in the patient’s left eye.

During the treatment period, the ophthalmologist did not thoroughly discuss with the patient or document thoroughly discussing with the patient the option of cataract surgery alone versus cataract surgery with the ERM.

On 8/27/2015, the ophthalmologist performed a cataract removal and intraocular lens implantation on the patient’s right eye.

On 10/8/2015, the ophthalmologist performed a cataract removal and epiretinal membrane peel on the patient’s left eye.

During the treatment period, the ophthalmologist did not maintain medical records that justified an appropriate plan or treatment for the patient’s condition.

The Board judged the ophthalmologist’s conduct to be below the minimal standard of competence given that he failed to perform and document appropriate diagnostic and preoperative testing.  The ophthalmologist also failed to discuss with the patient the option of cataract surgery alone versus cataract surgery with the ERM.

It was requested that the Board order one or more of the following penalties for the ophthalmologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.

State: Florida


Date: October 2017


Specialty: Ophthalmology


Symptom: Vision Problems


Diagnosis: Ocular Disease


Medical Error: Failure to order appropriate diagnostic test, Failure to examine or evaluate patient properly, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Ophthalmology – Failure To Utilize Optical Coherence Tomography To Evaluate A Patient For Macular Conditions



An ophthalmologist treated a 90-year-old female from 1/26/2012 to 3/12/2014.  The patient presented to the ophthalmologist on 1/26/2012 with complaints of decreased vision and a prior history of Avastin injections.

The ophthalmologist diagnosed the patient with wet macular degeneration, vitreous membranes, posterior vitreous detachments, dry eyes, and previous cataract surgery with intraocular lenses.

The ophthalmologist performed fluorescein and indocyanine angiographies and ultrasonography.  The ophthalmologist performed a Lucentis injection in the right eye.

Over the course of his treatment of the patient, the ophthalmologist performed focal laser treatments in the patient’s left eye six times and in his right eye seven times;  intravitreal Lucentis injections in the patient’s left eye twenty-one times and the patient’s right eye twenty-two times;  intravitreal Avastin injections in both of the patient’s eyes four times;  fundus photos, fluorescein angiography and indocyanine green angiography over forty times, and ultrasounds on both of the patient’s eyes eight times.

The ophthalmologist failed to utilize, or did not create, keep, or maintain adequate, legible documentation of utilizing optical coherence tomography to evaluate the patient.

At all times material to this complaint, the prevailing standard of care dictates that a physician:  perform testing and/or treatment that are medically justified; provide medical justification for the testing and treatment provided to the patient;  utilize optical coherence tomography to evaluate a patient for macular conditions;  and record the lot number and/or other identifying information from used vials of Lucentis.

The ophthalmologist performed focal laser treatment on both of the patient’s eyes excessively and/or without medical justification on one or more occasions.  He also performed fluorescein and indocyanine angiography on the patient’s eyes excessively and/or without medical justification on one or more occasions.  The ophthalmologist performed ultrasounds on both of the patient’s eyes without medical justification on one or more occasions.  He did not document, or did not create, keep, or maintain adequate, legible documentation of the lot number of any other identifying information from any of the vials of Lucentis used during the course of treatment in the patient.  The ophthalmologist did not document, or did not create, keep, or maintain adequate, legible documentation of the patient’s conditions, any changes in the patient’s conditions, and/or medical indications for the testing and treatment.

It was requested that the Board order one or more of the following penalties for the ophthalmologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Board deemed appropriate.

State: Florida


Date: August 2017


Specialty: Ophthalmology


Symptom: Vision Problems


Diagnosis: Ocular Disease


Medical Error: Unnecessary or excessive treatment or surgery, Failure to order appropriate diagnostic test, Unnecessary or excessive diagnostic tests, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



Washington, D.C. – Ophthalmology – Floaters And Decreased Vision Following Cataract Surgery



On 8/12/2011, an ophthalmologist performed cataract surgery on a patient’s left eye, which resulted in serious complications immediately following the surgery.  During the procedure, a rent occurred in the capsule.  On the following day, the patient met with the ophthalmologist during a post-operative appointment, and the patient allegedly informed the ophthalmologist that he suffered pain and discomfort in the left eye.  The ophthalmologist allegedly told the patient that his eye “looked okay” as there were no floaters, cells, or flair in vitreous, and scheduled a follow-up appointment for the following week.

