Affirmed and Opinion filed August 29, 2019.

In The 

Fourteenth Court of Appeals 

NO. 14-18-00476-CV

MEMORIAL HERMANN HEALTH SYSTEM, INDIVIDUALLY AND 

D/B/A MEMORIAL HERMANN-KATY HOSPITAL; MIKAEL LUCAS, 

M.D.; MIKAEL LUCAS, M.D., PLLC; RANDOLPH WHITFORD, M.D.; 

AND EYES OVER TEXAS EYE CARE P.A., Appellants 

V.

DONNIE HEINZEN, Appellee 

On Appeal from the 129th District Court 

Harris County, Texas 

Trial Court Cause No. 2017-33241 

O P I N I O N 

Under the Texas Medical Liability Act (“the Act”),

1

a medical-negligence

claim is subject to dismissal on the motion of the defendant physician or health-care 

provider if the claimant fails to timely serve reports by qualified experts opining that 

 

1 TEX. CIV. PRAC. & REM. CODE ANN. § 74.001–.507.
2

the defendant’s breach of the applicable standard of care caused the harm alleged. 

Appellee Donnie Heinzen brought medical-negligence claims after she suffered 

permanent vision loss from acute angle-closure glaucoma, and she alleges that the 

damage would have been minimal and reversible but for the breaches of the 

respective standards of care by a hospital’s emergency-room nurses, an emergencyroom doctor, and the ophthalmologist who examined her in the hospital. The various 

defendants challenged some or all of Heinzen’s four expert reports, and the trial 

court denied their respective motions to dismiss. 

 On appeal, the defendants argue that the trial court improperly gave Heinzen 

three 30-day extensions to serve the required expert reports rather than the single 30-

day extension authorized by the Act, and that the trial court improperly considered

expert reports served after the initial extension expired. Some defendants also 

challenge the qualifications of a given report’s author and the adequacy of the reports 

themselves. 

 We conclude that the trial court did not give Heinzen a 30-day extension from 

the date of the oral hearing on the defendants’ objections as they contend, and that 

each of the trial court’s three signed orders granted Heinzen a 30-day extension, 

beginning from the date the order was signed, to cure the original expert report’s 

deficiencies concerning the defendant or defendants named in the order. We further 

conclude that Dr. David Tasker was qualified to render the expert opinions he 

expressed, and that his opinion or opinions applicable to each defendant before us 

satisfied the Act’s requirements. We accordingly affirm the trial court’s orders 

denying the motions to dismiss. 

I. BACKGROUND

 Heinzen contends that she sought treatment for angle-closure glaucoma from 

physicians and health-care providers Dr. Mikael Lucas and Mikael Lucas M.D., 
3

PLLC (collectively, “Dr. Lucas”);2 Memorial Hermann Health System d/b/a 

Memorial Hermann–Katy Hospital (“Memorial Hermann”), and Dr. Randolph 

Whitford.3 According to the allegations in Heinzen’s petition, these individuals and 

entities, whom we refer to collectively as “the Providers,” failed to timely recognize 

and treat Heinzen’s angle-closure glaucoma, and the delay in treatment caused 

permanent damage to Heinzen’s retina and loss of her visual field. 

 After Heinzen served the Providers with the original expert report and 

curriculum vitae of board-certified ophthalmologist Dr. David I. Tasker, the 

Providers timely objected to the report’s sufficiency. Memorial Hermann and Dr. 

Lucas additionally objected that Dr. Tasker was not qualified to render an expert 

opinion. All of the Providers contend that at the December 11, 2017, hearing on their 

objections, the trial court orally granted Heinzen a 30-day extension—that is, until 

January 10, 2018—to supplement her expert report. Heinzen served no supplemental 

expert reports by that date. 

 On January 24, 2018, the trial court signed two orders, each of which granted

Heinzen a 30-day extension to cure any defects in the expert report. The two orders 

differ only in that one order recites that the trial court considered Memorial 

Hermann’s “Objections to Plaintiff’s Expert Report, the response, and the arguments 

of counsel,” and the other substitutes Dr. Whitford’s name for Memorial Hermann’s. 

Thirty days after the trial court signed the orders, Heinzen supplemented Dr. 

 

2 Both at trial and on appeal, the parties have included Dr. Lucas’s professional limitedliability company in their references to Dr. Lucas as an individual, and we do likewise.

3 Heinzen also alleged that other individuals and entities were medically negligent, but the 

case before us concerns only the objections and motions to dismiss of Dr. Lucas, Memorial 

Hermann, and Dr. Whitford. Although Eyes Over Texas Eye Care P.A. purports to join in Dr. 

Whitford’s brief, that entity did not object to any expert report, move to dismiss the claims against 

it, or file a notice of appeal. Thus, unlike Dr. Lucas’s company, Eyes Over Texas Eye Care P.A. 

is not a party to this proceeding.
4

Tasker’s original expert report with a second report by Dr. Tasker and with the report 

and curriculum vitae of Dr. Lige B. Rushing Jr., who is board-certified in internal 

medicine, rheumatology, and geriatrics. Both of Dr. Tasker’s reports address the 

conduct of all of the Providers, but Dr. Rushing offered no opinion regarding Dr. 

Whitford. 

 The Providers objected that these supplemental reports served on February 

23, 2018, were untimely and could not be considered. Drs. Whitford and Lucas also 

objected that Dr. Tasker’s second report did not adequately address the standard of 

care, breach, and causation, and Dr. Lucas repeated those objections as to Dr. 

Rushing’s report. Memorial Hermann reurged its objection to Dr. Tasker’s 

qualifications and objected that both of the February 2018 reports contained 

conclusory opinions of causation. All of the Providers moved for dismissal of the 

respective claims against them. 

 On February 28, 2018, the trial court signed a third order granting Heinzen a 

30-day extension. It is identical to the trial court’s two previous orders except that 

the Provider named is Dr. Lucas. On March 30, 2018, Heinzen served the parties 

with a second report by Dr. Rushing. This report was directed only to the alleged 

negligence of Dr. Lucas and to Dr. Rushing’s qualifications to opine on that issue. 

Dr. Lucas again objected and moved for dismissal. 

 The trial court overruled all objections to the supplemental expert reports and 

denied the Providers’ respective motions to dismiss. The Providers bring this 

interlocutory appeal challenging those rulings. 

II. ISSUES PRESENTED

 All of the Providers argue in their first issue that the trial court abused its 

discretion by giving Heinzen three 30-day extensions to supplement her expert 
5

report and by considering untimely reports. Memorial Hermann also asserts in its 

second issue that Dr. Tasker is not qualified to render an expert opinion regarding 

the conduct of the nursing staff, and that the reports of Drs. Tasker and Rushing are 

conclusory as to causation. In his second issue, Dr. Lucas challenges both experts’ 

qualifications and argues that their reports do not adequately address the applicable 

standard of care, breach, or causation. 

