UP Law F2021 Lucas v Tuano

Medical Jurisprudence 2009 Chico-Nazario

SUMMARY

Peter Lucas approached Dr. Tuano to consult re: his extended bout of sore eyes. After repeated incidents of
the recurring sore eyes, Lucas was diagnosed with EKC which Dr. Tuaño treated with a steroid based
medicine called Maxitrol. After using the Maxitrol, Lucas complained of blurry vision and head aches, which
was diagnosed by Dr. Tuaño as open angle glaucoma. After several consultations with Dr. Tuaño, second
opinions obtained from various opthalmologists, doses of medication and two laser surgeries – Lucas filed
this petition. He alleges that Dr. Tuaño’s prescription of Maxitrol, which is known to have an adverse effect
on 5% of the population, was the cause for his glaucoma. In medical negligence cases, four things must prove
the following: (1) duty, (2) breach, (3) injury, and (4) proximate causation. Medical negligence cases are best
proved by opinions of expert witnesses belonging in the same general neighborhood and the same general
line of practice as defendant physician or surgeon. A doctor is acting within the standards of a reasonable
doctor if his practice or act is supported by the practice of professionals in the same field. Onus probandi
remains with the plaintiff.

FACTS

 August 1988, Peter Lucas contracted sore eyes in his right eye. Complaining of a red right eye and swollen
eyelid, Peter made use of his health care insurance issued by Philamcare, for consultation
o Philamcare Coordinator Dr. Edwin Oca, M.D., referred Peter to respondent, Dr. Prospero Ma. C. Tuaño,
M.D., an ophthalmologist at St. Luke's Medical Center, for an eye consultation.
o Upon consultation with Dr. Tuaño, Peter narrated that it had been nine (9) days since the problem with
his right eye began; and that he was already taking Maxitrol to address the problem in his eye.
o Dr. Tuaño diagnosed that Peter was suffering from conjunctivitis1 or "sore eyes." Dr. Tuaño then
prescribed Spersacet-C2 eye drops for Peter and told the latter to return for follow-up after one week.
 Peter went back to Dr. Tuaño on 9 September 1988. Upon examination, Dr. Tuaño told Peter that the "sore
eyes" in the latter's right eye had already cleared up and he could discontinue the Spersacet-C. However, the
same eye developed Epidemic Kerato Conjunctivitis (EKC)3
o To address the new problem with Peter's right eye, Dr. Tuaño prescribed to the former a steroid-based
eye drop called Maxitrol4
o To recall, Peter had already been using Maxitrol prior to his consult with Dr. Tuaño.
 21 September 1988, Peter saw Dr. Tuaño for a follow-up consultation. Dr. Tuaño instructed the former to
taper down the dosage of Maxitrol, because the EKC in his right eye had already resolved.
o Peter was cautioned that Maxitrol had to be withdrawn gradually since it is a steroid, otherwise, EKC
might occur.
 6 October, Peter returned feeling as if there was something in his eyes. Dr. Tuaño examined Peter's eyes and
found that the right eye had once more developed EKC. He instructed Peter to resume Maxitrol at six (6) drops
per day
o Peter was unable to get a hold of Maxitrol, as it was out of stock. Consequently, Peter was told by Dr.
Tuano to take Blephamide5 another steroid-based medication, but with a lower concentration, as
substitute for the unavailable Maxitrol, to be used three (3) times a day for five (5) days
 18 October 1988, Peter went to see Dr. Tuaño at his clinic, alleging severe eye pain, feeling as if his eyes were
about to "pop-out," a headache and blurred vision.

