How an Ophthalmologist Expert Witness Evaluates in Delayed Diagnosis Cases

Introduction

Consider a patient who reports new floaters and flashes of light. The clinic checks vision, sees nothing alarming, and schedules a routine follow-up. Then weeks later, the retina detaches, and cases like this drive a large share of eye care claims. One Ophthalmic Mutual Insurance Company claimed a review of 1,613 malpractice claims, of which nearly 14 percent alleged a diagnostic error. The retinal detachment made up 29 percent of those.

I am Dr. Duane Bryant, a board-certified ophthalmologist with more than three decades of clinical experience. I work as an ophthalmologist expert witness for both plaintiff and defense attorneys. This article explains how an ophthalmology expert witness evaluates a delayed diagnosis and how attorneys can prepare for that review.

Why Delayed Diagnosis Claims Are Hard to Evaluate

Eye Diseases That Give No Warning

The most classic example is glaucoma. According to the National Eye Institute, about half of the people who have it do not know. The disease takes peripheral vision first, and then holds up to the sharp central vision. Patients keep driving and reading without noticing a problem. By the time they do notice something, the lost vision cannot be restored. Glaucoma is not the only disease that can progress silently, diabetic retinopathy can also reach an advanced stage before a patient sees any change.

When a Late Diagnosis Is Not an Error

A late diagnosis is not automatically a mistake. If a patient reports new flashes and the physician never performs a dilated exam, it is a concern. But consider a different situation where a physician performed a careful dilated exam, found a normal retina, and the patient developed a retinal tear a month later. These are two different situations entirely. An ophthalmologist expert witness has to tell these two situations apart. The medical record is what allows the expert to make that distinction.

How an Ophthalmology Expert Witness Reviews a Delayed Diagnosis

When I open a chart, I start with the medical record at the first visit and read forward. The goal is to understand what the patient reported, what the physician found, and which risk factors were known. Diabetes, high myopia, prior eye surgery, and a family history of glaucoma all affect what a careful exam should include. The review also pays attention to what may have been overlooked or left undocumented. For instance, if a patient has an elevated pressure reading that no one addressed at the next visit, it becomes a finding in itself.

The next question is whether the care matched what a reasonably careful ophthalmologist would have done with the same information. Should the patient have been dilated? Was imaging or visual field testing indicated? Was the follow-up interval reasonable, and did the patient need a referral? In California, courts use CACI No. 502 when evaluating the standard of care. It focuses on the skill and care ordinarily used by specialists in similar circumstances.

Tracing the Timeline and Causation

The timeline includes every visit, test, phone call, and missed appointment. Some delays belong to the clinician, others belong to the patient, who may have skipped a follow-up or declined a referral. But identifying delay is not the only part. A delay can also affect the outcome to matter legally. 

In glaucoma, lost nerve tissue does not grow back, so the real question is how much damage earlier treatment could have prevented. In retinal detachment cases, the answer often turns on whether the macula was still attached at the first visit. Because causation standards differ by state, so I word my opinion to fit the jurisdiction.

The review then turns to prognosis and future care. I explain what the patient can expect, including whether the vision loss is permanent and what treatment lies ahead. Attorneys use these opinions to calculate damages and build life care plans.

Retinal Detachment Claims

In the Ophthalmic Mutual Insurance Company study, retinal detachment was the most frequently missed diagnosis. The study’s author said nothing else came close. Even 85 percent of the misdiagnosed patients had risk factors specific to retinal detachment. In other words, most of these patients showed warning signs. The claims also frequently raise the need for a prompt dilated eye exam with scleral depression. This technique lets the physician see the far edge of the retina.

Risk Factors in the Chart

High myopia raises the risk of detachment several times over. Cataract surgery adds risk too. Registry data show that about one in 500 cataract surgeries in patients older than 40 is followed by detachment within a year. Among patients who develop a detachment, lattice degeneration has been associated with the highest odds. 