III. TIMELINESS OF THE SUPPLEMENTAL EXPERT REPORTS

 A claimant under the Act must serve an expert’s report and curriculum vitae 

upon each defendant within 120 days after the defendant answers the suit. TEX. CIV.

PRAC. & REM. CODE ANN. § 74.351(a). The defendant must file and serve any 

objections to the report’s sufficiency within twenty-one days after the later of (a) the

date the defendant answered the suit, or (b) the date the report was served. See id. If 

the report is deficient, the trial court may grant the claimant one 30-day extension to 

cure deficiencies. Id. § 74.351(c). “If the claimant does not receive notice of the 

court’s ruling granting the extension until after the 120-day deadline has passed, then 

the 30-day extension shall run from the date the plaintiff first received the notice.”

Id.

 All of the Providers answered the suit on June 9, 2017, and Heinzen timely 

served Dr. Tasker’s curriculum vitae and first expert report on all of the Providers 

on August 2, 2017. The Providers timely objected, and the trial court held an oral 

hearing on their objections on December 11, 2017, which was more than 120 days 

after the Providers answered the suit. Thus, the 30-day extension began to run from 

the date Heinzen first received notice of the trial court’s ruling granting the extension 

to cure the report’s deficiencies as to a given Provider. 

 The Providers contend that Heinzen received such notice when the trial court 

orally granted Heinzen’s request for an extension at the hearing, and that the trial 
6

court improperly granted second and third extensions in January and February 2018. 

Based on this view of events, the Providers argue that the trial court could not 

properly consider any of Heinzen’s three supplemental reports or Dr. Rushing’s 

curriculum vitae. Heinzen responds that the trial court did not orally grant an 

extension at the hearing, and that in each of the trial court’s three signed orders, it 

granted a single 30-day extension to supplement her expert report as to a different 

Provider. 

A. The Alleged Oral Order of December 11, 2017 

 In asserting that the trial court granted Heinzen an extension during the oral 

hearing on their objections, the Providers rely on these two excerpts from the 

transcript: 

MR. HELLER [Heinzen’s counsel]: Your Honor, of course what we’re 

asking for is if—if you feel that any of the reports as to any specific 

defendants [is] deficient, we ask—we’re requesting a 30-day— 

THE COURT: I will give you the 30 days. 

. . .

THE COURT: So—so I’m going to go ahead and grant the objection 

and give you 30 days, and I’ll—I’ll sign the order. 

 By this language, the trial court did not grant an extension. The trial court 

instead stated it “will give you the 30 days”; that it was “going to go ahead and grant 

the objection” and that it shall or will “sign the order.”4

 When used in the first person, 

“going to,” “shall,” and “will” are all verbs in the future tense.5 Thus, the words the 

trial court used at the hearing expressed its intention to grant an extension in the 

future. Cf. State v. Naylor, 466 S.W.3d 783, 788 (Tex. 2015) (“A trial court renders 

 

4

 “I’ll” is a contraction for “I shall” or “I will.” NEW OXFORD AMERICAN DICTIONARY 866 

(Angus Stevenson & Christine Lindberg eds., 3d ed. 2010). 

5

See id. at 742, 1604, and 1977. 
7

judgment orally when it announces rendition as a present act and not as an ‘intention 

to render judgment in the future.’” (quoting S & A. Rest. Corp. v. Leal, 892 S.W.2d 

855, 857 (Tex. 1995) (per curiam)). The oral statements were ineffective to grant the 

extension. See Reese v. Piperi, 534 S.W.2d 329, 330 (Tex. 1976) (trial court’s 

statements “I have to grant a new trial” and “I will grant it” did not constitute oral 

rendition but expressed the trial court’s intention to render judgment in the future); 

Inwood Forest Cmty. Improvement Ass’n. v. Arce, 485 S.W.3d 65, 71–72 (Tex. 

App.—Houston [14th Dist.] 2015, pet. denied) (trial judge’s statement “that she was 

‘going to grant the motions to dismiss’” was “ineffective to constitute a ruling”); see 

also Lopez v. Brown, 356 S.W.3d 599, 602–03 (Tex. App.—Houston [14th Dist.] 

2011, no pet.) (“[T]he notice [of the court’s ruling] provided for in section 74.351(c) 

must be in the form of a written order, rather than a trial court’s mere oral 

pronouncement from the bench.”). We therefore reject the Providers’ argument that 

Heinzen had to serve any supplemental expert reports within thirty days after the 

hearing, and we overrule this part of the Providers’ first issue. 

B. The Signed Orders 

 The trial court signed two orders on January 24, 2018 (“the January Orders”), 

each granting a 30-day extension to cure any deficiencies in Dr. Tasker’s original 

August 2018 report. Pursuant to those orders, Heinzen served the Providers on 

February 23, 2018, with Dr. Tasker’s second report and with Dr. Rushing’s 

curriculum vitae and first report. On February 28, 2018, the trial court signed a third 

order (“the February Order”) granting Heinzen another 30-day extension to cure any 

deficiencies in the original expert report, and in accordance with that order, Heinzen 

served the Providers on March 30, 2018, with Dr. Rushing’s second report. The 

question is, which materials are included within the scope of our review in 
8

determining whether the trial court erred in denying a given Provider’s motion to 

dismiss? 

 Under the Act, the deadline to serve an expert report is specific to a given 

Provider. See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(a) (“[A] claimant shall, 

not later than the 120th day after the date each defendant’s original answer is filed, 

serve on that party or the party’s attorney one or more expert reports, with 

curriculum vitae . . . for each physician or health care provider against whom a 

liability claim is asserted.”) (emphasis added). If the report—that is, the report as to 

“that party”—is deficient, the trial court may grant a single 30-day extension to cure 

the deficiency as to “that party.” Id. § 74.351(c). Thus, in determining whether the 

trial court erred in denying each Provider’s motion to dismiss, we consider (1) the 

materials served within 120 days of that Provider’s answer, and (2) the materials 

served within thirty days after the trial court signed an order granting Heinzen an 

extension to cure the initial report’s deficiencies as to that Provider. 

 The first set of materials is the same for all Providers: all of the Providers 

answered the suit on the same day, and within 120 days, Heinzen served all of the 

Providers with Dr. Tasker’s curriculum vitae and his first report, in which he opined 

on the conduct of each Provider. In contrast, the supplemental materials included 

within the scope of our review are different for different providers. 

 Heinzen contends that the trial court’s January Orders granted her a 30-day 

extension to cure any deficiencies in Dr. Tasker’s first report as it pertains to 

Memorial Hermann and Dr. Whitford, and the February Order granted her a 30-day 

extension to cure deficiencies in Dr. Tasker’s first report with respect to Dr. Lucas. 

We agree, and that conclusion dictates the scope of our review as to the Providers’ 

appeals of the denials of their respective motions to dismiss. 
9

1. The supplemental material included in our review of Memorial 

Hermann’s and Dr. Whitford’s motions to dismiss consists only of Dr. 

