Infant Suffers Optic Nerve Damage From Delayed Glaucoma Diagnosis

This case involves a 6-month-old baby who developed uneven pupils. The baby was taken to the emergency room and was noted to have a less reactive left eye as well as mild left ptosis. A fundus exam revealed that the right eye had a sharp disc margin. The baby was diagnosed with anisocoria (unequal size of the eyes’ pupils), but the physician also noted that it could be Horner’s syndrome. An MRI was ordered and performed 3 months later. The results showed minimal changes of myelin vacuolization in the deep cerebellar white matter but were otherwise unremarkable. The baby was seen by an ophthalmologist whose assessment was microphthalmia. The ophthalmologist then performed an exam under anesthesia in which all findings were consistent with minor microphthalmia. The doctor instructed that patching begin immediately on the right eye to protect the visual acuity of the left. The parents were instructed to return to the clinic in 6 months. One month later, the patch began to irritate the baby, his eye became hazy, and the pupil became oval shaped. The parents attempted to get an appointment with the ophthalmologist but were told that the doctor was overbooked and couldn’t see the baby for at least 2 months. The baby was seen by his primary care physician who agreed with the ophthalmologist’s assessment but suggested no further follow up with respect to the eye. The child was then taken to the emergency room with complaints that one eye was larger than the other, and that the eye exhibited redness and drainage. The baby was diagnosed with pink eye and given an antibiotic. The baby returned to the ophthalmologist where he was noted to have light sensitivity and improved redness but was still tearing. The baby’s tonometry pressure was high and the ophthalmologist instructed him to return in 1 week. The ophthalmologist was unavailable the following week, however, so the baby was seen by another doctor. This second physician was immediately concerned that the patient had glaucoma. The baby’s tonometry pressure was 30 and the right cornea was noted to have inferior corneal haze and a non-reactive pupil. The right disc was also dysplastic. The baby was seen by a glaucoma specialist the following day and diagnosed with infantile glaucoma. The baby underwent goniotomy surgery, which confirmed that he had glaucoma. During the goniotomy, the baby responded poorly and required a trabeculotomy to allow fluid to drain from his eye. The baby suffered severe optic nerve damage due to the increased pressures.

Question(s) For Expert Witness

1. How often do you treat infantile glaucoma?

2. What are certain signs and symptoms that warrant workup to diagnose infantile glaucoma?

Expert Witness Response E-128261

There is considerable evidence that the ophthalmologist who examined the patient and did an EUA may have been negligent. Particular concerns include the following: The 3-month interval between the decision to perform an EUA and the performance of the EUA seems excessive. The difference between RE and LE at EUA with respect to eye pressure, axial length, corneal thickness, and disc cupping, all possible signs of glaucoma in the right eye, appear to have generated inadequate concern. The planned 6-month interval between EUA and follow-up was excessive. Failure to respond appropriately to the family's expression of concern about pupil appearance and haze is very troubling. The ophthalmologist may have failed to document several very important abnormalities during his examination. It is likely that the outcome would have been better with earlier diagnosis and treatment. I published a review article on treatment of pediatric glaucoma in the early 1990s, and addressed the subject in a book-length review of pediatric ophthalmology that I authored in 2011.