Virginia Lawyers Weekly VA Lawyers Weekly
On Sept. 22, 2009, the plaintiff was seen by the defendant neuro-opthalmologist for evaluation. The plaintiff reported a history of approximately six months of intermittent bilateral blurred vision and the acute onset of flashes of light bilaterally, which would encompass the entire visual field in both eyes and cause temporary blindness. He noticed these symptoms particularly when he changed position of his head. The plaintiff also reported that in the prior one to two weeks, his vision became worse and the episodes more progressively frequent and were associated with headaches. The defendant diagnosed the plaintiff with papilledema secondary to increased intracranial pressure. The plan was for an MRA and MRV to rule out vasculitis or venous sinus thrombosis as causes of the increased intracranial pressure, and then to perform a lumbar puncture if the imaging studies were normal.
On Sept. 23, 2009, the plaintiff had an MRA/MRV of the head which were reported as normal with no evidence of dural sinus thrombosis. A week later, on Oct.1, the plaintiff underwent a lumbar puncture. The defendant recorded an opening pressure of 47 and his findings were increased cerebral spinal fluid pressure which he concluded was pseudotumor cerebri. He started the plaintiff on Diamox 500 mg a day and told him to return in two months. However, on Oct. 19, 2009, the plaintiff returned to see the defendant for worsening of loss of vision. The defendant increased the Diamox to 1000 mg a day with instructions for the plaintiff to return in three days, at which point he would re-evaluate his visual fields and consider optic nerve sheath fenestration or shunt.
On Oct. 22, the plaintiff returned for follow up with the defendant, who again increased the dose of Diamox to 1500 mg a day and referred the plaintiff to neurosurgery for evaluation the following day. Rather than wait, the plaintiff proceeded straight from the defendant’s office to the neurosurgeon’s office and was seen that evening. Based on his evaluation, the neurosurgeon scheduled an emergency lumboperitoneal shunt placement for the next morning to relieve the intracranial pressure.
Plaintiff’s experts opined that the defendant breached the standard of care because a patient presenting with moderate vision loss should be immediately treated with Diamox at a dosage of at least 1,000 mg per day to 2,000 mg per day and a trial of medical management should last no more than one to two weeks. If the vision loss did not begin to improve with medical management after this period, the standard of care required that the patient receive an optic nerve fenestration or a shunt to surgically relieve the increased intracranial pressure. It was plaintiff’s expert’s opinion that in this case, the standard of care required that surgical intervention, i.e. placement of a shunt, take place no later than Oct. 7.
Plaintiff’s expert opined that increased intracranial pressure puts the optic nerve at risk, which in turn, if the pressure is allowed to continue untreated, can cause permanent injury to the optic nerve and as a consequence permanent visual loss, both central vision and peripheral vision. This scenario is what happened in this case, with a delay of more than two weeks before the shunt was placed to relieve the intracranial pressure.
This permanent vision loss will affect the plaintiff’s functioning with those activities that require central and peripheral vision, such as driving a car, certain employment tasks and certain activities of daily living. Before his injury, the plaintiff worked in television production. He was unable to return to work due to his vision loss. Plaintiff’s vocational rehabilitation expert opined that his loss of earning capacity over his lifetime ranged from $500,010 to $1,802,815.
The defendant claimed that his timeline of treatment was within the standard of care. He further claimed that earlier treatment ultimately wouldn’t have mattered, because the plaintiff was later diagnosed with a venous sinus thrombosis and dural arteriovenous fistula, a very rare condition requiring surgical repair. The defense claimed this condition caused the intracranial pressure and plaintiff’s vision loss.
Plaintiff’s experts rebutted this by stating that, despite what is causing the intracranial pressure, it must be aggressively treated to prevent damage to the optic nerve. They claimed the plaintiff’s vision loss had occurred prior to any evidence of a VST or dural AVF.
[13-T-155]Type of action: Medical malpractice
Injuries alleged: Vision loss
Verdict or settlement: Settlement
Amount: $1,100,000
Attorneys for plaintiffs: Charles J. Zauzig and Melissa G. Ray, Woodbridge
