Case Summary
This case involves a professional hockey player who suffered acute vision loss without an apparent cause in his left eye while on the ice.
The team physician examined him and stated he believed the player had suffered either a retinal detachment or stroke. He chose to treat his patient for retinal detachment. The physician then referred the player to an ophthalmologist as opposed to the emergency room.
The patient presented for his eye appointment 24 hours later. During the examination, the ophthalmologist immediately referred the patient to the emergency room. In the emergency room, the patient received a diagnosis of a congenital cardiac defect. He immediately underwent surgery to close a Patent Foramen Ovale (PFO).
His central vision had been compromised, and his visual field was reduced to only the periphery of his left eye.
Case Theory
Emergency physicians treat an estimated 2 million patients annually in the US for acute vision loss. Immediate identification of the cause of vision loss is paramount in the preservation of sight. PFO is a congenital interatrial communication of the heart, from right to left which fails to close normally during the first year of life. This creates the potential for a right-left shunt. The prevalence of PFO is 10–15% of the diagnosed population and 26% in autopsy studies.
PFO is normally asymptomatic but predisposes the patient to embolic events (stroke) which may involve the eye.
In this case, the team physician developed two possible medical theories, both incorrect. The physician was not qualified or prepared to confirm a diagnosis. He subsequently violated the standard of care. His patient was in danger of permanent sight loss in an affected eye or could have been suffering a life-threatening stroke, per his assumptive differential diagnosis. The physician had a duty to send the patient directly to the emergency room. The failure to urgently refer his patient to the emergency room caused the patient to suffer permanent vision loss.
Expert Witness Q&A
- What workup or referrals should be immediately considered when evaluating a patient with acute visual loss?
- Did the delay in diagnosis cause permanent vision loss?
- Could vision loss have been restored if the patient had received immediate care?
Expert Witness Involvement
Team Medicine Physician/ Internal Medicine
An internal medicine sports doctor can speak to the standard of care for a player with acute, sudden onset vision loss.
Neuro-opthalmologist
An expert in neuro-opthalmology can speak to the cause of visual loss and the likelihood of visual restoration. This expert can also testify to the probable outcome with prompt treatment.
Cardiologist
An expert in cardiology can opine on the risks of delay in treatment and the benefits of expeditiously closing the PFO upon diagnosis.