Bucks Montgomery Physician Fall 2020 - 16

FEATURE

Thinking "out of the box" is exemplified by the following
two cases. A teenager was gardening in his yard when he
suddenly felt like he had something in his eye. His mother
washed the eye with water, but the irritation continued
for a few days. He then sought the help of a pediatric
ophthalmologist when the eye became red. He was treated
with topical ocular steroids for several weeks but the
intraocular inflammation [anterior uveitis] continued and
increased. An extensive workup for Juvenile idiopathic
arthritis [JIA] was normal. A retinal consult suggested
to increase the steroid dose. It did not help. A PCR test
revealed a fungus etiology and appropriate treatment with
voriconazole. However, vision was significantly lost in
the involved eye prior to the initiation of treatment. The
physicians in this case never considered other possible
causes of the uveitis despite the history of gardening.
Since the etiology of anterior uveitis is often never
uncovered despite laboratory blood test, the possibility of
a non-bacterial infectious cause was never considered.
A retired research professor at a renowned eastern
university developed bilateral anterior uveitis. He was
treated using topical steroids by an ophthalmologist
whose subspecialty was cornea and external disease. She
treated him continually with no improvement, worsening

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inflammation, decreasing visual acuity, and increasing
high intraocular pressures. Finally, a PCR test revealed
a viral etiology, but the damage was already done. The
PCR test was recommended by another specialist. The
use of Foscarnet as an antiviral agent was too late to
save the patient's eyesight. The patient was left blind.
Thinking of what could be the reason for the increasing
steroid dosing was not resulting in improvement of
the uveitis was not considered. An open mind should
have been utilized by the academic corneal specialist.
Thus, I have discussed some cases that resulted in
malpractice litigation that could have been avoided
if the physicians involved had an open mind and
considered all the possibilities, however rare. Ruling
out all possibilities first would have prevented
untoward outcomes. Always keep an open mind.
Harold P. Koller, M.D., FACS, FAAP
Professor of Ophthalmology, Thomas Jefferson University
Past Chair, Section on Ophthalmology
American Academy of Pediatrics
Teaching Staff, Wills Eye Hospital, Philadelphia
Clinical Affiliate, Children's Hospital of Philadelphia
Bucks Montgomery Physician Fall 2020

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