Tasker’s second report, Dr. Rushing’s curriculum vitae, and Dr. 

Rushing’s first report. 

 Of the two January Orders, one states that the trial court considered Memorial 

Hermann’s objections, the response, and the arguments of counsel, and the other 

states that the trial court considered Dr. Whitford’s objections, the response, and the 

arguments of counsel. By their terms, these orders granted Heinzen thirty days to 

cure the original report’s deficiencies pertaining to Memorial Hermann and Dr. 

Whitford. If the trial court intended in its January Orders to grant Heinzen an 

extension to cure the deficiencies in Dr. Tasker’s first report with respect to all of 

the Providers, there would have been no need to sign two orders on the same day, or 

to sign a total of three orders, each referring to a different Provider.6

 Because Heinzen served Dr. Tasker’s second report and Dr. Rushing’s first 

report and curriculum vitae thirty days after the trial court signed the January Orders, 

the trial court could properly consider these materials when ruling on Memorial 

Hermann’s and Dr. Whitford’s respective objections and motions to dismiss. We 

therefore overrule Memorial Hermann’s and Dr. Whitford’s challenge to the 

timeliness of these reports, and we include them within the scope of our review as 

to these Providers. Because Dr. Rushing’s second report was served after the January 

Orders’ extension expired, we sustain Memorial Hermann’s and Dr. Whitford’s 

 

6 Although the January Orders are not ambiguous, this result accords with the longstanding 

rule that when construing an ambiguous judgment, the reviewing court must “adopt the 

construction that correctly applies the law.” MacGregor v. Rich, 941 S.W.2d 74, 75 (Tex. 1997) 

(per curiam) (citing Gough v. Jones, 212 S.W. 943, 944 (Tex. Comm’n App. 1919, judgm’t 

adopted)). If one of the January Orders granted Heinzen a 30-day extension to cure the original 

expert report’s deficiencies as to all of the Providers, then the trial court would have incorrectly 

applied the law in signing the February Order impermissibly granting Heinzen a second thirty-day 

extension.
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challenge to the timeliness of that report, and we do not include it within the scope 

of our review of the trial court’s denials of their motions to dismiss. 

2. The only supplemental material included in our review of Dr. Lucas’s 

motion to dismiss is Dr. Rushing’s second report.

 The February Order contains the same language as the January Orders, except 

that it refers only to Dr. Lucas. Because Heinzen served Dr. Rushing’s second report 

within thirty days after the trial court signed this order, we overrule Dr. Lucas’s 

challenge to the timeliness of that report, and we include it in the scope of our review 

in determining whether the trial court erred in denying Dr. Lucas’s motion to 

dismiss. 

 On the other hand, we do not consider Dr. Tasker’s second report, Dr. 

Rushing’s curriculum vitae, or Dr. Rushing’s first report, because these materials 

were neither served within 120 days of Dr. Lucas’s answer nor served within thirty 

days after the trial court granted Heinzen an extension to cure deficiencies in the 

original expert report regarding Dr. Lucas. We sustain Dr. Lucas’s challenge to the 

timeliness of this material, and we do not include it within the scope of our review 

of the denial of his motion to dismiss. 

IV. DR. WHITFORD’S APPEAL

 Dr. Whitford challenges the denial of his motion to dismiss only on the ground 

that the trial court improperly considered the supplemental material served on 

February 23, 2018. Because we have concluded that this material was timely served, 

and Dr. Whitford does not contend the reports are otherwise deficient, we affirm the 

order denying Dr. Whitford’s motion to dismiss. 
11

V. MEMORIAL HERMANN’S APPEAL

 Memorial Hermann contends that Dr. Tasker is unqualified to offer an expert 

opinion regarding the conduct of the hospital nurses, and that Drs. Tasker and 

Rushing offer only conclusory statements of causation. When reviewing the trial 

court’s rulings on an expert’s qualifications and the adequacy of the expert’s report, 

we apply the abuse-of-discretion standard. San Jacinto Methodist Hosp. v. Bennett, 

256 S.W.3d 806, 811 (Tex. App.—Houston [14th Dist.] 2008, no pet.). A trial court 

abuses its discretion if it acts without reference to guiding rules or principles such 

that its ruling is arbitrary or unreasonable. Downer v. Aquamarine Operators, Inc., 

701 S.W.2d 238, 241–42 (Tex. 1985). A trial court does not abuse its discretion 

merely because an appellate justice in similar circumstances would have decided the 

matter differently. Id. at 242. 

A. Dr. Tasker’s Qualifications

To be qualified to opine that an institutional health-care provider breached the 

applicable standard of care, a person must have “knowledge of accepted standards 

of care for health care providers for the diagnosis, care, or treatment of the illness, 

injury, or condition involved in the claim” and be “qualified on the basis of training 

or experience to offer an expert opinion regarding those accepted standards of health 

care.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.402(b)(2), (b)(3).

 Dr. Tasker’s curriculum vitae states that he graduated from Temple University 

School of Medicine in 1969; that he has had a private ophthalmology practice since 

1975; and that he has been board-certified in ophthalmology since 1976. He states 

in his supplemental report that in his last year of medical school, he “was a 

contracted floor nurse at Temple University School of Medicine for ten weeks fulltime.” He also states that during his three-year residency from 1970 to 1972, he 

worked in the emergency rooms of Painesville Memorial Hospital, Kaiser 
12

Permanente Hospital of Cleveland, Altman General Hospital of Akron/Canton, and 

Mt. Sinai Hospital of Cleveland, and that he “became intimately familiar with the 

minimum standards for emergency room nurses, floor nurses, and staff in hospitals 

like Memorial Hermann Hospital.” 

 Memorial Hermann challenges Dr. Tasker’s qualifications only on the ground 

that these experiences predate Heinzen’s claim by several decades. Memorial 

Hermann emphasizes that “Dr. Tasker has not practiced as a nurse in 46 years, and 

he has no current training or experience as a nurse, nor does his report or CV indicate 

he is familiar with the current requirements of conducting and documenting a 

nursing triage assessment in 2015.” 

 While it is true that for certain medical-negligence claims against nonphysicians, a person is qualified to render an expert report only if the person is or 

was engaged in a field of health-care practice “that involves the same type of care or 

treatment as that delivered by the defendant health care provider . . . at the time the 

testimony is given or . . . at the time the claim arose,” that requirement applies only 

“if the defendant health care provider is an individual.” Id. § 74.402(b)(1). Because 

Memorial Hermann is not an individual, this provision does not apply to Dr. Tasker’s 

expert report regarding the care Memorial Hermann provided through its nursing 

staff. See, e.g., Harvey v. Kindred Healthcare Operating, Inc., __S.W.3d__, No. 14-

17-00479-CV, 2019 WL 2063110, *3–4 (Tex. App.—Houston [14th Dist.] May 9, 

2019, no pet.) (holding this subsection inapplicable to an expert report addressing a 

claim against a hospital for its nursing staff’s conduct). 