At the follow-up appointment, the patient complained of floaters and decreased vision in the left eye and the ophthalmologist referred the patient to a retina specialist, who determined that there was a tear of the capsule in the left eye and that there was still some cortex within the eye.  The retina specialist performed corrective surgery and the patient received treatment and medical care from the retina specialist thereafter.  After the corrective surgery, the patient allegedly continued to suffer pain and decreased vision in the left eye.

At the time of the procedure performed by the ophthalmologist, the patient’s pre-surgical best corrected vision was allegedly 20/40-20/100; after the cataract surgery performed by the ophthalmologist and subsequent retina surgery performed by the retina surgeon, the patient’s vision was reduced to 20/70-20/100.  The patient was sent back to the ophthalmologist for glasses but was upset when the ophthalmologist recommended “temporary readers” until his vision became stable.  The patient never returned for a follow-up examination.

The Board obtained the patient’s medical records so that those records could be reviewed by an independent peer reviewer.  The peer reviewer concluded that the “overall patient management did not meet the standard of care.”  Specifically, the peer reviewer found that the ophthalmologist failed to provide a comprehensive evaluation of the patient prior to cataract surgery.  The patient’s medical records did not reflect a complete eye examination with visual acuity, refraction for best correct vision, pupil evaluation, slit lamp evaluation for rubeosis iridis, or posterior segment evaluation.  In view of the patient’s pre-surgical vision of 20/100, the peer reviewer noted the ophthalmologist’s inadequate discussion of the surgery, the reasons for the surgery, possible complications, and alternative management.

For this allegation and others, the Board judged the ophthalmologist’s conduct to be below the minimum standard of competence given his significant complications post-cataract surgery in several cases, his consistent use of-of the incorrect intraocular lens type when a posterior capsule tear occurred, and his inadequate record documentation.

For this allegation and others, the Board ordered the ophthalmologist not to perform any procedures, make any appropriate and/or necessary referrals for his patients, and undergo an assessment and audit of his practice every 3 months until this requirement is terminated by the Board.

State: Washington D.C.


Date: February 2017


Specialty: Ophthalmology


Symptom: Vision Problems


Diagnosis: Post-operative/Operative Complication, Ocular Disease


Medical Error: Procedural error, Failure to examine or evaluate patient properly, Failure of communication with patient or patient relations, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 2


Link to Original Case File: Download PDF



Florida – Ophthalmology – Entropion Surgical Repair Performed On Patient’s Right Lower Eyelid Instead Of The Left Lower Eyelid



On 3/18/2015, a patient presented to an ophthalmologist for a left lower eyelid entropion surgical repair.

Prior to initiating the procedure, the ophthalmologist marked the patient’s left lower eyelid as the operative site, performed a timeout identifying the patient and procedure to be performed, and administered a local anesthetic to the patient’s left lower eyelid.

After performing the timeout but prior to beginning the procedure, the ophthalmologist briefly left the operating room.

After returning to the operating room, the ophthalmologist performed a second verbal timeout;  however, he failed to create or maintain documentation of performing the second verbal timeout.

Despite the foregoing measures, the ophthalmologist mistakenly made his initial incision on the patient’s right lower eyelid (incorrect site) as opposed to the left lower eyelid (correct site).  He recognized this error, closed the incision on the incorrect site, and then proceeded to perform the procedure on the correct site.

The Medical Board of Florida issued a letter of concern against the ophthalmologist’s license.  The Medical Board of Florida ordered that he pay a fine of $4,000 against his license and pay reimbursement costs for the case at a minimum of $1,328.84 and not to exceed $3,328.84,  The Medical Board of Florida also ordered that the ophthalmologist complete five hours of continuing medical education in “risk management” and complete a one hour lecture/seminar on wrong site surgeries.

