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Ribeiro v. The Rhode Island Eye Institute

Supreme Court of Rhode Island

May 10, 2016

Antonio Ribeiro
The Rhode Island Eye Institute, et al.

Providence County Superior Court, PC 07-4069, EDWARD C. CLIFTON ASSOCIATE JUSTICE.

For Plaintiff: Patrick C. Barry, Esq., Douglas E. Chabot, Esq.

For Defendants: Paul F. Galamaga, Esq. Michael G. Sarli, Esq. Stephen J. Sypole, Esq.

Present: Suttell, C.J., Goldberg, Flaherty, Robinson, and Indeglia, JJ.



These appeals arise from a medical malpractice lawsuit brought by the plaintiff, Antonio Ribeiro, against his optometrist, Dr. Martin Newman, and Dr. Newman's employer, the Rhode Island Eye Institute, LLC. At trial, Ribeiro argued that Dr. Newman had breached the duty of care to him because he failed to diagnose a detached retina, and that that negligence had resulted in a permanent vision loss in Ribeiro's right eye. Ribeiro also sought to hold the Eye Institute liable vicariously for Dr. Newman's negligence. At the close of Ribeiro's case, the defendants moved for judgment as a matter of law, pursuant to Rule 50 of the Superior Court Rules of Civil Procedure, arguing that Ribeiro had failed to meet his burden of proving that there had been a deviation from the standard of care, proximate causation, and damages. The trial justice took the motions under advisement and the defendants proceeded with their case.

After hearing all the evidence, the jury returned a verdict in favor of defendants, finding that, although Dr. Newman had violated the standard of care in treating Ribeiro, that violation was not the cause of Ribeiro's vision loss. All parties then filed posttrial motions. Ribeiro moved for a new trial, arguing that the trial justice erred by restricting the trial testimony of his causation expert. The defendants renewed their motions for judgment as a matter of law and, in the alternative, moved for a new trial on the issue of standard of care. The trial justice denied all posttrial motions. The parties, having timely appealed and cross-appealed, are now before this Court, arguing that the trial justice erred in denying their respective motions. We conclude that the trial justice impermissibly limited the testimony of Ribeiro's causation expert. Consequently, we vacate the judgment and remand for a new trial on all issues.


Facts and Travel

A. The Appointments

The August 24, 2004 Appointment

On August 24, 2004, Antonio Ribeiro, a forty-year-old tradesman, came to see Dr. Newman at the Eye Institute because he had been experiencing blurred vision in his right eye for the previous three to four weeks. Doctor Newman testified that he examined Ribeiro's eye, and, during the course of that exam, he employed five separate diagnostic tests to determine the cause of Ribeiro's blurred vision.

First, Dr. Newman said, he set out to determine Ribeiro's visual acuity and to determine to what extent Ribeiro could see out of his right eye. Doctor Newman found that Ribeiro's corrected vision in his right eye was 20/60, whereas previously it had been 20/20.[1] Second, Dr. Newman performed an Amsler Grid Test, which revealed that, although Ribeiro had normal peripheral vision in his right eye, his direct vision-the point at which the eye focuses-was blurry.[2] Third, Dr. Newman said that he conducted a Confrontation Visual Field Test; this test also indicated that Ribeiro had normal peripheral vision. Doctor Newman then performed a physical examination on Ribeiro's right eye. Using a slit lamp, Dr. Newman determined that the front of the eye appeared normal. Finally, Dr. Newman used an ophthalmoscope to examine the back of Ribeiro's eye-including the retina, the macula, and the fovea-by performing what is known as a fundoscopy.[3] Doctor Newman testified that at that point, he noticed that something was amiss: a "circumscribed elevation" in the macula of Ribeiro's right eye that appeared to be filled with fluid.

