Systemic failures led to a patient under the care of Arizona optometrists going blind. What lessons can be learned—and what harm has been done to the reputation of optometry?
A case of preventable blindness and the resultant disciplinary actions taken by the Arizona State Board of Optometry (USA) against two optometrists, Dr. Jordan Bluth and Dr. Lisa Field-Sherlock, both of Southwestern Eye Center, underscore how small deviations from standard protocols can have catastrophic outcomes.
DH, an anonymous monocular patient with a history of retinal detachment in the fellow eye, underwent cataract surgery on December 11, 2023. But what began as a routine procedure spiraled into a nightmare when DH reported new floaters and worsening vision during her postoperative visits.
Despite these red flags, no posterior retinal examination was performed—until it was too late. By the time DH saw a retinal specialist on January 10, 2024, a macula-off retinal detachment had occurred, leaving her blind in her remaining functional eye.
“I kept telling everybody, there’s something wrong. I can’t see good. Not like I was supposed to, not even close. It kept getting worse,” DH said in an exclusive interview. “I figured that they were specialists; they should know what they’re doing.”
The Board’s findings
The Arizona State Board of Optometry found significant shortcomings in the care provided by Dr. Bluth and Dr. Field-Sherlock during DH’s postoperative management.
“It was noted at that time that the cornea still had one-plus edema [on December 18, 2023], but the patient complained of seeing black dots in her vision. That’s a retinal complaint, and everyone—all the doctors in this meeting—knows immediately when you have new floaters in the vision, you should dilate the patient,” said Board President Dr. Kelly Moffat during the hearing on October 4, 2024.
“The patient was dilated at that visit…but there was no posterior retinal exam done. This is highly questionable to me.”1
Despite DH’s persistent complaints of worsening vision and new floaters, neither optometrist performed a posterior retinal examination during pivotal follow-up visits.
“This patient was telling you there’s a problem, and I do not think she got proper care. This was absolutely heartbreaking,” noted Board Vice President Dr. Stephanie Mastores.1
The Board emphasized the heightened diligence required when managing monocular patients, particularly those with a history of retinal detachment. DH’s complex medical history and her repeated complaints should have prompted more thorough evaluations and closer monitoring.
“I believe that professional conduct like this, where a patient is severely harmed by lackluster and incompetent behavior of the doctor…should send a message to all doctors providing this care: provide the care that’s due…or don’t do this kind of work,” said Dr. Moffat.1
Disciplinary actions
The Board’s investigation concluded that these lapses represented a deviation from the standard of care. Dr. Bluth was found to have violated multiple statutes, including failure to meet examination standards. His penalties include a two-week license suspension, a $5,000 civil penalty and 10 hours of continuing education in retinal pathology.
Dr. Field-Sherlock faced similar scrutiny for failing to adequately address DH’s symptoms.
“Had Dr. Field-Sherlock dilated and ruled out any problem in the macula or the retina at that visit, she would essentially be off the hook here,” Dr. Moffat stated. “There’s no excuse. This is our job: to watch the patient’s vision and watch out for the patient’s welfare.”
Her penalties include a $5,000 fine, a two-week suspension and one year of probation.2
A call for reform
Failures, such as skipping standard practices like dilating patients with new floaters and poor communication between co-managing specialists, highlight systemic gaps that must be addressed.
The case also raises broader concerns about the structure of co-management in ophthalmic care. “When we take over that care, it’s at the trust of the surgeon that we can do it, and it’s our trust that we think we’re capable of providing the care to see the patient from surgery to recovery,” said Board member Dr. Stephen Cohen.1
DH’s devastating experience serves as a stark reminder of the stakes in ophthalmic care. “This patient lost her vision. She’s blind now for the rest of her life, and it’s complacency at a minimum on the part of Dr. Bluth, if not complete incompetency,” said Dr. Moffat.1
This case challenges all eye care professionals to prioritize diligence and accountability, ensuring that no opportunity to preserve vision is ever overlooked again. Through reflection and reform, the industry can better serve and protect its patients.
Note: Dr. Bluth and Southwestern Eye Center, through their parent company American Vision Partners, were contacted for comment but did not respond.
References
- Arizona State Board of Optometry. Meeting Minutes. October 4, 2024. Available at: https://optometry.az.gov/meeting-minutes/2684. Accessed on January 11, 2025.
- Arizona State Board of Optometry. Meeting Minutes. October 4, 2024. Available at: https://optometry.az.gov/meeting-minutes/2686. Accessed on January 11, 2025.
- Moustafa GA, Borkar DS, Borboli-Gerogiannis, et al. Optimization of cataract surgery follow-up: A standard set of questions can predict unexpected management changes at postoperative week one. PLoS One. 2019;14(9):e0221243
