Why is neuroophthalmology a special risk for general ophthalmic medical malpractice claims? Neuroophthalmology is a relatively small part of most general ophthalmic practices. Unfortunately, several features of neuroophthalmic practice create special risk for the comprehensive ophthalmologist. It has been my experience that, although claims against neuroophthalmologists are rare, neuroophthalmic-based claims against comprehensive ophthalmologists are not. First, clinical decisions about neuroophthalmic conditions may have vision-threatening or life-threatening consequences. Second, because these are often high stakes decisions, earlier diagnosis and treatment make a big difference in final outcome. Third, as opposed to other more common ophthalmic subspecialties, neuroophthalmic consultation may not be easily accessible, timely, or available to the comprehensive ophthalmologist. Fourth, the cost of a neuroophthalmic paid claim is often higher than the typical ophthalmology claim. About 15% of the paid claims (n = 17) of the Ophthalmology Mutual Insurance Company (OMIC) closed with a large loss ($ 250,000). These 17 paid claims represented a disproportionate 59% of OMIC's total paid indemnity (average $ 433,285). Interestingly, in the OMIC series, the number one payout was $790,000 for a failure to diagnose brain tumor that led to death. In addition, a second case of failure to diagnose giant cell arteritis (≥$250,000) was among the large loss cases. This chapter presents composite but real closed cases as well as a few modified cases drawn from the author's medicolegal consultation practice to highlight specific areas of concern, risk management and the potential for systems based failures in neuroophthalmic cases. I want to emphasize that the recommendations in this chapter are meant to be guidelines for care and not necessarily the standard of care.
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