 Although Memorial Hermann does not dispute that Dr. Tasker’s experiences 

working in emergency rooms and as a floor nurse were sufficient to familiarize Dr. 

Tasker with the standard of care applicable to emergency-department nurses in the 

early 1970s, Memorial Hermann offers no argument or authority for its implicit 
13

assumption that the knowledge gained from these experiences has somehow expired. 

A person can be qualified to render an expert opinion about the standard of care 

applicable to a hospital’s nursing staff based on experience acquired years earlier. 

For example, in Columbia Valley Healthcare System L.P. v. Zamarripa (“Zamarripa 

I”), the claimant relied on an expert report by a registered nurse to establish the 

standard of care applicable to registered nurses staffing a hospital’s labor-anddelivery unit. 520 S.W.3d 62, 69–70 (Tex. App.—Corpus Christi-Edinburg 2015) 

(mem. op.), rev’d on other grounds (“Zamarripa II”), 526 S.W.3d 453 (Tex. 2017). 

The defendant hospital objected to the nurse’s qualifications, pointing out that she 

currently practiced in a hematology-and-oncology unit and had last practiced in a 

labor-and-delivery unit nine years earlier as a licensed vocational nurse. See id. at 

69. Although the Texas Supreme Court reversed on other grounds, it expressly held 

that “[t]he trial court was within its discretion to determine that [the nurse’s] training 

as a registered nurse and her prior experience in the labor and delivery unit qualified 

her to opine on the standard of care.” Zamarripa II, 526 S.W.3d at 461 n.37. 

 Applying this reasoning to the present case, we conclude that the trial court 

did not abuse its discretion in overruling Memorial Hermann’s objections to Dr. 

Tasker’s qualifications. 

B. The Adequacy of Dr. Tasker’s Reports 

An expert report satisfies the Act’s requirements if it “provides a fair summary 

of the expert’s opinions . . . regarding applicable standards of care, the manner in 

which the care rendered by the physician or health care provider failed to meet the 

standards, and the causal relationship between that failure and the injury, harm, or 

damages claimed.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.351(r)(6). Regarding

causation, “[a]n expert must explain, based on facts set out in the report, how and 

why [a health care provider’s] breach [of the standard of care] caused the injury. A 
14

bare expert opinion that the breach caused the injury will not suffice.” Zamarripa II, 

526 S.W.3d at 459–60 (quoting Van Ness v. ETMC First Physicians, 461 S.W.3d 

140, 142 (Tex. 2015) (per curiam) (alterations in original)).

 In his first report, Dr. Tasker stated that Heinzen’s primary complaint in the 

emergency room was eye pain, and that days passed before a non-party 

ophthalmologist diagnosed her acute angle-closure glaucoma. Dr. Tasker explained 

that in acute angle-closure glaucoma, intraocular eye pressure “rises rapidly as a 

result of relatively sudden blockage of the trabecular meshwork by the iris via 

papillary block mechanisms.” He stated that prolonged elevation of intraocular eye 

pressure leads to glaucomatous changes in the optic nerve head and loss of optic 

nerve axons, which in turn leads to a progressive loss of the visual field. 

 Dr. Tasker related that when Heinzen was in the emergency room, her eye 

pain was so severe that she rated it as a 10, and the emergency-room nurse gave 

Heinzen three doses of morphine. Under “primary pain location,” the nurse wrote 

“eye,” but the nurse described “the reason for the visit was headache, with the chief 

complaints of nausea and vomiting for two days, light sensitivity on arrival, and no 

apparent distress.” Dr. Tasker also explained in his first report that if Heinzen had 

been treated in the emergency room, the damage to her vision likely would have 

been minimal and reversible, but the damage to her vision increased each hour that 

her acute angle-closure glaucoma remained untreated. 

 In his second report, Dr. Tasker stated, 

[It] is critically important for nurses and hospital staff to properly 

document complaints and patient history accurately and in order of 

importance. That is true because each successful [sic] healthcare 

provider who reviews the history and complaints taken down by the 

emergency room nurses and staff will rely upon that history to make 

critical decisions. If a nurse makes an error in the order of the history 

and the importance of the history, successive healthcare providers are 
15

likely to rely on that data and make further errors in treatment and 

diagnosis. . . . [T]he emergency-room nurse breached the standard of 

care by failing to take a proper history and to indicate the most 

important item in [Heinzen’s] history was eye pain. Instead the nurse 

focused on headaches. This caused each successive practitioner to focus 

on headaches rather than eye injuries. Needless wasted time was caused 

by the emergency room nurses because they failed to take a proper 

history. The physicians started looking for a head injury and obscure 

diseases rather than the eye injuries that were presented. The nurses 

caused a delay in proper diagnosis by the physicians and further caused 

Donnie Heinzen to suffer acute angle closure for hours and days after 

it should have been diagnosed, and further caused her permanent eye

injuries as a result of the untreated glaucoma.

 Memorial Hermann contends that Dr. Tasker’s reports insufficiently address 

causation because he does not explain how a nursing assessment caused the 

physician defendants to delay making the correct diagnosis, given that “[p]hysicians 

perform their own assessment and create a differential medical diagnosis after 

performing their own examination of the patient.” Memorial Hermann argues that 

under the reasoning of Zamarripa II regarding causation, Dr. Tasker had to explain 

how the nurses had the right or the means to persuade the physicians to make a 

different medical diagnosis.7

 In Zamarripa II, Yolanda Flores was in the third trimester of a pregnancy 

when she experienced fever, vomiting, abdominal pain, and contractions. 526 

S.W.3d at 456. She was taken by ambulance to Valley Regional Medical Center’s 

emergency room, where Dr. Patrick Ellis ordered her transferred to another hospital 

159 miles away. Id. at 456–57. While en route, Flores began to bleed and went into 

 

7

 Memorial Hermann seeks to further support this argument with seven pages of medical 

records, which it includes in the appendix to its brief. When evaluating the sufficiency of expert 

reports, however, courts consider only the reports themselves. Am. Transitional Care Ctrs. of Tex., 

Inc. v. Palacios, 46 S.W.3d 873, 878 (Tex. 2001). Because the medical records are not part of the 

expert reports—indeed, they are not even part of the appellate record—we do not consider them 

or Memorial Hermann’s characterization of their contents. See also TEX. R. APP. P. 34.1.
16

cardiac arrest. See id. at 457. She died shortly after doctors at the receiving hospital 

delivered her stillborn child by cesarean section. See id. 

 The guardian of Flores’s surviving minor children sued the transferring 

hospital, among others, and served the expert reports of an obstetrician/gynecologist 

and of a nurse with labor-and-delivery and emergency-room experience. See id. The 

hospital argued that the expert reports did not adequately show causation. See id. 

