6955Leal

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CONFIDENTIAL WORK PRODUCT SUBJECT TO CHANGE AND REMOVAL

RE:    Alejandro Michel v City of Culver City

          Case Number ADJ19107654

          Date of Alleged Injury: 02/01/2024

Dear Mr. Leal,

          The following is my report regarding the above described case.  My report is limited to the ophthalmologic aspects of the case and it is based on my review of records from the following sources:

Records

  1. Michel, Alejandro, Deposition August 20, 2024
  2. Kaiser Permanente (KP)
  3. Timothy Daniel Hanaway, M.D.
  4. Elisa Marie, Chen, M.D.
  5. Gregory Thier, M.D.
  6. Yanique Campbell, PA-C
  7. Jeffrey Belabin, PA0C
  8. Frank, Lin, M.D.
  9. Edwin Haronian, M.D.
  10. Concentra, El Segundo
  11. James Senechal, M.D.
  12. John Lee Sanghun, M.D.
  13. Chau Duc Nguyen, M.D.
  14. Kevin Kao, M.D.
  15. Hetal S. Patel, M.D.
  1. Monica L. Lavarreda, M.D.
  2. Kim A. Quach, M.D.
  3. Frank Kuo, M.D.
  4. Robert Liou, M.D.
  5. Erika J. Ramirez, M.D.
  6. Jeffrey A. Berman, M.D.
  7. Lisa Kwan, P.T.
  8. Sports Ortho PT
  9. Andrew Schreiber, M.D.
  10. Breathe Diagnostics
  11. Andrew O. Schreriber, M.D.
  12. Andrew Berman, M.D.
  13. Dynamic Medical Imaging
  14. Daniel Lee, M.D.
  15. MAX MRI Radiology
  16. Saeed Yadegar, M.D.
  17. James D. Senechal, M.D.
  18. Concntra
  19. Frank P. Lin, M.D. (FL)
  20. Young Yang, Lac
  21. Elan Howard Rosenthal, M.D.
  22. Alejandro Michel, deposition, August 20, 2024
  23. Erika Ramirez Jimenez, M.D.

Sincerely,

Michael Reynard, M.D.

Board Certified Eye Expert

Clinical History

On February 1, 2024, Mr. Alejandro Michel was allegedly picking up trash when a “metal pole from the trash got loose and hit him on the right temple part of his head and face” (FL, 0972).  Mr. Michel did not suffer and cuts or lacerations.  Mr. Michel did not experience loss of consciousness.  Mr. Michel seen at Concentra Urgent Care in El Segundo, CA, and then at a hospital the same day where he was discharged (ED, 67).   Following the alleged injury Mr. Michel developed headache, dizziness, syncope, brain fog, light sensitivity, and noise sensitivity (FL, 0972).  Mr. Michel allegedly began experiencing headaches and dizziness that a month following alleged injury (1195).  Mr. Michel also reported hearing loss, tinnitus, and dizziness with the onset in 2024 (1195).

On February 1, 2024, Mr. Michel was seen by James D. Senechal, M.D. at Concentra in El Segundo, California, for a facial contusion.  Mr. Michel was referred to for emergency treatment and radiologic studies, and treated with hot/cold compresses and Naprosyn (406, 407).

On Febryuary 5, 2024, Mr. Michel was seen at Concentra “with patient doing worse.”Mr. Michel reported that his right cheek bone was hit by a metal bar that broke off a trash bin during lifting.  Mr. Michel complained of a hard time driving with dizziness and headaches (408).  Mr. Michel reported eye pain “but no visual disturbances (282) and no loss of consciousness (408). Facial exam showed no facial lesions.  The conjunctiva and lids did not have swelling, erythema, or discharge.  The extraocular movements were intact (408).  The head was atraumatic, and extraocular movement was intact.  The pupils were equal and round (409).  The assessment was “facial contusion, initial encounter” (409).

On March 1, 2024, Mr. Michel was seen at Concentra for healthy issues that included follow-up for a facial contusion and post-concussion headache on the right side of his head (426).  Mr. Michel complained of facial pain.  There was no evidence of eye redness (427).  Mr. Michel was treated with acupuncture any Young Yang, Lac (463), and physical therapy (438).

On May 15, 2024, Mr. Michel was seen by neurologist Frank P. Lin, M.D.   Eye exam showed pupils that were equal and round, and reactive.  There was no visual field defect and the extraocular movements were full (455)

On June 26, 2024, Mr. Michel was seen by Dr. Lin.  Mr. Michel;s subjective complaints included headaches on the right side of his head, ringing in his ear, and dizziness.  Mr. Michel did not report vision issues.  On eye examination Mr. Michel did not have visual field defects or an abnormal pupil exam. (488).   The diagnosis was concussion and post-concussion syndrome (489).