State: Florida


Date: February 2017


Specialty: Ophthalmology


Symptom: N/A


Diagnosis: Ocular Disease


Medical Error: Wrong site procedure, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Ophthalmology – Excessive Or Unjustified Use Of Focal Laser Treatment, Fundus Photography, Lucentis Injections, Fluorescein And Indocyanine Angiography, And Ultrasounds For A Patient With Ocular Disease



An ophthalmologist treated a 50-year-old male from 7/30/2014 to 3/18/2015.

On 7/30/2014, the patient presented to the ophthalmologist for evaluation of macular degeneration.

The ophthalmologist diagnosed the patient with wet age-related macular degeneration in the right eye, localized retinal detachment in both eyes, posterior vitreous detachment in vitreous membranes in both eyes, and retinal tears in both eyes.

Over the course of his treatment of the patient, the ophthalmologist performed ultrasonography four times, Lucentis injections seven times, focal laser treatments four times, fundus photography twelve times, and fluorescein angiography and indocyanine green angiography twenty-six times.

The ophthalmologist failed to utilize, or did not create, keep, or maintain adequate, legible documentation of utilizing, optical coherence tomography to evaluate the patient

The prevailing standard of care dictated that a physician: correctly diagnose the patient; perform testing and/or treatments that are medically justified; provide medical justification for the testing and treatments provided to the patient; prioritize treatment of localized retinal detachments before treatment of other conditions; not perform a Lucentis injection before treating localized retinal detachments; utilize optical coherence tomography to evaluate a patient for macular conditions; and record the lot number and/or other identifying information from used vials of Lucentis.

The ophthalmologist incorrectly and/or falsely diagnosed the patient with wet macular degeneration in the right eye.

On 3/18/2015, the ophthalmologist performed a focal laser treatment on the patient’s right eye without medical justification.

The ophthalmologist performed fundus photography on the patient’s eyes excessively and/or without medical justification on one or more occasions.

The ophthalmologist performed Lucentis injections on the patient’s right eye without medical justification on one or more occasions.

The ophthalmologist performed fluorescein and indocyanine angiography on the patient’s eyes excessively and/or without medical justification on one or more occasions.

The ophthalmologist performed ultrasounds on the patient’s eyes without medical justification on one or more occasions.

The ophthalmologist inappropriately delayed treating the patient’s localized retinal detachments.

The ophthalmologist performed an intravitreal Lucentis injection in the patient’s right eye before treating the patient’s retinal detachment and tears.

The ophthalmologist failed to utilize optical coherence tomography to evaluate the patient.

The ophthalmologist did not document, or did not create, keep, or maintain adequate, legible documentation of the lot number or any other identifying information from any of the vials of Lucentis used during the course of the treatment for the patient.

It was requested that the Medical Board of Florida order one or more of the following penalties for the ophthalmologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida


Date: December 2016


Specialty: Ophthalmology


Symptom: N/A


Diagnosis: Ocular Disease


Medical Error: Unnecessary or excessive treatment or surgery, Delay in proper treatment, Diagnostic error, Failure to order appropriate diagnostic test, Improper treatment, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 3


Link to Original Case File: Download PDF



Florida – Ophthalmology – Multiple Medical Errors In A Patient With Numerous Ocular Complications



An ophthalmologist treated a 48-year-old female from 2/2/2009 to 10/24/2014.

On 10/29/2013, the ophthalmologist documented a diagnosis of proliferative diabetic retinopathy with diabetic macular edema in both eyes, wet macular degeneration in both eyes, vitreous hemorrhage with posterior vitreous detachment in both eyes, subretinal macular hemorrhage in both eyes, posterior change intraocular lens in the right eye, cataract in the left eye, and dry eye syndrome in both eyes.