The nurse stated in her report that the transferring hospital’s nursing staff breached 

the standard of care by allowing Flores’s transfer to a distant hospital while in 

preterm labor and “by not advocating for” additional treatment, for further 

investigation of Flores’s condition, and for Flores’s retention at Valley Regional. 

See id. at 457–58. The obstetrician’s expert report stated that the nursing staff’s 

breaches of care “in permitting and facilitating” the transfer caused Flores to be in 

an ambulance, where an emergency cesarean section and hysterectomy were 

unavailable, when she began to bleed, and that the bleeding caused her cardiac arrest 

and death. See id. at 458. 

 Valley Regional argued that the reports failed to show how it caused Flores’s 

death, given that it was the doctor, and not the hospital, who ordered the transfer. Id. 

The Texas Supreme Court agreed, stating that the plaintiff’s physician expert “does 

not explain how Valley Regional permitted or facilitated Flores’s transfer, or even 

whether Valley Regional had any say in the matter.” Id. at 461. The court pointed 

out that the nurse’s expert report does not explain how further investigation of 

Flores’s condition would have averted the transfer, and that neither expert 

“explain[ed] how Valley Regional had either the right or the means to persuade Dr. 

Ellis not to order the transfer or to stop it when he did.” Id.

 The facts in this case are distinguishable from those of Zamarripa, which dealt 

with an expert’s unexplained assumption that a hospital’s nursing staff had the right 
17

and ability to persuade a doctor either to refrain from ordering the patient transferred 

or to revoke the order once issued. In contrast, Dr. Tasker opined that Memorial 

Hermann’s nursing staff omitted relevant information and mischaracterized a 

patient’s primary complaint in medical records on which other health care providers 

could and did rely, and that this reliance on faulty records contributed to the delay 

in correctly diagnosing and treating the patient. These circumstances differ from 

those presented in Zamarripa, and more closely resemble the facts in Abshire v. 

Christus Health Southeast Texas, 563 S.W.3d 219 (Tex. 2018) (per curiam). 

 In that case, the plaintiff Abshire had osteogenesis imperfecta (OI), which 

causes brittle bones that easily fracture. See id. at 221. She presented to the defendant 

hospital’s emergency room with complaints of chest and back pain, and the hospital 

discharged her with instructions to follow up with a cardiologist. See id. at 221 & 

n.2. Two days later, Abshire was back, and although her OI was noted, the physician 

ordered only a chest x-ray before releasing her. Id. at 221. She returned the next day 

complaining of pain in her shoulder, neck, back, and chest. Hospital staff again 

documented Abshire’s history of OI and discharged her with diagnoses of 

constipation, musculoskeletal pain, and pleurisy, which is an inflammation of the 

lungs. See id. at 221 & n.4. 

 Six days later, Abshire was taken by ambulance to the same emergency room, 

again complaining of chest and back pain. She remained hospitalized for three days 

and a second chest x-ray was taken, but throughout this time, her OI was not 

documented in her chart. Id. at 221. The day after the hospital discharged her, she 

returned to the emergency room with complaints of weakness in her legs. Id. at 222. 

She was transferred to a rehabilitation facility, with continuing complaints of pain 

and severe weakness, which now were accompanied by bowel and bladder 

incontinence. See id. Abshire was sent back to the same hospital for further 
18

evaluation and once more was medically cleared. Id. at 222. When the hospital again 

tried to send Abshire to the rehabilitation facility, a doctor there intervened and had 

her transferred to another hospital. See id. There, doctors ordered an MRI and 

discovered a compression fracture in a thoracic vertebrae, and the injury to Abshire’s 

spinal cord from the untreated fracture rendered her paraplegic and incontinent. See 

id. 

In Abshire’s suit against the original hospital, her expert opined that the 

nursing staff failed to consider the patient’s prior relevant medical history and 

ignored signs of spinal injury so that they instead focused on a possible cardiac 

problem as the source of Abshire’s symptoms. See id. at 224. The expert explained 

that these breaches of the standard of care caused delay in diagnosing and treating

the compression fracture, which in turn led to Abshire’s paralysis and incontinence. 

See id.

 The Texas Supreme Court held that the expert report sufficiently addressed 

causation by “draw[ing] a line directly from the nurses’ failure to properly document 

Abshire’s OI and back pain, to a delay in diagnosis and proper treatment (imaging 

of her back and spinal fusion), to the ultimate injury (paraplegia).” Id. at 225. The 

intermediate court of appeals had held that the opinion suffered from an analytic gap 

in that doctors did not order tests or provide spinal treatment even on those occasions 

when Abshire’s OI was noted in the record. See id. The Texas Supreme Court 

rejected that view, stating, “it appears the court of appeals simply did not agree with 

[the expert’s] conclusions in light of Abshire’s overall course of treatment,” but “the 

court’s disagreement with the expert’s opinion does not render the expert report 

conclusory.” Id. at 226. 

 Just as the expert report in Abshire drew a line of causation from the nursing 

staff’s failure to properly document the patient’s relevant medical history to the 
19

delay in diagnosis and treatment and thence to the resulting injury, so too do Dr. 

Tasker’s reports causally link the failure of Memorial Hermann’s nursing staff to 

properly document Heinzen’s primary complaint, to the delay in her diagnosis and 

treatment, and then to her resulting vision loss. 

 We conclude that the trial court did not abuse its discretion in overruling 

Memorial Hermann’s objection that Dr. Tasker’s reports were conclusory on the 

causation issue. Thus, without deciding whether Dr. Rushing’s report similarly 

supports Heinzen’s claims against the hospital, we affirm the order denying 

Memorial Hermann’s motion to dismiss. 

VI. DR. LUCAS’S APPEAL

 Dr. Lucas challenges the qualifications of Drs. Tasker and Rushing and argues 

that the reports of both experts fail to adequately address the standard of care, breach, 

and causation. Because we conclude that Dr. Tasker was qualified to opine that Dr. 

Lucas’s breach of the applicable standard of care caused Heinzen’s vision loss, and 

that his opinion satisfied the statutory requirements, we need not consider Dr. 

Lucas’s issues concerning Dr. Rushing.8

A. Qualifications 

 The qualifications necessary to author an expert report in a medicalnegligence claim against a physician are described in the Act as follows: 

(a) In a suit involving a health care liability claim against a physician 

for injury to or death of a patient, a person may qualify as an 

expert witness on the issue of whether the physician departed 

from accepted standards of medical care only if the person is a 

physician who: 

 

8 As previously discussed, the scope of our review of Dr. Lucas’s appeal includes Dr. 

Tasker’s first report and curriculum vitae and Dr. Rushing’s second report, but does not include 

Dr. Tasker’s second report, Dr. Rushing’s first report, or Dr. Rushing’s curriculum vitae.
20

(1) is practicing medicine at the time such testimony is given 

or was practicing medicine at the time the claim arose; 

(2) has knowledge of accepted standards of medical care for 

the diagnosis, care, or treatment of the illness, injury, or 

condition involved in the claim; and 

(3) is qualified on the basis of training or experience to offer 

an expert opinion regarding those accepted standards of 

medical care. 

