Court Opinion

ID: 771127
Source: CourtListenerOpinion
Date Created: 2012-04-18 10:46:13+00
Date Added: 2024-06-11T17:55:55.276347
License: Public Domain

232 F.3d 595 (7th Cir. 2000)
ROBERT E. DONAIS, Plaintiff-Appellant,v.UNITED STATES OF AMERICA, Defendant-Appellee.
No. 99-3340
In the  United States Court of Appeals  For the Seventh Circuit
Argued April 13, 2000Decided November 13, 2000

Appeal from the United States District Court  for the Northern District of Illinois, Eastern  Division.  No. 96 C 3948--James T. Moody, Judge.
Before HARLINGTON WOOD, JR., ROVNER, and  DIANE P. WOOD, Circuit Judges.
HARLINGTON WOOD, JR., Circuit Judge.

1
In  June 1996, Robert E. Donais sued the  United States pursuant to the Federal  Tort Claims Act, 28 U.S.C. sec.sec. 2671-  2680, alleging that a third-year resident  at the Edward Hines Veterans  Administration Hospital (the "VA") in  Hines, Illinois, committed medical  malpractice in treating Donais for  cataracts by negligently fitting and  implanting an intra-ocular lens in  Donais's right eye, causing the eyesight  to deteriorate and requiring further  surgery to correct the problem. Following  a bench trial, the district court entered  judgment for the United States. Donais  appeals.

I.  BACKGROUND

2
Donais was an accountant who specialized  in tax preparation. Donais, who had never  worn glasses, began to experience  difficulties with his vision in late  1991/early 1992. He first went to a  private ophthalmologist, where he was  diagnosed with cataracts. Surgery was  discussed. Donais contacted the local VA  hospital, where, as a veteran, he would  be covered for cataract surgery. In June  1992, Donais sought an eye examination  and evaluation at the VA eye clinic. At  that time, where a refraction of 0  diopters is equivalent to 20/20 vision,  Donais's right eye had a myopic  refraction of -6.0 diopters and his left  eye had a myopic refraction of -4.0  diopters. Although he had cataracts in  both eyes, he was told that he needed  surgery on his right eye but not on the  left. He was referred to Dr. George  Yanik, a third-year ophthalmology  resident, for cataract surgery.

3
The surgery would replace Donais's  natural lens with an artificial lens  placed in the capsular bag. Yanik's  target was to give Donais a myopic  refraction level of -4.5 to -4.6  diopters.1 Refraction of -4.6 was a  spherical equivalent measurement, which  reflects a combination of the eye's  myopic refraction and the degree of  astigmatism (misshaping of the cornea)  occurring. Astigmatism can often occur as  a consequence of cataract surgery. Yanik  chose this refraction level so Donais's  right eye would be balanced with his  left. Generally, when the two eyes are  not balanced, the imbalance may cause a  condition called "anisometropia," which  makes vision difficult. Yanik also chose  the -4.5 to -4.6 target because Donais  indicated that he did not want to wear  reading glasses, and with this myopic  refraction reading glasses would be  unnecessary.

4
In order to determine the appropriate  power of the implanted lens, two  measurements were used. The first was a K  reading, which measures the curvature of  the cornea. The second was an ultrasound  probe known as an A-scan, which measures  the axial length of the eye from the  front of the cornea to the back of the  retina. These two measurements are then  used in a computer analysis which  calculates the correct lens power.  Yanik's procedure was to take five or  more separate A-scan measurements. If all  of the measurements were within two-  tenths of a millimeter, Yanik would use  the resulting average as the patient's  axial length. The only other figure  needed is known as the "A constant" of  the artificial lens, which is provided by  the lens manufacturer. Using an  established and accepted calculation  known as the SRK formula, Yanik  determined that he would need a 29  diopter lens to achieve his target of  -4.5 to -4.6 diopters.

5
In July 1992, Yanik performed the  surgery without any complications. Soon  after, however, it was discovered that  the right eye was providing a greater  degree of myopic refraction than the  intended -4.6 diopters. Such a difference  is referred to as a "power overshoot."  Six weeks after the surgery, the post-  operative spherical equivalent was -6.63  diopters. Between August and December  1992, the power overshoot in Donais's  right eye was measured six more times,  and remained in the -6 diopter range. In  December, Donais was informed that he  needed surgery for the cataracts in his  left eye. Due to the work demands of the  tax season, Donais did not return to the  VA clinic until May 1993. At that time, a  trial framing (which uses a series of  loose lenses until the patient arrives at  the most accurate correction for him) was  done to determine the refraction as  opposed to an automated machine  refraction which had been used for the  first seven readings. The refraction in  the right eye was -9.5 (myopic reading)  +2.75 (astigmatism), or a spherical  equivalent of -8.12 diopters, as compared  to the December reading of -7.25 +1.0.