1
Conjunctivitis, also known as pinkeye, is an inflammation of the conjunctiva, the thin, clear tissue that lies over the white part of the eye and lines the inside of the eyelid
2
The generic name of Spersacet-C ophthalmic drops is Sulfacetamide. It is prescribed for the treatment and prophylaxis of conjunctivitis due to susceptible organisms;
corneal ulcers; adjunctive treatment with systemic sulfonamides for therapy of trachoma
3
Epidemic kerato conjunctivitis is a type of adenovirus ocular infection. The presence of adenovirus by culture is indicative of active infection.
4
Neomycin/polymyxin B sulfates/dexamethasone is the generic name of Maxitrol Ophthalmic Ointment. It is a multiple dose anti-infective steroid combination in sterile
form for topical application
5
This medication contains an antibiotic (sulfacetamide) that stops the growth of bacteria and a corticosteroid (prednisolone) that reduces inflammation
 o Dr. Tuaño examined Peter's eyes and discovered that the EKC was again present in his right eye. As a
result, Dr. Tuaño told Peter to resume the maximum dosage of Blephamide.
 4 November 1988, Peter again went for consultation.
o Dr. Tuaño's examination showed that only the periphery of Peter's right eye was positive for EKC;
hence, Dr. Tuaño prescribed a lower dosage of Blephamide.
 It was also about this time that Fatima Gladys Lucas (Fatima), Peter's spouse, read the accompanying literature
of Maxitrol and found therein the following warning against the prolonged use of such steroids:
o “Prolonged use may result in glaucoma, with damage to the optic nerve, defects in visual acuity and
fields of vision, and posterior, subcapsular cataract formation. Prolonged use may suppress the host
response and thus increase the hazard of secondary ocular infractions, in those diseases causing
thinning of the cornea or sclera, perforations have been known to occur with the use of topical steroids
xxx”
 26 November 1988, Peter returned to Dr. Tuaño's clinic, complaining of feeling worse.
o It appeared that the EKC had spread to the whole of Peter's right eye yet again. Thus, Dr. Tuaño
instructed Peter to resume the use of Maxitrol.
o Peter already made mention to Dr. Tuaño during said visit of the above-quoted warning against the
prolonged use of steroids, but Dr. Tuaño supposedly brushed aside Peter's concern as mere paranoia,
 13 December 1988, Peter had no vision in his right eye. Fatima observed that Peter's right eye appeared to
bloody and swollen
o Upon examination, Dr. Tuaño noted the hardness of Peter's right eye. With the use of a tonometer to
verify the exact intraocular pressure (IOP)
o Dr. Tuaño discovered that the tension in Peter's right eye was 39.0 Hg, that of his left was 17.0 Hg
o Since the tension in Peter's right eye was way over the normal IOP, which merely ranged from 10.0 Hg
to 21.0 Hg,[19] Dr. Tuaño ordered him to immediately discontinue the use of Maxitrol and prescribed
to the latter Diamox6 and Normoglaucon7, instead
 15 December, the tonometer reading of Peter's right eye yielded a high normal level, i.e., 21.0 Hg. Hence, Dr.
Tuaño told Peter to continue using Diamox and Normoglaucon. But upon Peter's complaint of "stomach pains
and tingling sensation in his fingers," Dr. Tuaño discontinued Peter's use of Diamox
 21 December, Peter went to see another ophthalmologist, Dr. Ramon T. Batungbacal. Dr. Batungbacal's
diagnosis was Glaucoma8 O.D. He recommended Laser Trabeculoplasty9 for Peter's right eye.
 23 December, Peter returned to Dr. Tuaño where tonometer measured IOP of 41 Hg of right eye. Dr. Tuaño
addressed the problem by advising Peter to resume taking Diamox along with Normoglaucon.
 28 December, Dr. Tuaño noted the recurrence of EKC in Peter's right eye. Considering, however, that the IOP
of Peter's right eye was still quite high at 41.0 Hg, Dr. Tuaño was at a loss as to how to balance the treatment of
Peter's EKC vis-à-vis the presence of glaucoma in the same eye. Dr. Tuaño, thus, referred Peter to Dr. Manuel B.
Agulto, M.D
 Peter went to see Dr. Agulto on 29 December 1988. Dr. Agulto wrote Dr. Tuaño a letter:
o “Rolly, I feel that Peter Lucas has really sustained significant glaucoma amage. I suggest that we do a
baseline visual fields and push medication to lowest possible levels. If I may suggest further, I think we
should prescribe Timolol10 in lieu of Normoglaucon. If the IOP is still inadequate, we may try D'epifrin11
BID OD (despite low PAS). I'm in favor of retaining Diamox or similar CAI.”
 Peter went to see Dr. Tuaño on 31 December 1988, bearing Dr. Agulto's aforementioned letter.
o Though Peter's right and left eyes then had normal IOP of 21.0 Hg and 17.0 Hg, respectively, Dr. Tuaño
still gave him a prescription for Timolol
 2 January 1989, the IOP of Peter's right eye remained elevated at 21.0 Hg. Dr. Tuaño conducted a visual field
study of Peter's eyes, which revealed that the latter had tubular vision
 13 January, Peter consulted Dr. Jaime Lapuz, M.D., an ophthalmologist, who, in turn, referred Peter to Dr. Mario
V. Aquino, M.D., another ophthalmologist who specializes in the treatment of glaucoma and who could
undertake the long term care of Peter's eyes.

