Quiroz ex rel. Cardona v. Llamas-Soforo

483 S.W.3d 710, 2016 Tex. App. LEXIS 43, 2016 WL 90668
CourtCourt of Appeals of Texas
DecidedJanuary 6, 2016
DocketNo. 08-14-00073-CV
StatusPublished
Cited by5 cases

This text of 483 S.W.3d 710 (Quiroz ex rel. Cardona v. Llamas-Soforo) is published on Counsel Stack Legal Research, covering Court of Appeals of Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Quiroz ex rel. Cardona v. Llamas-Soforo, 483 S.W.3d 710, 2016 Tex. App. LEXIS 43, 2016 WL 90668 (Tex. Ct. App. 2016).

Opinion

OPINION

STEVEN L. HUGHES, Justice

This is a medical malpractice case. Elizabeth Quiroz brought suit as next friend of her son, Joseph' Cardona, against Dr. Jorge Fabio Llamas-Soforo, his professional association,1 and others.2 Quiroz alleged Dr. Llamas was negligent in screening and'treating Joseph’s retinopa-thy of prematurity (ROP) resulting in complete blindness in Joseph’s right eye and minimal vision in his left. In particular, Quiroz alleged that Dr. Llamas failed to adequately evaluate Joseph’s condition and to perform proper cryotherapy on Joseph’s eyes. - The jury answered “no” to the question whether Dr. Llamas’ negligence, if any, proximately caused Joseph’s injury, and the trial court rendered a take-nothing judgment on the jury’s verdict. On' appeal, Quiroz contends the jury’s finding is against the great weight and preponderance of the evidence, and also asserts the trial court committed various" procedural errors requiring a new trial. We affirm.

BACKGROUND

Joseph Cardona suffered a premature birth on August 9,1998, when he was born to Elizabeth'Quiroz as the second of twin sons. Joseph was born at 24 weeks’ gestation,3 weighed only 525 grams, and was at the limit of viability.4 While all premature babies are “at risk,” prematurely-born twins face additional difficulties in terms of viability.5 Joseph had less than a 50 percent chance of survival at birth, and suffered from respiratory distress syndrome, hypocalcemia, hypernatremia, hyperbiliru-binemia, bilateral inguinal hernia, intra-ventricular hemorrhage, periventricular leukomalacia, feeding problems, and sepsis — an “overwhelming infection” capable of damaging brain and body., Joseph was also diagnosed with cerebral palsy.

[714]*714As a premature infant, Joseph’s risk for retinopathy of prematurity (ROP) .was very high. ROP is a disease resulting from premature birth in which the blood vessels of the retina6 develop abnormally. Left untreated, ROP can lead to retinal traction folds,, retinal detachments, and blindness.

A premature infant’s retina is not yet vascularized and has no blood supply. From being outside the womb, a premature infant’s unvascularized retina sends a chemical signal to encourage vascularization to get an adequate blood supply. ROP develops when these blood vessels grow in an unorganized manner into .the eye cavity,instead of along the back wall. Their outward growth into the eyé cavity and its effects are described in ascending severity as stages 1 through 5, with stage 5 representing total detachment of the retina into the center of the eye. The location of the blood vessels is described according to the “zone” of the eye, with zone I being the inner circle, surrounded by zones II and III. Zone ! is the most dangerous area because ROP can develop swiftly there, whereas ROP in zone II often has “a more benign course[.]”' The quantity and location of ROP within a zone is described by “clock hours.”

These abnormal blood vessels bleed and release proteins that produce fibrous bands and scar tissue that pulls the retina off center. If not timely treated, this “traction” leads to retinal detachment and limited or total loss of vision, depending on the degree of detachment.

ROP develops at a variable, non-linear rate, but most premature babies who develop ROP experience improvement without surgical treatment.7 If untreated, ROP can blind the child in as little as a few days, or it may take a few weeks. Children born between 28 to 35 weeks gestation with a 500-gram birth weight can be blinded within one week if not timely treated. One of the complications of ROP is “plus disease,” which occurs when blood vessels around .the optic nerve are dilated, engorged and follow a tortuous route, and are more likely to break and bleed into the eye. Bleeding inside the eye can indicate possible “plus disease.”

ROP is treated by ablation of the peripheral retina to eliminate the cells releasing the chemical stimulating abnormal blood vessel growth. Ablation can be accomplished through cryotherapy, also called cryosurgery, by freezing the tissue using a cryoprobe. The freezing occurs when the surgeon touches the probe tip to the outside of the eye, while looking inside the eye to see the ice ball that forms. Properly performed, cryotherapy causes minimal restriction of visual field and very little vision loss. It also leaves permanent scars. Incorrect cryotherapy can result in cataracts or retinal detachment. A study addressing the use of cryotherapy for ROP determined that infants receiving proper and timely treatment often experience good outcomes, but that cryotherapy treatment did not guarantee the avoidance of a bad outcome, including blindness. Dr. Llamas testified that 44 percent of the children who received timely and appropriate treatment during trials experienced a bad outcome. The American Academy of Pediatrics, the American Association [715]*715for Pediatric Ophthalmology and Strabis-mus, and the American Academy of Ophthalmology published a joint statement entitled, “Screening Examination of Premature Infants for Retinopathy of Prematurity,” in which they suggested guidelines for screening infants at high risk for ROP. The guidelines, which were in effect when Joseph was born in 1998, recommended that infants with a'birth weight of less than 1500 grams or with a gestational age of 28 weeks' or less should have an ophthalmoscopic examination to detect ROP by an ophthalmologist, specifically one having experience in the examination of preterm infants. The guidelines suggested the examination be performed between 4 and 6 weeks’ chronological age or between 31 and 33 weeks’ postconceptional age (defined as gestational age at birth plus chronological age), as determined by the infant’s attending pediatrician or neo-natologist.

The guidelines provide that the scheduling of follow-up examinations is best determined by the findings of the first examination, and specify' that if the retinal vasculature is immature and in zone II but no plus disease is present, follow-up examinations should be planned at approximately two to four week intervals until vascularization proceeds to zone III. For infants with ROP or immature vessels detected in zone I, the most dangerous zone, examinations should be at least every one to two weeks until normal vascularization proceeds to zone III or the risk of attaining threshold conditions has passed. Infants with “threshold disease”8 should be considered candidates for ablative therapy within 72 hours of diagnosis.

An ROP examination is not benign. It is traumatic for a baby, whose eyes are very small. The procedure involves using an eyelid speculum to open the baby’s eyes and a scleral depressor to press on the wall of the eye. The pressure placed >on the eye may increase thé infant’s heart rate. The drops that aré placed in the baby’s eyes also may affect heart rate, as well as the stomach and digestion; The baby may stop breathing during the examination. For these treasons, according to Dr. Llamas, the guidelines suggest weekly rather than daily examinations because it is unreasonable to expose a baby to these risks on a daily basis. \

Joseph, who was born on August 9,1998, was 30 weeks’ posteonceptual age on September 21, 1998., That day, as requested by a neonatologist, Dr, Llamas, a retinologist, performed his .initial examination of Joseph’s eyes and found no ROP.

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483 S.W.3d 710, 2016 Tex. App. LEXIS 43, 2016 WL 90668, Counsel Stack Legal Research, https://law.counselstack.com/opinion/quiroz-ex-rel-cardona-v-llamas-soforo-texapp-2016.