Delay in diagnosis, inadequate treatment, and failure to pursue aggressive intervention in a timely fashion can result in glaucoma and, in some cases, blindness.
Glaucoma is categorized into primary glaucoma (i.e. cases that do not have an otherwise obvious cause) and secondary glaucoma that occurs to another disease process either systematic or in the eye.
Glaucoma is the second leading cause of glaucoma worldwide. It is estimated that there will be 79.6 million cases by 2020, mostly open angle glaucoma. Bilateral blindness will occur in up to 5.9 million with open angle glaucoma, and 5.3 million with angle closure glaucoma. Women and Asians are disproportionally affected. (Br J Ophthalmol 2006;90:262-267)
There are multiple causes of the secondary glaucomas. Some of the glaucomas can occur after a clogged artery or vein destroys much of the retina. This can leave the eye vulnerable to secondary glaucoma where the eye then becomes painful and has a chance of losing even more vision. Other glaucomas can occur secondary to injuries or administration of certain drugs, particularly steroids either topically or systemically administered. There can be diseases such as inflammation within the eye and postoperative conditions such as after cataract surgery, retina surgery, or even procedures within the eye such as intravitreal injections.
Case Study #1
Young man with inflammatory disease in the eye and secondary glaucoma. This patient was in his 40s and has a long history of intermediate uveitis in both eyes, which had generally been controlled without treatment for many years. He presented to an ophthalmologist with elevated pressures unresponsive to medications. A new type of surgical procedure was chosen without a long track record of success, and this procedure was performed without realization that the glaucoma was really a secondary glaucoma because of the inflammation. This is only evident on examination of the anterior chamber angle where there were characteristic scarring of the drain in the eye and a careful look at the eye for any signs of inflammation and a good history obtained at a later date.
Case Study #2
Glaucoma exacerbated by cataract surgery. An elderly man had glaucoma surgery. He had a prior history of glaucoma that was treated with a few different medications. It was a large group practice where the operating surgeon rarely saw his own postoperative patients and most of them were followed by physician extenders or optometrists. In the postoperative period, the pressures went very high and the patient was treated with multiple medications over some period of time. The pressures went high enough that further visual field loss had occurred over months. The pressures were extremely high and visual loss occurred. The operating physician finally saw the patient again and then referred the patient for glaucoma surgery. This patient could have been referred earlier to a glaucoma specialist for glaucoma surgery, but this was not performed until the patient has essentially lost most of the vision.
Case Study #3
I was an expert for the defense of a doctor who was among many different doctors who had treated the plaintiff for glaucoma for over 15 years. The disease was slowly progressive and severe after many years. The patient had many other medical problems and other causes for his visual field loss before the doctor was involved in his care. The patient had difficulty tolerating most of the prescribed topical medications and was frequently non-compliant in his use of the medications. The treating doctor discontinued one of the topical medications, and during the short time he was off medications, the patient experienced some visual loss. He was suing the doctor because this one change in his medications caused a subjective loss of vision. This doctor was involved in his care for only about one of his 15 years of disease.
A careful review of an extensive amount of records revealed that the patient had multiple episodes of subjective visual loss. Later surgery was delayed by another treating doctor. When surgery was finally performed, it failed and left the eye functionally blind.
I read the deposition of the plaintiff’s expert and found the expert did not have plausible evidence that the lapse in treatment caused any damage. The case was later dropped by the plaintiff.
Most of the medical legal problems that occur with primary glaucoma are the problems that occur because is the disease is often difficult to detect, and the diagnosis may have been delayed for a variety of reasons. Most of the problems involve delay in diagnosis or inadequate treatment of the disease, or failure to refer to a specialist for aggressive intervention in a timely fashion.
In regards to the secondary glaucomas, many of these patients have the disease as a result of other procedures previously performed, and often after the glaucoma has appeared.
About the Author
Dr. Lawrence M. Hurvitz has been practicing as a glaucoma specialist for 36 years in his private practice in Sarasota, Florida. Over the course of those years, he has extensive experience with general ophthalmology with his own patient care. In dealing with his glaucoma patients, he is a primary ophthalmologist who is also taking care of the patient’s glaucoma. He therefore has a lot of experience with the common practice of general ophthalmology and cataract surgery by his own hands. He is an experienced expert witness who has been called upon many times for case reviews by both plaintiffs’ attorneys and defendants’ attorneys.