Based upon Ribeiro's age and complaints, Dr. Newman determined that Ribeiro was suffering from central serous retinopathy, commonly referred to as CSR. Doctor Newman explained that CSR occurs when fluid accumulates behind the retina, and that it will normally appear as a "blister" on the back of the eye. He said that central serous retinopathy is not normally a serious condition and that it often resolves on its own when the fluid is reabsorbed into the eye. Doctor Newman testified that he instructed Ribeiro to return for a follow-up appointment in six to eight weeks because that is normally how long it takes for CSR to resolve. However, he also cautioned Ribeiro that if his condition worsened, or if it did not improve in the course of the six to eight weeks, that Ribeiro should contact him.

Finally, Dr. Newman referred the patient for an Optical Coherence Tomography scan, or OCT. Doctor Newman testified that he ordered the scan to confirm his diagnosis and to garner additional information about Ribeiro's eye. At the time of Ribeiro's visit, OCT was a relatively new technology that Dr. Newman had been using for several months. A fundoscopy provides a two-dimensional view of the back of the eye, but OCT gives optometrists a better view of the back of the eye by taking a series of photographs that result in a more detailed, three-dimensional scan. Doctor Newman testified that he interpreted the six images from the OCT scan the following day, August 25, 2004. He said that, based on the images from the test, he was able to confirm that Ribeiro was, in fact, suffering from CSR. Doctor Newman said that he did not report the results of the OCT to Ribeiro because they merely reinforced his earlier diagnosis of CSR.

The October 25, 2004 Appointment

Ribeiro traveled to Portugal for a family vacation from mid-September into early October. While he was away, his vision worsened. Ribeiro testified that towards the end of the trip, he was experiencing increasingly blurred vision. Ribeiro returned to see Dr. Newman on October 25, 2004. This time, when Dr. Newman examined Ribeiro, he noticed that the vision in Ribeiro's right eye had significantly worsened from 20/60 in August to 20/400 in October. Doctor Newman conducted another fundoscopy and slit lamp exam, and he ordered another set of OCT scans. Doctor Newman also dilated Ribeiro's eye and examined it. Doctor Newman testified that, despite the patient's deteriorating vision, his eye appeared "very similar" in October as it had appeared to be in August. He said that he did not "find anything additional going on in the retina that [he] had seen back in August." Doctor Newman again diagnosed Ribeiro with CSR. However, because Ribeiro's symptoms had not resolved on their own, Dr. Newman also referred Ribeiro to a retinal specialist, Dr. Timothy You, an ophthalmologist at the Eye Institute.

The November 1, 2004 Appointment

Ribeiro met with Dr. You on November 1, 2004. After examining Ribeiro, Dr. You diagnosed Ribeiro not with CSR, but with a retinal detachment.[4] The record reveals that although CSR and retinal detachments each involve fluid buildup in the back of the eye, a retinal detachment, unlike CSR, is a serious condition that has the potential to cause permanent vision loss. When the retina is detached, a tear develops in the back of the eye. That tear fills with fluid, eventually causing the retina to pull away from the eye. Over time, the retina loses its blood supply and ceases to function. Because of the significant risk of vision loss from a retinal detachment, Dr. You recommended surgery. Ribeiro agreed, and three days later he underwent surgery in hopes of repairing the tear and restoring blood flow to his eye. Despite Dr. You's efforts, however, surgery was unable to improve Ribeiro's vision. The result has been that since November 2004, Ribeiro's corrected vision is 20/400, he has lost his central vision, and his vision remains blurry.

B. The Evidentiary Rulings

Before and during trial, defendants made several motions that sought to limit the scope of the issues to be determined by the jury and to limit which witnesses would be allowed to testify about those issues. The plaintiff disclosed that he would be calling two expert witnesses. First, he would produce an optometrist, David Greenstein, O.D., who would testify that Dr. Newman deviated from the standard of care when he failed to rule out a detached retina on August 24, 2004. Second, he would call Susan Bressler, M.D., an ophthalmologist, who would testify to the causes and consequences of the fluid buildup in Ribeiro's right eye in August 2004. Because Ribeiro alleged that Dr. Newman was negligent only on August 24, 2004, much of the discussion between the parties and ...

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