. . .

(c) In determining whether a witness is qualified on the basis of 

training or experience, the court shall consider whether, at the 

time the claim arose or at the time the testimony is given, the 

witness: 

(1) is board certified or has other substantial training or 

experience in an area of medical practice relevant to the 

claim; and 

(2) is actively practicing medicine in rendering medical care 

services relevant to the claim. 

TEX. CIV. PRAC. & REM. CODE ANN. § 74.401. 

 When determining whether the person meets these qualifications, we look 

only to the four corners of the expert report and the curriculum vitae. Methodist 

Hosp. v. Addison, 574 S.W.3d 490, 503–04 (Tex. App.—Houston [14th Dist.] 2018, 

no pet.) (citing Mem’l Hermann Healthcare Sys. v. Burrell, 230 S.W.3d 755, 758 

(Tex. App.—Houston [14th Dist.] 2007, no pet.)). These materials must establish 

the expert’s knowledge, skill, experience, training, or education regarding the 

specific issue before the court. Id. at 504 (citing Baylor Coll. of Med. v. Pokluda, 

283 S.W.3d 110, 118–19 (Tex. App.—Houston [14th Dist.] 2009, no pet.)). 

Dr. Lucas contends that Dr. Tasker is not qualified to render an expert opinion 

regarding the claims against Dr. Lucas because Dr. Tasker was not actively 

practicing emergency medicine at the time the claim arose or at the time of his report. 
21

To clarify the required qualifications, an expert must know the “accepted standards 

of medical care for the diagnosis, care, or treatment of the illness, injury, or condition

involved in the claim.” TEX. CIV. PRAC. & REM. CODE ANN. § 74.401(a)(2) 

(emphasis added). By its plain language, the statute does not focus on the defendant 

doctor’s area of expertise, but on the condition involved in the claim. See Blan v. 

Ali, 7 S.W.3d 741, 746 (Tex. App.—Houston [14th Dist.] 1999, no pet.). As 

previously mentioned, a witness providing an expert report concerning a nonphysician individual must be “practicing health care in a field of practice that 

involves the same type of care or treatment as that delivered by the defendant health 

care provider . . . at the time the testimony is given or was practicing that type of 

health care at the time the claim arose,” TEX. CIV. PRAC. & REM. CODE ANN. 

§ 74.402(b)(1), but the provision governing qualifications to issue an expert report 

concerning a physician does not contain this language. See id. § 74.401.

 The “illness, injury, or condition” involved in Heinzen’s claim is acute angleclosure glaucoma. Thus, to offer an expert opinion, Dr. Tasker must be “qualified 

on the basis of training or experience to offer an expert opinion regarding those

accepted standards of medical care,” that is, “the accepted standards of medical care 

for the diagnosis, care, or treatment” of acute angle-closure glaucoma. See id.

§ 74.401(a)(3) (emphasis added). And to determine whether Dr. Tasker is qualified 

on the basis of training or experience to offer an expert opinion on the standards of 

care for the diagnosis, care, or treatment of acute angle-closure glaucoma, the trial 

court was required to consider whether, at the time the claim arose or at the time he 

authored the reports, Dr. Tasker had substantial training and experience in “an area 

of medical practice relevant to the claim” and was actively practicing medicine in 

rendering medical care services “relevant to the claim.”
22

 Dr. Tasker is board-certified in ophthalmology, and Dr. Lucas does not 

dispute that Dr. Tasker knows the accepted standards of medical care for the 

diagnosis, care, or treatment of acute angle-closure glaucoma; Dr. Lucas instead 

asserts that Dr. Tasker failed to demonstrate any experience, training, or education 

in emergency medicine. But Dr. Tasker stated in his report, “I currently care for 

patients with similar conditions as Ms. Donnie Heinzen and in hospital facilities 

similar to Memorial Hermann emergency room”9

 and “[t]he standard of care that 

applies to the care I provide, applies in an identical manner to that of Memorial 

Hermann Hospital emergency room.” He further stated, 

I am qualified to have an opinion on the standard of care of any and all 

physicians who treat patients who have ophthalmologic emergencies, 

ophthalmologic diseases, and conditions, as every medical doctor who 

specializes in the field of ophthalmology and who treats such patients 

as Ms. Heinzen. Also, I have a fundamental knowledge of the effects 

of misdiagnosis and the inability to recognize the ophthalmologic 

emergency condition of angle closure glaucoma. I know and understand 

how to do an ophthalmologic examination on a patient like Ms. Heinzen 

and how to emergency [sic] conditions such as angle closure glaucoma 

and how to follow patients like Ms. Heinzen during and after angle 

closure glaucoma. I am qualified to have an opinion on the standard of 

care of emergency room physicians presented with an ophthalmologic 

emergency such as angle closure . . . , as they should have been trained 

on what actions to take and how to diagnose and treat a patient with 

angle closure glaucoma who presents to the hospital with severe eye 

pain, severe visual loss in both eyes, headache, red eyes, conjunctiva 

swelling, nausea, and vomiting such as Ms. Heinzen.

 Given these statements, we cannot say that the trial court abused its discretion 

in concluding that Dr. Tasker is qualified to render an expert opinion concerning 

Heinzen’s claims against Dr. Lucas. 

 

9 Emphasis added.
23

B. Adequacy of the Report 

 Dr. Lucas also contends that Dr. Tasker’s expert reports fail to adequately 

address the applicable standard of care, breach, and causation. Because the same 

excerpts from Dr. Tasker’s first report address both the standard of care and breach, 

we address those alleged deficiencies together. 

1. The Standard of Care and Breach

 According to Dr. Lucas, Dr. Tasker opines that the standard of care requires 

that an emergency-room physician (1) must recognize angle-closure glaucoma, 

(2) must not misdiagnose angle-closure glaucoma as some other condition, (3) must 

call or refer the patient to an ophthalmologist for emergency treatment, and (4) must 

treat angle-closure glaucoma to lower intraocular pressure to avoid vision loss. Dr. 

Lucas argues that Dr. Tasker’s reports are deficient in that he does not state how an 

emergency-room physician is to avoid misdiagnosis; how or why the physician is to 

recognize angle-closure glaucoma; why the physician must call or refer the patient 

to an ophthalmologist for emergency treatment; or how the physician must lower 

intraocular pressure. 

(a) Failure to Correctly Diagnose, or to Transfer for Diagnosis 

 Dr. Lucas’s arguments are based solely on Dr. Tasker’s second report, which 

we do not consider, but the standard of care applicable to an emergency-room 

physician and the breach of that standard were addressed in Dr. Tasker’s first report. 

There he wrote, 

The standard of care is clear for the history, examination, testing, 

diagnosis, and treatment of the ophthalmologic emergency of angle 

closure glaucoma. It should be recognized by any emergency room 

staff, emergency room physician, and of course an ophthalmologist. 

