Primary Evidence
This section is designed to allow reviewing counsel and experts to move directly from the analysis to the underlying evidence.
Medical Records
Documents should be organized chronologically and include:
- Preoperative ophthalmology records
- MPC operative report
- February postoperative examinations
- February 23 examination
- March 28 YAG record
- September 27 complete encounter
- Subsequent ophthalmology records
- Retinal or posterior-segment evaluations
- OCT reports and images
- B-scan studies, if performed
- Fundus photographs
- Visual-field testing
- Refraction records
- Complete medication history
Visual Acuity & IOP
A separate chart should display every documented measurement of:
Date | Visual Acuity OS | IOP OS | Procedure/Change | Relevant Finding
This allows reviewers to see the clinical trajectory without searching hundreds of pages.
Pred Forte / Prednisolone
The steroid issue should remain analytically separate from the initial February visual collapse unless medical evidence establishes a causal relationship.
The early record reflects intensive postoperative steroid therapy followed by a taper plan.
Later records contain additional medication activity, including discontinuation/reordering and an indication that the medication may have been taken differently or “as needed.”
That creates questions requiring the complete medication audit trail.
Records Still Needed
The following evidence is particularly important:
- Complete September 27, 2024 encounter
- Complete steroid prescribing history
- Pharmacy dispensing/refill history
- Medication reconciliation records
- Patient communications concerning steroid use
- All posterior-segment imaging
- OCT results
- B-scan results, if any
- Fundus photography
- Subsequent retinal examinations
- Any record establishing an anatomical diagnosis for the permanent visual loss
Important Evidentiary Limitation
Absence of a document from the materials presently assembled does not establish that an examination or test never occurred.
For that reason, this website distinguishes between:
“Not documented in the records presently available”
and
“Not performed.”
Only the complete record and appropriate expert review can resolve that distinction.