6
Donais continued to have problems but  waited until November 1993, after he  turned 65 and was eligible for Medicare  coverage, to schedule an appointment with  Dr. Manus Kraff, a private  ophthalmologist who is a well-known  expert in the treatment of cataracts and  co-creator of the SRK formula used by  Yanik. Kraff proposed a two-step surgical  procedure. First, he would perform  cataract surgery on the left eye to make  the refraction 0 diopters (20/20). After  Donais's recovery, Kraff would then  exchange the too powerful 29 diopter lens  in Donais's right eye with a 23 diopter  lens to make the right eye 0 diopters as  well. Kraff performed the operations in  December 1993 and March 1994,  respectively.

7
Several months after Kraff's second  surgery, Donais began to experience  blurred vision in his right eye due  toincreased astigmatism. Kraff testified  that the increased astigmatism resulted  from the multiple surgeries and the  compromised ability to heal. Donais has  had no problems with his left eye.  However, because of the resulting differ  ences between the two eyes, Donais cannot  tolerate a prescription for the right  eye. Kraff recommended additional  procedures for the right eye to reduce  the astigmatism, but Donais declined to  undergo further surgery. During the  trial, Donais testified that he continues  to suffer from blurry vision, but is able  to read, drive, and watch television for  approximately one to two hours at a time.

8
At trial, Kraff provided expert  testimony on Donais's behalf. Kraff  testified that before the original  surgery, Yanik most likely mismeasured  Donais's right eye, and that was the  reason Yanik chose a too powerful lens.  However, Kraff also testified that a  power overshoot is not always a breach of  the standard of care, and that he himself  has overshot the lens power. Kraff  theorized that the measurements taken by  the VA between August and December 1992  were wrong, and therefore the actual  overshoot after the surgery was higher  than indicated.

9
Dr. Randy Epstein, expert witness for  the United States, stated that Yanik did  not breach any standard of care when he  chose to balance Donais's right eye with  his left eye, even though Epstein himself  would probably not have chosen that  particular refraction. Epstein testified  that power overshoots are common, and, in  1992, the means of measuring the eye were  not always precise and that  mismeasurement causing a power overshoot  would not necessarily be a breach of  care. According to Epstein, the "spike"  in the overshoot could not be caused by  the improper lens power since the lens  power remained constant.

10
The district court found that Donais  failed to provide expert testimony that  proved Yanik breached an applicable  standard of care, and failed to show that  any breach by Yanik proximately caused  Donais's injury.

II.  ANALYSIS

11
Following a bench trial, we apply a  clearly erroneous standard when reviewing  the district court's findings of fact.  Keller v. United States, 58 F.3d 1194,  1197 (7th Cir. 1995) (citation omitted).  The Federal Tort Claims Act provides a  remedy for personal injury caused by the  negligent or wrongful act of any  government employee acting within the  scope of his employment, "under  circumstances where the United States, if  a private person, would be liable to the  claimant for the act in accordance with  the law of the place" where the act  occurred. 28 U.S.C. sec. 1346(b); see  also Midwest Knitting Mills, Inc. v.  United States, 950 F.2d 1295, 1297 (7th  Cir. 1991). Therefore, we apply the law  of Illinois in this action.

12
Under Illinois law, in a medical  malpractice action, the burden is on the  plaintiff to prove (1) the proper  standard of care by which a physician's  conduct may be measured, (2) a negligent  failure to comply with the applicable  standard, and (3) a resulting injury  proximately caused by the physician's  lack of skill or care. Purtill v. Hess,  489 N.E.2d 867, 872 (Ill. 1986)  (citations omitted). "Unless the  physician's negligence is so grossly  apparent or the treatment so common as to  be within the everyday knowledge of a  layperson, expert medical testimony is  required to establish the standard of  care and the defendant physician's  deviation from that standard." Id.  (citations omitted); see also Walski v.  Tiesenga, 381 N.E.2d 279, 282 (Ill.  1978). To establish that a doctor is  guilty of malpractice, the plaintiff must  "introduce evidence of the standard of  care to which the defendants were bound  to adhere." Walski, 381 N.E.2d at 283-84.  The only issue in the present case is  whether Yanik committed medical  malpractice. Therefore, Donais must first  establish an accepted standard of care.

13
Kraff did not state a definitive  baseline standard of care. Kraff  disagreed with Yanik's plan of treatment,  maintaining that "the wrong power of lens  was implanted in Mr. Donais's eye," and  that a target of -4.6 diopters with an  end result of -9 diopters was a breach of  the standard of care. Kraff believed that  Yanik should have targeted the right eye  for a 0 diopter correction, because the  cataract in the left eye would  necessitate surgery and that surgery  would correct the left eye to 0 diopter,  leaving both eyes balanced. Kraff was  unable to determine a specific amount of  overshoot which would constitute a breach  of care. In his deposition, Kraff stated  that an overshoot of 3 diopters would not  be a breach but that 5 diopters would.  However, he also stated that after  surgery where the target was -4.0 to -  4.6, a reading of -7 "is an error, but  that would be hard to say breach." Kraff  also testified that a power overshoot is  not necessarily a breach of care, and  that he himself had on several occasions  missed the target refraction and has had  to replant a different lens.

