The Expert: Dr. Keith Sanders, a neurologist testifying for the defense, details the patient’s symptoms and the defendant physician’s exam, and concludes the physician did not breach the standard of care during treatment.
During a 2019 Georgia medical malpractice trial, Dr. Keith Sanders, a specialist in neurology and electrodiagnostic medicine, testifies for the defense. The plaintiff claimed that an ophthalmologist’s failure to properly diagnose or treat her idiopathic intracranial hypertension [IIH] left her blind.
The testimony revolves around the expert’s assessment of the examinations and testing of the plaintiff by her neurologist as well as of the ophthalmologist that he referred her to. In responding to the lawyer’s questioning, Sanders begins by agreeing that questions concerning orientation and memory are typical for the initial part of a neurologic exam, which then moves to the evaluation of sensory and motor function and reflexes. The expert explains that cranial nerves originate in the brainstem and supply the face, head, and neck. There are 12 cranial nerves, but numbers 2, 4, and 6 are the only ones that are related to the eye. Specifically, the second cranial nerve, the optic nerve, deals with visual acuity, so testing for this is evaluating the function of the optic nerve.
Sanders then breaks down the components of the funduscopic exam that was performed. By looking carefully at the back of the eyeball with a bright light and magnification, one can see whether there is swelling around the optic disc, if the blood vessels coming from the optic disc have a normal appearance and whether there is bleeding or the accumulation of fluid within the retina or behind it. All such abnormalities can be signs of brain swelling or papilledema.
The defendant neurologist concludes that this patient is suffering from headaches, dizziness, and intermittent visual field disturbances. He voices support for the way the defendant organized his evaluation, considering each of these three symptoms individually and how they should be handled. For instance, with no localizing neurologic symptoms and worsening headaches, the standard of care would call for an MRI of the brain to be performed as was planned. Similarly, the complaint of dizziness without difficulties in coordination seems to point to an inner ear problem. Finally the intermittent subjective blindness might be suggestive of ocular migraine.
The patient’s neurologist considered each of these symptoms and planned a thorough workup according to the testimony of this expert. This proposed workup included the MRI of the brain, an MRA of the carotid arteries, an EEG, and blood tests. The brain MRI would help to rule out a tumor, arteriovenous malformation, structural problem, or cerebrovascular accident [stroke] as an etiology of these symptoms. The MRA would be appropriate to evaluate the blood supply to the brain in a very detailed way. An EEG measures the electrical brain waves to see if the patient is having seizures that are affecting her vision. The blood work would evaluate the kidney, liver, or blood problems that can be related to these symptoms.
The neurologist then referred his patient to the ophthalmologist concerning her visual problems. This was appropriate because increasing intracranial pressure could cause narrowing of the visual fields and enlargement of the blind spot, or there could be a primary ocular problem. The testifying expert opines that the patient could not have had fulminant idiopathic intracranial hypertension on the day that she was examined by the ophthalmologist because a key component of this condition is visual loss. Visual acuity and full visual fields were documented on that day. Since this was the case, there was no suspicion of idiopathic intracranial hypertension at that time, and no indication for an immediate lumbar puncture or eye dilation.
Chronic idiopathic intracranial pressure is a condition that is usually followed as an outpatient. An exacerbation can lead to fulminant idiopathic intracranial pressure, but in this case these diagnoses would not be high on the list of differential diagnoses since key features of these problems were missing during the exam.
The lawyer states that, “We have been told that intermittent visual obscurations, pulsatile tinnitus, and worsening headaches are classic signs for IIH, and require a physician to put that at the top of his differential list.” The expert disagrees and says that these are only subjective symptoms and not signs, yet since there were no objective findings to support that diagnosis, it would be appropriate to have IIH on the list, but not near the top. Other possibilities were more likely. He did not feel that there was any breach in the standard of care by the defendant, since objective abnormalities that demanded a more invasive workup could not be demonstrated.
The jury concurred and ruled for the defense.
Gary Gansar, MD, is residency-trained in general surgery. He served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Touro Infirmary and Mercy Hospital in New Orleans, LA. Dr. Gansar was Board Certified in general surgery while in active practice. He joined AMFS in 2015 as a Physician Medical Director.
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