Acute angle closure, as with Ms. Heinzen[,] is clear when one presents 

with blurring of vision, painful red eye, headache, nausea, and 
24

vomiting. Diagnosis is made by testing for high intraocular pressure 

(IOP), corneal edema, shallow anterior chamber, and a closed angle on 

gonioscopy. Medical or surgical therapy is directed at widening the 

angle and preventing further angle closure. The pressure must be 

lowered or the patient [sic] peripheral vision loss will occur due to the 

destruction of the nerve fiber layer and optic nerve. . . . A typical 

history of angle closure includes reduced vision, eye redness, corneal 

edema, engorged conjunctival vessels, halos around lights, aching eye 

or brow pain, and headache. Here, Ms. Heinzen presented with severe 

eye pain in both eyes, severe visual loss, headache, redness, conjunctiva 

swelling, tearing, light sensitivity, a hazy cornea and nausea and 

vomiting. These signs and symptoms are classic for angle closure 

glaucoma and high intraocular pressure. These alone should have made 

the emergency room doctor and ophthalmologist think to rule out angle 

closure glaucoma. If properly examined[,] reduced acuity, a closed 

angle upon gonioscopy, high intraocular pressure, corneal edema, a 

fixed dilated pupil, and engorged conjunctival vessels are typically 

found. Dr. Lucas should have been able to diagnose Ms. Heinzen as 

presenting with angle closure glaucoma. Proper examination was not 

done by Dr. Lucas. . . .

 It is imperative that a thorough ophthalmologic examination is 

done by an emergency room physician or ophthalmologist. If these tests 

cannot be done at the presenting hospital, the patient should be 

immediately transferred to a hospital or facility with the ability to 

assess, test, diagnose, and treat the patient. A thorough ophthalmologic 

examination is not documented in the medical record by Dr. Lucas on 

the date of Ms. Heinzen’s presentation to the emergency room. A slit 

lamp exam, gonioscopy examination, and perimetry were never done.

There is no documentation that an intraocular pressure was ever 

done. . . . Without an intraocular pressure being taken one would never 

even know if the intraocular pressure was high or suspect angle closure 

glaucoma. Not doing an accurate ophthalmologic examination in a 

timely fashion is below the standard of care. Not recognizing the typical 

signs and symptoms of angle closure and ophthalmologic emergency is 

below the standard of care. 

 If properly diagnosed upon presentation dynamic gonioscopy, 

oral carbonic anhydrase inhibitors and or topical beta blocker and or 

topical alpha 2 agonist, topical cholinergic agonists, hyperosmotic 
25

agents and of course laser peripheral iridotomy after the acute attack is 

resolved and corneal edema resolves should be done. 

. . .

First tests to order after the history and exam reveals symptoms of angle 

closure glaucoma: 

 Gonioscopy: 

Definitive test for diagnosing angle closure; gonioscopy of both 

eyes should be performed on all patients in whom angle closure 

is suspected.10 It should also be performed prior to instilling 

dilating medications to rule out eyes susceptible to angle closure. 

. . . .

Gonioscopy may be therapeutic in breaking the attack of acute 

angle closure. 

Result: TM is not visible in angle closure because the peripheral 

iris is in contact with it. 

Dr. Lucas . . . did not do this test.

 Slit lamp examination:

The best method of examining the optic disc is with the slit lamp 

combined with a high magnification posterior pole lens. The 

anterior chamber depth should be noted and the size of the phakic 

lens. 

Result: shallow anterior chamber; and signs of glaucoma: large 

optic cup, narrowing of the neuroretinal rim, splinter 

hemorrhage, nerve fiber loss. 

This was not documented as done by Dr. Lucas . . . .

 Automatic static perimetry:

Identifies the presence, and quantifies the amount, of 

glaucomatous visual field loss during initial diagnosis and 

subsequently during follow-up care. 

Result: visual field defects 

 

10 Dr. Tasker explained elsewhere in his report, “Gonioscopy enables the health care 

provider to view the anterior chamber angle so as to evaluate the angle structures.”
26

This was not done by Dr. Lucas. . . . 

As Dr. Tasker stated, the standard of care requires an emergency room 

physician to recognize that “severe eye pain in both eyes, severe visual loss, 

headache, redness, conjunctiva swelling, tearing, light sensitivity, a hazy cornea and 

nausea and vomiting” are “classic” symptoms of acute angle-closure glaucoma. He 

further explained that when a patient presents with such symptoms, acute angleclosure glaucoma must be diagnosed or ruled out by performing gonioscopy, a slit 

lamp examination, and automatic static perimetry. Gonioscopy is the “[d]efinitive 

test for diagnosing angle closure,” and “may be therapeutic in breaking the attack.”

He also stated that the emergency-room physician must view the optic disc and note 

the depth of the anterior chamber and the size of the phakic lens by performing a slit 

lamp examination and must additionally identify and quantify any glaucomatous 

visual field loss by ordering or performing automatic static perimetry. Having 

identified the symptoms suggesting acute angle-closure glaucoma and the diagnostic 

tests required by the standard of care, Dr. Tasker added that if the hospital could not

perform the tests, then the standard of care required the emergency-room physician 

have the patient transferred to a facility that could do so. He opined that Dr. Lucas 

did none of these things.

 We accordingly conclude that Dr. Tasker sufficiently (i) identified the reasons 

that Dr. Lucas would have recognized acute angle-closure glaucoma if he had 

adhered to the standard of care, and (ii) described how Dr. Lucas’s breach of the 

standard of care delayed Heinzen’s correct diagnosis and treatment. 

(b) Failure to Treat, or to Transfer for Treatment 

 Dr. Lucas also contends that Dr. Tasker’s reports are deficient in that he 

opines that the standard of care required an emergency-room physician in the 

circumstances presented here to call or refer the patient to an ophthalmologist and 
27

to treat angle-closure glaucoma to lower intraocular pressure, but he does not say 

why an ophthalmologist must be called or how the condition must be treated. 

 In support of these arguments, Dr. Lucas again cites only Dr. Tasker’s 

inapplicable second report, but the treatment required by the standard of care and the 

role of an ophthalmologist are detailed in Dr. Tasker’s first report: 

 Once diagnosed, the initial intervention includes acetazolamide, 

a topical beta-blocker, and a topical steroid. Acetazolamide should be 

given as a stat dose of 500 mg IV followed by 500 mg PO. A dose of a 

topical beta-blocker (i.e., carteolol, timolol) will also aid in lowering 

IOP [intraocular pressure]. Beta-blockers and acetazolamide decrease 

aqueous humor production and help to open the angle. An alpha-agonist 

can be added for a further decrease in IOP. Inflammation causes the

pathophysiology and presenting symptoms. Topical steroids are used to 

decrease the inflammatory reaction and reduce optic nerve damage. The 

current recommendation is for 1-2 doses of topical steroids. . . . 