6
This medication is a potent carbonic anhydrase inhibitor, effective in the control of fluid secretion
7
It is used for the reduction of intraocular pressure in patients with glaucoma
8
Glaucoma is an eye condition which develops when too much fluid pressure builds up inside of the eye. The increased pressure, called the intraocular pressure, can
damage the optic nerve, which transmits images to the brain. If the damage to the optic nerve from high eye pressure continues, glaucoma will cause loss of vision
9
Kind of surgery which uses a very focused beam of light to treat the drainage angle of the eye. This surgery makes it easier for fluid to flow out of the front part of the eye,
decreasing pressure in the eye
10
Is a generic name of a drug in ophthalmic dosage form used in treatment of elevated intraocular pressure by reducing aqueous humor production or possibly outflow
11
It is used to treat open-angle glaucoma or ocular hypertension by reducing the amount of fluid in the eye thereby decreasing intraocular pressure
 May 1990 and June 1991, Peter underwent two (2) procedures of laser trabeculoplasty to attempt to control
the high IOP of his right eye.
 Petitioners then filed case for damages against Dr. Tuaño Averred that as the "direct consequence of [Peter's]
prolonged use of Maxitrol, he suffered from steroid induced glaucoma which caused the elevation of his intra-
ocular pressure.
o Additionally alleged that the visual impairment of Peter's right eye caused him and his family so much
grief. Because of his present condition, Peter now needed close medical supervision forever
o In the end, he sought pecuniary award for their supposed pain and suffering, which were ultimately
brought about by Dr. Tuaño's grossly negligent conduct in prescribing to Peter the medicine Maxitrol
for a period of 3 months, without monitoring Peter's IOP
 Dr. Tuaño asserted that the treatment made by him more than three years ago has no causal connection to the
present glaucoma or condition.
 RTC: dismissed civil case. Petitioners failed to prove by preponderance of evidence that Dr. Tuaño was negligent
in his treatment of Peter's condition. In the absence of "any medical evidence to the contrary, this court cannot
accept [petitioners'] claim that the use of steroid is the proximate cause of the damage sustained by [Peter's]
eye.
 CA: affirmed

ISSUE: W/N Dr. Tuano is liable for negligence. NO

RATIO

 No. Petitioner insists that Peter's glaucoma is the direct result of Dr. Tuaño's negligence in improper
administration of the drug Maxitrol
 In this type of suit, the patient or his heirs, in order to prevail, is required to prove by preponderance of evidence
that the physician failed to exercise that degree of skill, care, and learning possessed by other persons in the
same profession; and that as a proximate result of such failure, the patient or his heirs suffered damages.
 In medical negligence cases, also called medical malpractice suits, there exist a physician-patient relationship
between the doctor and the victim. But just like any other proceeding for damages, four essential (4) elements:

o Duty
 In treating his patient, a physician is under a duty to exercise that degree of care, skill and
diligence which physicians in the same general neighborhood and in the same general line of
practice ordinarily possess and exercise in like cases.
 This standard level of care, skill and diligence is a matter best addressed by expert medical
testimony
o Breach & Injury
 There is breach of duty of care, skill and diligence, or the improper performance of such duty,
by the attending physician when the patient is injured in body or in health [and this] constitutes
the actionable malpractice.
o Proximate causation
 It must be shown that the "injury for which recovery is sought must be the legitimate
consequence of the wrong done; the connection between the negligence and the injury must be
a direct and natural sequence of events, unbroken by intervening efficient causes
 From the foregoing, it is apparent that medical negligence cases are best proved by opinions of expert
witnesses belonging in the same general neighborhood and in the same general line of practice as
defendant physician or surgeon. The deference of courts to the expert opinion of qualified physicians [or
surgeons] stems from the former's realization that the latter possess unusual technical skills which laymen in
most instances are incapable of intelligently evaluating
 The onus probandi was on the patient to establish before the trial court that the physicians ignored standard
medical procedure, prescribed and administered medication with recklessness and exhibited an absence of the
competence and skills expected of general practitioners similarly situated."
 Unfortunately, in this case, there was absolute failure on the part of petitioners to present any expert testimony
to establish the 4 elements.
 On duty, breach, injury
o Absent a definitive standard of care or diligence required of Dr. Tuaño under the circumstances, we
 have no means to determine whether he was able to comply with the same in his diagnosis and
treatment of Peter.
o Dr. Tuaño was able to clearly explain that what is only required of ophthalmologists, in cases such as
Peter's, is the conduct of standard tests/procedures known as "ocular routine examination
o Court cannot but agree with Dr. Tuaño's assertion that when a doctor sees a patient, he cannot
determine immediately whether the latter would react adversely to the use of steroids; all the doctor
can do is map out a course of treatment recognized as correct by the standards of the medical
profession. It must be remembered that a physician is not an insurer of the good result of
treatment. The mere fact that the patient does not get well or that a bad result occurs does not
in itself indicate failure to exercise due care.
o Moreover, that Dr. Tuaño saw it fit to prescribe Maxitrol to Peter was justified by the fact that the latter
was already using the same medication when he first came to see Dr. Tuaño
 On causation
o The causation between the physician's negligence and the patient's injury may only be established by
the presentation of proof that Peter's glaucoma would not have occurred but for Dr. Tuaño's supposed
negligent conduct. Once more, petitioners failed in this regard.

FALLO petition is DENIED for lack of merit. The assailed Decision dated 27 September 2006 and Resolution
dated 3 July 2007, both of the Court of Appeals in CA-G.R. CV No. 68666, are hereby AFFIRMED. No cost.