Florida optometrists play a vital role in providing comprehensive eye care to their patients. Like any medical professional, however, optometrists must exercise reasonable and appropriate clinical judgment to avoid needlessly harming patients. One critical area where negligence can have serious consequences is in the dilation of patients’ eyes.  It is critical that an optometrist first properly and thoroughly evaluate a patient’s eyes, particularly their anterior eye chambers, before dilation.  This can help guard against serious and unnecessary harm which can stem from dilating a patient’s eyes in the presence for narrow angles. This blog explores the medical malpractice implications of such negligence, the risk factors for narrow angles, and the emergency nature of acute angle closure glaucoma (AACG).

Understanding Acute Angle Closure Glaucoma

Acute angle closure glaucoma is a severe and potentially blinding condition that occurs when the drainage angle of the eye—formed by the cornea and iris—is suddenly blocked. This blockage can lead to a rapid increase in intraocular pressure causing damage to the optic nerve and permanent eye damage, including vision loss.

Effects of Acute Angle Closure Glaucoma

Symptoms of acute angle closure glaucoma can include:

• Severe eye pain
• Blurred vision
• Nausea and vomiting
• Halos around lights
• Redness of the eye

Absent timely intervention, AACG can lead to permanent blindness in the affected eye. This condition is considered a medical emergency requiring immediate treatment to lower intraocular pressure, typically through medications or laser peripheral iridotomy.

Risk Factors for Narrow Angles and AACG

Certain individuals are predisposed to narrow angles and, consequently, an increased risk of AACG. Key risk factors include:

• Anatomical Predispositions: Individuals with shorter axial lengths and hyperopia (farsightedness) are more likely to have narrow anterior chamber angles.
• Age: Older adults are at greater risk due to changes in lens thickness and anterior chamber anatomy.
• Gender: Females are more commonly affected than males.
• Ethnicity: People of East Asian or Inuit descents have a higher prevalence of narrow angles and AACG.
• Family History: A family history of angle closure glaucoma increases the risk of developing this condition.

The Role of Gonioscopy in Detecting Narrow Angles

Gonioscopy is the gold standard for evaluating the anterior chamber angle and identifying narrow angles. This diagnostic test involves using a specialized lens to visualize the angle directly, allowing the optometrist to assess whether dilation could precipitate an angle closure. Neglecting to perform gonioscopy, particularly in at-risk patients, can result in catastrophic outcomes if dilation triggers AACG.

Medical Malpractice Implications

Florida optometrists are held to a professional standard of care which requires thoroughly assessing a patient’s risk for narrow angles and AACG before dilation. The standard of care for healthcare providers in Florida is simply what a reasonably careful and prudent physician would do under similar circumstances. Failure to appreciate a patient’s risk factors for AACG or failure to thoroughly assess a patient’s anterior chambers before dilation may constitute medical negligence if harm results. Key legal considerations include:

• Standard of Care: To prevail in a medical malpractice case against a Florida optometrist, the plaintiff must establish that the treating optometrist deviated from the professional and acceptable standard of care applicable to optometrists treating patients under similar circumstances.  Florida Statutes § 463.0135 outlines some of the responsibilities of optometrists when managing patients with suspected glaucoma and requires them to refer such patients to a physician skilled in diseases of the eye, such as an ophthalmologist or other medical doctor, promptly advise patients of the serious nature of glaucoma, and placed documentation in the patient’s permanent record.
• Breach of Duty: If an optometrist negligently dilates a patient’s eyes without proper evaluation, this may be considered negligence or a breach of the optometrist’s legal duty.
• Causation and Damages: The plaintiff must demonstrate that the optometrist’s actions directly caused harm, such as eye damage or vision loss.

Who a Plaintiff Would Need to Retain as an Expert Witness

Under Florida law, a plaintiff pursuing a medical malpractice claim against an optometrist must retain an expert witness to establish the standard of care and demonstrate how it was breached. Florida Statutes §766.102 and §766.202 outline specific requirements for expert witnesses in medical malpractice cases. The expert witness will review the case, testify to the applicable standard of care, and explain how the defendant’s actions (or inactions) caused the plaintiff’s injury. Expert testimony is critical in these cases as it is needed to help explain to jurors complex medical issues and determine liability.

Why AACG Is a Medical Emergency

The rapid onset and severity of AACG make it a true medical emergency. Delays in treatment can result in irreversible optic nerve damage within hours. Early identification and prompt referral to an ophthalmologist are essential. Interventions may include:

• Medications to reduce intraocular pressure.
• Laser peripheral iridotomy to create an alternative drainage pathway.
• Surgery.

Neglecting to act quickly not only jeopardizes the patient’s vision but also increases liability exposure for the optometrist.

Issues Affecting Medical Malpractice Liability

Florida optometrists may be held liable under Florida’s medical malpractice laws for any of the following, depending on the particular circumstances of the case:

1. Failing to Perform a Comprehensive Risk Assessment: Optometrists should thoroughly assess patients for risk factors associated with narrow angles.
2. Failing to Use Gonioscopy: Optometrists should always utilize gonioscopy or other angle assessment techniques before dilating the eyes of high-risk patients or where there is any doubt as to whether a patient’s angles are safe to dilate.
3. Failing to Document Thoroughly: Optometrists must maintain detailed records of evaluations and their clinical decision-making processes. Failing to do so can raise serious questions in a malpractice action.
4. Failing to Refer Patients Appropriately: Optometrists should promptly refer patients to ophthalmologists if AACG is suspected or detected.

Conclusion

Acute angle closure glaucoma is a potentially devastating condition that underscores the importance of appropriate patient evaluation before dilation. Florida optometrists who fail to properly assess anterior chamber angles risk not only their patients’ vision but also significant legal repercussions.