From 10/29/2013 to 10/24/2014, the ophthalmologist performed panretinal laser treatment on the patient’s eyes four times; intravitreal Avastin injections in both eyes twelve times; focal laser treatments in the patient’s left eye four times, and the patient’s right eye three times; fluorescein angiography and indocyanine green angiography twenty-six times; ultrasonography five times; and intravitreal injection of antibiotics in the right eye.

The Medical Board of Florida judged the ophthalmologist’s conduct to be below the minimal standard of competence given that the ophthalmologist failed to utilize, or did not create, keep or maintain adequate, legible documentation of utilizing, optical coherence tomography to evaluate the patient.  The ophthalmologist incorrectly or falsely diagnosed the patient with wet macular degeneration.  He performed intravitreal Avastin injections on the patient’s eyes without medical justification on one or more occasions.  He performed focal laser treatments, panretinal laser photocoagulation, fluorescein and indocyanine green angiography, and ultrasounds on the patient’s eyes excessively or without medical justification on one or more occasions.”  He failed to utilize optical coherence tomography to evaluate the patient.  He did not document the lot number or any other identifying information from any of the vials of Lucentis used during his treatment of the patient.

It was requested that the Medical Board of Florida order one or more of the following penalties for the ophthalmologist: permanent revocation or suspension of his license, restriction of practice, imposition of an administrative fine, issuance of a reprimand, probation, corrective action, payment of fees, remedial education, and/or any other relief that the Medical Board of Florida deemed appropriate.

State: Florida


Date: October 2016


Specialty: Ophthalmology


Symptom: N/A


Diagnosis: Ocular Disease


Medical Error: Unnecessary or excessive treatment or surgery, Diagnostic error, Failure to order appropriate diagnostic test, Unnecessary or excessive diagnostic tests, Improper medication management, Lack of proper documentation


Significant Outcome: N/A


Case Rating: 2


Link to Original Case File: Download PDF



North Carolina – Ophthalmology – Loss Of Vision Secondary To Glaucoma



In July 2015, the Board received a complaint.

In March 2005, a patient presented with blurry vision.  The patient was seen frequently by an ophthalmologist over the subsequent nine years.  The patient had cataract surgery on her right eye in March 2007.  In 2013, the patient developed elevated intraocular pressure and was treated for glaucoma, but had progressive loss of vision in both of her eyes, including severe loss of vision in her right eye.

As a result of the complaint, the Board opened an investigation.  The Board obtained the patient’s records and sent them to a qualified independent medical expert for review.  The independent medical expert judged the ophthalmologist’s conduct to be below the minimum standard of competence given failure to treat the patient’s high intraocular pressure level within a reasonable amount of time and that the ophthalmologist’s medical records were incomplete.

The Board ordered the ophthalmologist to be reprimanded.  The incident was reported to the Federation of State Medical Boards and to the National Practitioner Data Bank.

State: North Carolina


Date: April 2016


Specialty: Ophthalmology


Symptom: Vision Problems


Diagnosis: Ocular Disease


Medical Error: Improper treatment, Lack of proper documentation


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 1


Link to Original Case File: Download PDF



California – Anesthesiology – Loss Of Vision And Eye Pain During Left Supraorbital Nerve Block



On 12/29/2008, a patient went to the hospital for a procedure to treat her migraines.  Specifically, she was to undergo a left greater occipital nerve block and a left supraorbital nerve block.  An anesthesiologist was the treating physician. A supraorbital nerve block is a rare procedure with few indications.  It involves blocking a small nerve that innervates a portion of the patient’s brow. Specifically, supraorbital nerve blocks are performed where the supraorbital nerve exits the supraorbital foramen, which lies approximately 2-3 cm lateral to the midline of the face at the inferior ridge of the supraorbital ridge.  The injection is usually performed with a 25-gauge needle and usually contains lidocaine or bupivacaine. The use of steroids in this type of injection is controversial.

The patient had a previous supraorbital nerve block performed by the anesthesiologist’s associate on 12/11/2008.  There was no indication that this block provided any significant improvement of her migraine headaches that would indicate that the second block was necessary for treatment.