New flashes, floaters, or visual field loss call for an urgent dilated exam. When those symptoms appear in the chart without documentation  of a dilated examination, the next step is to closely look at what happened that day.

Glaucoma Claims

While retinal detachment is one example of a condition where the timing of diagnosis can directly affect the outcome, glaucoma, on the other hand presents a different challenge as it can progress quietly, often without noticeable symptoms. 

Glaucoma damages the optic nerve, and the vision it takes cannot be restored. Failure to diagnose the disease and to document how it progresses has long been a major source of medico-legal exposure. Eye pressure is an important modifiable risk factor, so a chart with no pressure readings raises an immediate concern. The assessment typically involves looking at eye pressures, the optic nerve descriptions, the visual fields, and the optical coherence tomography (OCT) scans visit by visit. Visual fields are especially useful because they show how peripheral vision changes over time. A steady decline that no one commented on raises a clear standard-of-care question.

Diabetic Retinopathy Claims

The American Academy of Ophthalmology recommends a dilated eye exam every year for patients with diabetes. Patients with type 2 diabetes should have the first exam at diagnosis. Yet only about half of the patients who need screening actually get it. The delayed referrals from primary care physicians are one reason. Retinal photography can screen for the disease, but it does not replace a full eye exam. These claims often come down to responsibility. Did the primary care physician, an optometrist, or the ophthalmologist have responsibility for making sure the screening happened? The referral trail in the medical record can help answer that question.

Keeping the Opinion Objective

After reviewing the medical record and considering the standard of care, the next step is to make sure the opinion remains objective. A poor outcome can make a missed finding seem obvious in hindsight, but a bad result is not, by itself, proof of negligence.

 A credible ophthalmologist expert witness judges the case as it looked to the treating physician at the time. The American Academy of Ophthalmology’s ethics guidance takes the same approach. It requires objective, unbiased testimony. It also asks experts to separate negligence from maloccurrence, which is a poor result despite appropriate care. Experts must consider whether other factors contributed to the outcome. I have worked with both plaintiff and defense attorneys. Sometimes my opinion supports the claim, and sometimes it supports the physician.

What Attorneys Should Send for Review

Records and Imaging

A review by an ophthalmology expert witness goes best when the records are complete. Office notes, referral letters, and telephone logs from every provider help to establish what was reported, what was done and when it was done. Original diagnostic data matters too, including visual fields, OCT scans, and fundus photographs, because written reports only summarize them. Records from before and after the diagnosis show how quickly the disease progressed.

A short timeline of visits, missed appointments, and test results speeds up the review. It is also helpful to clearly identify the allegation and chronology to get a better understanding of the case before getting into other details. 

When to Retain an Ophthalmology Expert Witness

The best time to call is before a claim is filed or a defense strategy is set. An early record review shows whether a delay occurred and changed the outcome. This answer lets a client decide how to proceed before major costs pile up.

Conclusion

Most delayed diagnoses come down to four questions: what did the chart show at each visit? What should a careful ophthalmologist have done? How long was the delay? And did that change the result? As an ophthalmologist expert witness, I review the medical record, consider the standard of care, and explain the medical findings related to the outcome. 

Frequently Asked Questions

Can a Delayed Diagnosis Be Negligent if the Patient Had No Symptoms?

Yes, it can. Diseases such as glaucoma and diabetic retinopathy often cause no early symptoms. The question is whether the findings and risk factors called for testing, follow-up, or referral that did not occur.

Does a Late Diagnosis Mean the Physician Was Negligent?

No. A late diagnosis may result from a subtle presentation, a missed appointment, or a disease that progressed despite reasonable care. A claim still requires a deviation from the standard of care and a link between that deviation and the harm.

What Does an Ophthalmologist Expert Witness Do in a Delayed Diagnosis Case?

The expert reviews the records and imaging, applies the standard of care, evaluates causation, and explains the prognosis. The expert then communicates those opinions in a written report and, when needed, in deposition or at trial.