14
Kraff acknowledged that the seven  measurements taken in the first six  months after Yanik's surgery were all  less than a 3 diopter overshoot, which he  would not ordinarily consider a breach of  care. However, Kraff's explanation for  the "spike" between December 1992 and May  1993 was that it was nonexistent, that it  only appeared because the VA measurements  through December 1992 were inaccurate,  due to the use of automated refraction,  as opposed to the more accurate method of  trial framing, which finally revealed the  "accurate" refraction in May 1993. Kraff  stated that this was his assumption given  the fact that the component measurements  (such as the axial length and the corneal  curvature) used to arrive at the  automated refraction had not been kept in  the VA's records; only the final  refractive correction number was  recorded. However, there was no evidence  presented to support this assumption.  Absent a finding that the government  willfully destroyed evidence in bad  faith, the district court does not abuse  its discretion in declining to infer that  the evidence would have been unfavorable  to that party. Keller, 58 F.3d at 1197.  Therefore, the district court did not err  in declining to accept this portion of  Kraff's theory.

15
Epstein also could not state a  definitive standard of care which would  clearly indicate malpractice. According  to Epstein's deposition testimony,  although he personally might have chosen  a different diopter target, Yanik was not  necessarily wrong in planning a -4.6  diopter target for the right eye to  balance with the left eye. Therefore,  when Donais's right eye was measured at -  8.12 spherical (-9.25 +2.75) in May 1993  at the VA clinic, the resulting 3.6  overshoot would not be considered a  breach of care. Epstein testified, "I  don't think that there is any degree of  myopia that would have made Dr. Yanik  guilty of breaching the standard of care.  [A power overshoot is] just one of those  things that happens with cataract  surgery." He stated, "I would say one of  the recognized risks of cataract surgery  with lens implantation is that a patient  may wind up with a lens implant that is  the wrong power."

16
At trial, while Epstein testified that  up until December 1992, the overshoot was  caused by mismeasurements, he noted that  the additional "spike" in refraction that  was first recorded in May 1993 could  likely have been a result of the lens  repositioning itself due to scarring and  the natural healing process and that  "[i]t happens not infrequently." There  was evidence in the record to support the  fact that the lens had moved into the  sulcus. When Donais was examined in  August 1993, a VA doctor recorded that  the lens was "well fixated in the ciliary  sulcus," yet Yanik stated that he had  inserted the lens into the capsular bag.  When Kraff examined Donais, he recorded  that the lens was well-placed but could  not recall if it was in the bag or the  sulcus. According to Epstein, if the lens  did in fact move forward causing the  "spike" six months after surgery, then  the overshoot following the first five  months of surgery averaged below 3  diopters (spherical equivalent below 2),  which would not be considered outside an  acceptable standard of care. He also  testified that an overshoot of up to 12  diopters would not necessarily be  malpractice, and was unable to draw the  line as to where an overshoot would be  considered a breach of care.

17
When only conflicting opinions as to  what they consider the correct technique  should have been are presented by  testifying physicians, the Illinois  Supreme Court has held that "the  plaintiff has failed to present  sufficient evidence of a standard of care  in the medical community to submit the  case to the jury." Walski, 381 N.E.2d at  284 (listing cases). The plaintiff does  not establish a prima facie case merely  by presenting the testimony of another  physician who states that he would have  acted differently from the defendant. Id.  at 285. Because of the uncertainty of  both expert witnesses in determining the  applicable standard of care, Donais  failed to establish a prima facie case.  In addition, the moving party must  establish that a judgment cannot be  supported by the evidence in order to set  aside the district court's holding. See  Keller, 58 F.3d at 1199 (citations  omitted). Although Donais raises  alternative interpretations of the  evidence, these assertions alone are not  sufficient to show that the district  court's decision could not be supported  by the evidence. The district court  carefully and fully considered all  aspects of this technical case and did  not clearly err in finding for the  defendant based upon Donais's failure to  meet his burden of proof.

III.  CONCLUSION

18
For the above-stated reasons, the  judgment of the district court is  affirmed.

19
AFFIRMED.

Notes:

1
 Yanik testified at trial to these numbers. In his  deposition, he had stated the targeted refraction  was -4.0 to -4.5 diopters. However, throughout  his trial testimony, Yanik most often referred to  the -4.6 number.