Analgesics for pain and antiemetics for nausea and vomiting can 

increase IOP beyond its already elevated level. Ms. Heinzen was given 

antiemetics and pain medication which would have typically increased 

the intraocular pressure. Placing the patient in the supine position may 

aid in comfort and reduce IOP. This was not done. It is also believed 

that, while supine, the lens may fall away from the iris decreasing 

pupillary block. After the initial intervention, the patient should be 

reassessed. Reassessment includes evaluating IOP, evaluating drops, 

and considering the need for further intervention, such as osmotic 

agents and immediate iridotomy. . . .

 Approximately 1 hour after beginning treatment, pilocarpine, a 

miotic that leads to opening of the angle, should be administered every 

15 minutes for 2 doses. In the initial attack, the elevated pressure in the 

anterior chamber causes a pressure-induced ischemic paralysis of the 

iris. At this time, pilocarpine would be ineffective. During the second 

evaluation, the initial agents have decreased the elevated IOP and 

hopefully have reduced the ischemic paralysis so pilocarpine becomes 

beneficial in relieving pupillary block. This standard of care treatment 

[sic] was not provided due to the fact that no one in the emergency room

(Dr. Lucas . . .) . . . did not [sic] recognize, diagnose, or treat for angle 

closure glaucoma.
28

 . . . .If the intraocular pressure is not reduced 30 minutes after the 

second dose of pilocarpine, an osmotic agent must be considered. An 

oral agent like glycerol can be administered in nondiabetics. Ms. 

Heinzen is diabetic so oral isosorbide could be used to avoid the risk of 

hyperglycemia associated with glycerol. Patients who are unable to 

tolerate oral intake or do not experience a decrease in intraocular 

pressure despite oral therapy are candidates for intravenous mannitol to 

lower the pressure. This was not done by Dr. Lucas . . . .

 When medical therapy proves to be ineffective, corneal 

indentation (CI) can be used as a temporizing measure to reduce IOP 

until definitive treatment is available. As the cornea is indented, 

aqueous humor is displaced to the periphery of the anterior chamber, 

which serves to temporarily open the angle. This leads to immediate 

reduction of IOP and occasionally may completely abort the attack. 

After applying topical anesthetic, any smooth instrument can be used 

to perform this procedure, including a gonioprism (ideal, if available), 

or a cotton-tipped applicator. Obviously, a concern with performing CI

is the possibility for damage to the corneal epithelium, which may 

complicate the patient’s course.

 Laser peripheral iridotomy or LPI, performed 24-48 hours after 

IOP is controlled, is the standard of care therapy and considered the 

definitive treatment for angle closure glaucoma. . . . Lens extraction 

may also be considered by some to help reduce the intraocular pressure 

if cataracts may be blocking the angle. 

 The ophthalmologist should decide after testing including 

gonioscopy with complete visualization and inspection of the angle 

which therapy will be most beneficial to the patient. If ophthalmologic 

consultation is not immediately available, the standard of care is that 

the emergency department physician must begin pharmacologic 

therapy as described previously above. Therapy should reduce 

intraocular pressure and ophthalmologic evaluation must be quickly 

obtained either within the emergency room or by transferring the 

patient to a facility or emergency room with an ophthalmologist who 

can immediately treat the patient. If the IOP is unchanged or increased, 

with appropriate pharmacologic therapy, a laser iridotomy must be 

done immediately. Because outcome is adversely affected by the 

duration of symptoms, expeditious evaluation by an ophthalmologist is 

required. Ocular massage through a closed eyelid may be performed 
29

while waiting for ophthalmology if no other treatment reduces IOP. 

None of this was done by the emergency room doctors . . . . 

 We conclude that Dr. Tasker not only adequately explained the role of an 

ophthalmologist, but also sufficiently described the care that an emergency-room 

physician must render while awaiting an ophthalmologist’s evaluation, and which 

Dr. Lucas failed to perform. 

2. Causation

 Dr. Tasker opined that if Heinzen had been properly treated in the emergency 

room, the damage to her vision likely would have been minimal and reversible, and 

that the damage to her vision increased each hour that her acute angle-closure 

glaucoma remained untreated. Dr. Lucas contends that this causation opinion is 

deficient in that Dr. Tasker does not state how Dr. Lucas should have treated Heinzen 

and how that treatment would have stopped or reversed the damage. 

 Here, too, Dr. Lucas’s arguments rely solely on the content of Dr. Tasker’s 

second report, but as we have just seen, Dr. Tasker’s first report details the treatment 

Dr. Lucas should have provided. Dr. Tasker further explained how the delay in 

diagnosis and treatment allowed the damage to Heinzen’s eyes to progress: 

Angle-closure glaucoma (ACG) may be reversible and may be caused 

by mechanical blockage or by adhesions called synechia which close 

the anterior-chamber angle. The angle closure may occur in an acute or 

chronic form. In the acute form, the IOP rises rapidly as a result of 

relatively sudden blockage of the trabecular meshwork by the iris via 

papillary block mechanism. The chronic form may develop after acute 

angle closure where synechial closure of the angle persists, or it may 

develop over time as the angle closes from prolonged or repeated 

contact between the peripheral iris and the TM, which often leads to 

peripheral anterior synechiae (PAS) and functional damage to the 

angle. Time is of the essence. . . . It is well known that prolonged 

elevation of intraocular pressure leads anatomically to glaucomatous 

changes in the optic nerve head and loss of optic nerve axons and leads 
30

to a progressive loss of the visual field. This is what happened in all 

medical probability to Ms. Heinzen. 

. . .

Ms. Heinzen’s ocular status began to deteriorate from the time she 

arrived in the emergency room until days later when she was finally 

seen by Dr. Wycoff. In my opinion, earlier intervention (proper 

diagnosis and treatment) in all of these areas would have in medical 

probability have [sic] saved her peripheral vision, optic nerve, nerve 

fiber layer, and other such ocular damage. . . . The patient kept getting 

worse and the eye pain and ocular symptoms got worse. . . . No one 

addressed the fact that Ms. Heinzen’s conditioning was worsening . . . . 

 As with the physician’s expert report in Abshire, Dr. Tasker’s report in this 

case draws a line directly from Dr. Lucas’s breach of the standard of care, to the 

delay in diagnosis and treatment, and thence to the ultimate injury. See Abshire, 563 

S.W.3d at 225. We conclude that Dr. Tasker’s reports satisfied the statutory 

requirements, and we overrule Dr. Lucas’s second issue. 

VII. CONCLUSION

 Having affirmed the trial court’s overruling of the Providers’ dispositive 

objections to Dr. Tasker’s first and second expert reports, we affirm the denial of the 

Providers’ respective motions to dismiss. 

 

 /s/ Tracy Christopher 

 Justice 

Panel consists of Justices Christopher, Hassan, and Poissant.