Nonetheless, on 12/29/2008, the patient underwent an occipital nerve block at 2:10 p.m.  She underwent the supraorbital nerve block shortly thereafter. The anesthesiologist used a 27-gauge needle for the injection, which was extremely thin and flexible, and it also provides no feedback from the needle tip as to its position.  As previously noted, a 25-gauge needle was indicated for this type of procedure.

During the supraorbital nerve block, the patient immediately reported an unusual sharp pain and said that she couldn’t see when she opened her eye.  The patient reported that the immediate sharp pain in her eye was different from the previous injections that had been done. Immediately after the injection, the patient had lost nearly all sight in her left eye.

The anesthesiologist had admitted that the patient reported an immediate loss of vision after the injection.  Following the injection, there was an obvious presence of the anesthetic solution within the patient’s eye. The anesthesiologist’s records noted there was evidence of anesthetic solution within the conjunctiva while still in the procedure room.  In addition to the solution being visible in the patient’s eye, it was clear that there was swelling of the conjunctiva or pressure within her eye. The anesthesiologist stated during his deposition that he was concerned about the possibility that the intraocular injection was causing pressure within the patient’s eye.  After the procedure, the patient also had elevated blood pressure.

At this point in time, it was or should have been apparent to the anesthesiologist that the needle penetrated the patient’s globe and injected particulate corticosteroid, yet the anesthesiologist didn’t take the appropriate steps to treat this post-injection complication sustained by the patient.  He didn’t give the patient a proper eye examination and he didn’t refer her elsewhere for appropriate medical treatment to mitigate the damage caused by the injection. The anesthesiologist admitted that he didn’t have the proper equipment available or the expertise necessary to do a complete examination of the patient’s eye to determine what damage occurred or was occurring by the injection that he had done.  Following the procedure, the patient wasn’t taken to the emergency department, which was about 100 yards away from where the anesthesiologist performed the procedure. Instead, the patient was taken to the office’s recovery area with her first post-procedure vital signs noted at 2:40 p.m. The patient was discharged at 3:15 p.m., and she was told to call her primary care doctor if her vision remained impaired.

The patient called her primary care physician the next day and was seen by the physician’s associate.  The patient was noted to have a loss of vision in the left eye and was sent to a local ophthalmologist, who noted evidence of loss of vision with cloudiness of the vitreous.  The ophthalmologist was not able to see the fundus and immediately referred the patient to a retinal specialist. The patient saw the retinal specialist the next day on 12/31/2008.  He performed an urgent vitrectomy and attempted to remove the particles of the injected corticosteroid. The patient had a second operation on 3/18/2009 performed by the ophthalmologist.  Her vision had not returned to normal and she still had significant vision loss. The ophthalmologist found that it was evident that the patient’s left eye had been injected with a steroid, which resulted in a decrease in her vision.  The ophthalmologist found that the injected corticosteroid caused opacity of the vitreous as well as retinal damage.

The anesthesiologist’s operative report stated that the patient had a left-sided greater occipital nerve block with 2 ml of 0.25% bupivacaine and 40 mg Depo-Medrol and a left-sided supraorbital nerve block with 0.5 ml of normal saline with 20 mg of Kenalog.  However, in his deposition and interview with the Medical Board of California, the anesthesiologist stated that he injected the patient with local anesthetic and Kenalog. Also, the nurse’s notes indicated that only Depo-Medrol was provided at 60 mg with no indication that Kenalog was used during the procedure.  Moreover, the anesthesiologist wrote in his operative report, “The patient did have some of this injection track down to the conjunctiva, but it did not affect her extraocular eye muscles or orbital nerves. At this point, it has not affected her vision.” This statement was directly contradicted by both the patient’s and the anesthesiologist’s testimony during deposition, wherein both stated that the patient immediately reported that she could not see after the injection.

The Medical Board of California placed the anesthesiologist on probation for 3 years and ordered the anesthesiologist to complete a medical record-keeping course, education course (at least 40 hours for 3 years) and professionalism program (ethics course) offered at the University of California San Diego School of Medicine.

