Allegation
The parents of an infant boy allege the pediatrician’s office delay in diagnosis and treatment—failing to identify the absence of red reflex—caused retinal detachment and permanent blindness in his left eye. They claimed earlier diagnosis and referral would have allowed for specialist intervention to salvage the patient’s vision.
Case Details
The parents of an infant sued the pediatrician and APRN of the pediatric office following the patient since birth. The patient was born at 31 weeks gestation and remained in the NICU for a month. Upon discharge he was followed by the same pediatrician for two years with occasional APRN visits.
The patient’s initial visit at one month was normal, including his eye exam where red reflex was elicited upon examination. Red reflex was again noted to be elicited by the pediatrician at two months, and at three months by the APRN, who also noted normal fix and follow. Red reflex was again noted at four months and six months by the pediatrician and APRN. At seven months the mother was concerned with “staring spells” she noticed with the infant, and the pediatrician ordered a neurology referral. On this date red reflex was again noted. A few weeks later the neurologist also noted red reflex upon assessment. At the next visit with the pediatrician at nine months, red reflex and normal eyes were noted. At 12 months the APRN charted positive red reflex and excellent eye contact.
At the 13-month visit the pediatrician again noted red reflex was elicited. A vision screen done during this visit showed a discrepancy in visual acuity between the infant’s left and right eyes, with the left showing a much lower acuity. A positive red reflex was charted at 16 months by the pediatrician, and an outside allergist examining the child this same month did not mention red reflex following the eye assessment. In a visit at 19 months the APRN noted red reflex was elicited during examination.
During the 24-month visit, the APRN identified strabismus and the absence of red reflex in the left eye. Immediately she called the pediatrician and left a message and referred the patient to a pediatric ophthalmologist. She contacted the patient’s parents to discuss the abnormal findings and gave them the referral. The next day the APRN spoke with the toddler’s father, stressing the urgency of the specialist referral, and recommending not waiting for their scheduled appointment two weeks later.
The pediatric ophthalmologist was shown photos of the baby’s eyes from previous years and diagnosed a large retinal detachment in the left eye, as well as esotropia and strabismus, which he noted as new. He also diagnosed new Coats’ disease and left eye blindness. He noted the findings were demonstrated by the photos dating back to 13 months post birth.
The patient was seen for ophthalmological exams under anesthesia, where the retinal detachment was confirmed as well as other findings consistent with Coats’ disease. Between the 25th and 31st months post birth, the patient underwent a series of procedures resulting in successful reattachment of the retinal detachment, but with stable blindness in the left eye.
Expert Testimony
Plaintiffs’ experts were expected to argue that several photographs dating back to the six-month examination evidence an obvious white reflex in the infant’s left eye, versus a normal red reflex. It was expected the experts for the plaintiff would contend Coats’ disease (or at least its symptoms) was long present and missed by the pediatrician who failed to perform a proper examination. In addition, these experts were expected to point to the six-month visual screening revealing a discrepancy in visual acuity. The pediatrician’s non-acknowledgement of this discrepancy could be used as a missed opportunity for an earlier pediatric ophthalmology referral, providing time to diagnose the condition and save the child’s vision.
Defense experts opined that earlier detection of Coats’ disease, which is extremely rare, required a dilated examination by a pediatric ophthalmologist. The absence of red reflex and strabismus upon exam are indicators; however, by the time these symptoms appear it is more than likely that permanent vision loss has already been sustained. By the time the APRN identified the absent red reflex, the retina had almost completely detached, and the child’s vision was no longer salvageable. Defense experts noted concerns that pre-diagnosis photographs were suggestive of the absence of red reflex, and the vision exam showing a dramatic discrepancy in acuity between the left and right eye was an early chance for a specialist referral.
Resolution
This case dealt with a tragic permanent injury to a child and sympathetic plaintiff parents. Research revealed multi-million-dollar settlements and verdicts in pediatric cases related to vision loss allegedly caused by birth injury, failure to refer, improper eye exam, and missed diagnoses. Experts felt it was difficult to overcome the earlier photos showing white reflex and the lack of follow-up after the abnormal vision exam. Due to these factors, the case was settled on behalf of the pediatrician and APRN.
Risk Reduction Strategies
Whether earlier intervention would have changed the ultimate outcome remains unknown and for experts to opine. If a sooner absence of red reflex were noted, the same risk management strategies eventually used by the APRN would likely mitigate the claim:
- Comprehensive Documentation: Ensure complete, accurate, and timely documentation of abnormal exam findings. Thorough documentation is essential for capturing all relevant clinical information and providing a clear record and timeline of the patient's condition.
- Timely Referral to Specialist: Document STAT referral to an outside specialist without delay. Clear documentation of referral actions ensures that necessary follow-up care is promptly initiated and tracked.
- Patient and Family Discussion: Conduct documented, detailed discussions with the patient and family regarding findings and recommendations for examination and treatment by a specialist. Address questions and concerns raised by the family, ensuring that all interactions are clearly noted in the patient's chart.
- Notification to Supervising Physician: If working under the supervision of an MD or DO, ensure documented and timely notification to the physician of concerning findings. Collaboration with supervising physicians is critical for ensuring appropriate patient care and follow-up.
- Follow-Up Communication: Document follow-up with the patient and family regarding the urgency of the need to make an appointment with a specialist. Clear communication about the importance of follow-up care helps ensure that patients understand the seriousness of their condition and take appropriate action to seek further evaluation and treatment.
By adhering to these risk strategies and maintaining thorough documentation and communication practices, healthcare providers can mitigate liability risks associated with abnormal exam findings and specialist referrals. These strategies help ensure that patients receive timely and appropriate care while also providing a clear record of clinical decision-making and patient interactions.
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