Sample Case Evaluation Reports - Ophthalmology Expert Witness

The Antibiotic Prescribed For Acne Began To Cause Eye Damage From Brain Swelling And Was Not Discontinued. New!

At age 12, she was started on the anti-acne antibiotic Dynacin (minocycline) at Christmas 2000 by a Dermatologist, Dr. Laurie. Was she informed of the risks? When did she see him again?

On 1/12/01 she saw her Pediatrician, Dr. Michael, and complained of a headache for four days. On 1/13, she again saw him, and now also had nausea and vomiting. He used an ophthalmoscope and examined her retina (back of the eye) and found that the optic nerve was not normal. It had “? Ill-defined disc margins, ? Papilledema (swelling)” and “(optic) disc margin is ratty.”

Based on the above, he had a duty to take an adequate history (including new medications) and negligently failed to do so. He should have stopped Dynacin and most likely her symptoms would have subsided or have been more easily treated without surgery and severe vision loss.

He was further negligent in not immediately referring her to an Ophthalmologist and/or Neurologist (pediatric or adult).

Obtaining the MRI was good, but it was done without contrast, and may have been negligently interpreted by Dr. Goode. Obtaining a good copy (best is another one generated by their computer disc recording) for Independent Expert review.

A Physician who has found pathology cannot ignore it just because an MRI on the same date is interpreted as “normal MRI of the brain.”

She was hospitalized from 1/16-1/18 and no one ever did another funduscopic exam of her retina and optic disc. The “Primary Care Provider” was a pediatric medicine group. Dr. Ronald dictated the discharge summary on 1/18. He also performed the history and physical in which he noted she was taking Dynacin daily, and performed NO funduscopic exam. Dr. Michael also wrote an admitting note, which said re: January 13, “A funduscopic at that time showed ill-defined margins to her eyegrounds. Her (optic) discs were somewhat ratty looking (not a medical term) and somewhat ill defined." He did not re-examine her eyes, nor called for any in-hospital consultation for that purpose; further negligence. It would have shown progression.

The Hospital employee, Dr. Eric, did not do a funduscopic exam or note any concern regarding Dynacin. He saw her every day in the Hospital did nothing and was negligent.

On 1/18 Dr. Stephen, a Board Certified Child Neurologist, saw her and in his dictated three-page report of 1/18 did not do a funduscopic examination. That is grossly negligent. He noted she was taking Dynacin without comment or discontinuing it. That is negligent and still could have made a significant difference to her final need for surgery, re-operation and markedly impaired vision. He wrote by hand in the margin: "Addendum 1/25/01, fundi normal, venous pulsations seen on 1/18 exam."

That is not possible, because on 1/24 she had gross papilledema (marked swelling of the optic nerve disc), macular edema (swelling of the fine vision area of the retina) and hemorrhage. It could not have been "normal" on 1/18. Therefore, either Dr. Stephen falsified his record, or was negligent in the performance of the funduscopic exam, if he really did it. What do the patient and her mother recall? Also, obtain a copy of any of his handwritten notes from that visit.

On 1/25, Dr. Staci, an Ophthalmologist, found severe disease (as did the Optometrist, Dr. Harvey, on 1/24). He wrote to Dr. Michael with cc: to Dr. Stephen.

The spinal tap on 1/25 revealed a very high spinal fluid pressure, and after two spinal taps to try to lower the intracranial fluid pressure (which was causing the eye nerve damage), she was referred for a spinal fluid shunt (lumbar peritoneal) performed on 1/26 by Dr. Bryan and assistants. It was needed. Because the catheter (plastic tube) migrated (unfortunate), it was revised on 9/28.

Once the condition of the pseudotumor cerebri was diagnosed, the care was good. All Physicians and their Corporations and the Hospital that gave her care before 1/24 were negligent for all the reasons noted above. Their negligence caused and allowed her vision to be irreversibly damaged and required her to undergo the shunt operation, its revision, and potential future revisions.

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The Defense will contend she had a history of headaches, her mother had migraine headaches, and the MRI was negative. But the grossly abnormal ophthalmology exam Dr. Michael did on 1/13 was a red flag requiring immediate consultation, and discontinuation of Dynacin (a tetracycline), which is well known to cause pseudotumor cerebri (and therefore optic disc edema: swelling). Dynacin was not a life-saving drug. Each Doctor will probably point the finger of reliance on each other, but the optic disc pathology and gross progression from 1/13 to 1/24 is undeniable, and was untreated (no one stopped the Dynacin, as the first step).

I suggest you authorize the Medical Review Foundation, Inc. to have the following Board Certified Medical Experts review all the records: Pediatric Expert and an Ophthalmology Expert.

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