State: California


Date: April 2015


Specialty: Anesthesiology, Ophthalmology


Symptom: Vision Problems, Headache, Head/Neck Pain


Diagnosis: Post-operative/Operative Complication, Neurological Disease, Ocular Disease


Medical Error: Unnecessary or excessive treatment or surgery, Referral failure to hospital or specialist, Lack of proper documentation, Procedural error


Significant Outcome: Permanent Loss Of Functional Status Or Organ


Case Rating: 5


Link to Original Case File: Download PDF



Wisconsin – Emergency Medicine – Headache, Dizziness, Nausea, Blurry Vision, And Photophobia



At 1:41 p.m. on 07/07/2011, a 42-year-old woman presented to her primary care physician with dizziness, nausea, blurry vision, and light-sensitivity.  She complained of weakness and appeared to have orthostatic hypotension.  The patient had recently been initiated on a combination of topiramate, nortriptyline, and tramadol.  She was concerned that one of her medications were leading to her symptoms.  A neurologic exam was performed and revealed mild hyperreflexia, orthostatic hypotension, and very sluggishly reactive pupils which were slightly dilated.  The clinical impression was “adverse effect of unspecified drug.”  After discussion with an ED physician, the patient was sent to the emergency department for further evaluation.

At 2:22 pm on the same day, the patient presented to the emergency department.  Admission records noted that the patient presented to the emergency department for “Frontal headache + photophobia + N/V.  Sent over by [family physician] started taking tramadol Topamax and nortriptyline 7/5/11 by pain management, told she may be having a serotonin reaction, sent here for eval.”

The ED physician examined the pupils, which were documented as being equal, round, and reactive to light.  Neurological findings were normal except the patient’s visual difficulties.  The ED physician documented: “visual acuity was not checked as she said she cannot even really see anything to read.”  The patient denied eye pain and complained of a severe headache.  The ED physician talked to the neurologist who recommended a CT scan and MRI of the brain, which were both negative.  The ED physician reviewed Micromedex for all three medications.  Adverse effects for topiramate included “Ophthalmic: glaucoma, Myopia.”  It is noted that the manufacturer of topiramate lists as its first warning and precaution: “Acute myopia and secondary angle closure glaucoma: Untreated elevated intraocular pressure can lead to permanent visual loss.  The primary treatment to reverse symptoms is discontinuation of Topamax as rapidly as possible.”  The ED physician did not perform a slit lamp evaluation or take an eye pressure.  The patient was discharged with possible diagnoses of ocular migraine or side effects from medications.  The ED physician discontinued the three medications and recommended that the patient report to the primary care physician an update of her condition in the morning.

On 07/08/2011, the patient presented to the emergency department after she woke up with a headache, nausea, and decreased vision.  Examination revealed blurred vision, photophobia, pain, discharge and redness with no double vision.  The pupils were not reactive, there was corneal and lens edema, and there was clouding of the pupil.

An ophthalmology consult was obtained with performance of a slit lamp examination and intraocular pressure valuation, which revealed intraocular pressures of 33 right and 32 left.  The patient was diagnosed with bilateral acute angle-closure glaucoma induced by topiramate.  The patient improved with treatment.

The Board judged that the ED physician’s care fell below the minimum standards of competence by failing to obtain a slit lamp examination and intraocular pressures.  The ED physician subsequently attended a lecture on Eye problems You’re Sure to See.  She also completed 2 AMA PRA Category 1 Credits in Ophthalmic Emergencies and 20 AMA PRA Category 1 Credits in Emergency Medicine.

State: Wisconsin


Date: November 2012


Specialty: Emergency Medicine, Ophthalmology


Symptom: Vision Problems


Diagnosis: Drug Overdose, Side Effects, or Withdrawal


Medical Error: Diagnostic error


Significant Outcome: N/A


Case Rating: 4


Link to Original Case File: Download PDF



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