On July 10, 2024, Mr. Michel was seen by Young Yang, Lac for acupuncture therapy (520).  The medical record did have reports of vision or eye issues.

On August 7, 2024, Mr. Michel was seen by Frank, Lin, M.D.   Mr. Michel com[plained of headache, ringig in the ear,. Dizziness, and light sensitivity.  Mr. Michel was reportedly undergoing vestibular therapy at USC (540).  Eye exam showed normal pupils, full extraocular movement. And no defect in the visual fields (541).  The diagnosis was “contusion, initial encounter” (542).

On September 12, 2024, Mr. Michel was seen by neurologist Andrew Schreiber, M.D. complaining of “constant daily headache” (85).  Mr. Michel reported experiencing headache, dizziness, nausea, photophobia, tinnitus, and neck pain after blunt injury to the forehead and right side of his face. (84).  Eye exam showed normal visual fields, normal appearing optic nerve, normal extraocular movement and normal pupil reactions.  The diagnosis was 1) Closed head trauma with Grade 1 concussion, Chronic cervical sprain, 3) Headaches, 4) Sleep disturbance, and memory disturbance (130).

On September 18, 2024, Mr. Michel was seen by Frank Lin, M.D. complaining of frequent headache.  Pupil exam, visual field exam, and extraocular movements were normal (545).  There were no complaints of light sensitivity.

Mr. Michel was seen again in follow-up by Dr. Lin on February 1, 2024 (551), December 11, 2024 (558), Marcg 5, 2025 (566) with similar complaints.  On April 16, 2025, Mr. Michel reported that his headache had gotten less frequent and less severe.  Mr. Michel repotted that the headache was now occurring about once a week and was “not really bother him that much anymore” (sic).  Exam of the pupils, visual field, and extraocular movement was normal (570). Mr. Michel was seen again on April 16, 2025 (570).

On October 3, 2024, Mr. Michel was seen by Andrew G. Berman, M.D.  Eye exam showed no scleral icterus and clear conjunctiva.  Cranial nerve II exam revealed vision that was grossly intact and no evidence of nystagmus.

On October 9, 2024, Mr. Michel was seen by Bach Lan Linda Vu, M.D. at Linda Vision, Monterey Park, California, for evaluation related to a Worker’s Compensation Head Injury (134).  The medical record reports that Mr. Michel had difficulty with ocular movements after being hit by a metal bar on the side of his head (134).  Mr. Michel complained of light sensitivity with his right eye (134).

On October 9, 2024, uncorrected visual acuities were right eye, 20/20-1, and left eye, 20/20,  With pinhole correction the visual acuity in the right eye improved to 20/20.  Pupil reactions were normal and without an afferent pupil defect. Intraocular pressures were right eye, 12, and left eye, 13.  Motility of extraocular muscles was normal.  Visual fields were full to confrontation.  Eyelids had thick meibomian gland secretions in both eyes.  The cornea and lens in each eye were clear.  Dilated exam showed normal fundus exam in each eye with a cup:disc ratio of 0.3.  The impression was 1) Bilateral Meibomian gland dysfunction. Warm compresses were advised to treat meibomian glad dysfunction (135).  Follow-up was as needed (135).

On October 10, 2024, Mr. Michel was seen by Dr. Berman.  At that Mr. Michel reportedly had vestibular therapy since May 2024.  Mr. Michel reportedly was able to drive without limitations.  Mr. Michel reported high-pitched tinnitus in his right ear that he first noted in 2024.  The medical record on this date did not show any reports or evidence of vision problems.

On February 1, 2024, Mr. Michel was seen by Timothy D. Hanaway, M.D. at Kaiser Permanente complaining of tenderness over the right maxilla .  Mr. Michel reported “tingling” when abducting his right ear,.  There was no decrease in his extraocular movements (KP, 686).  Mr. Michel had normal conjunctivae and his pupils were equal, round, and reactive to light (KO, 686).   

On February 1, 2024, Mr. Michel had a CT scan of the head interpreted by Elisa Marie Chen, M.D. that showed no evidence of an intracranial bleed or biony fracture.  The orbital and facial sift tissues were unremarkable.  Minimal bilateral maxillary sinus disease and sphenoid sinus disease was present,

On February 13, 2024, Mr. Michel a seen by Yanique Campbell, M.D. complaining of pain on the right side of his face, blurred vision (right eye), and headaches (YC, 263).  Eye exam showed normal pupil reactions and normal extraocular movements.    The assessment was facial contusion and post0concuission headache  (YC, 264).

On February 24, 2024, an MRI performed at MAX MRI Radiology and interpreted by Saeed Yadegar, M.D. as showing a partial; empty sella and inflammatory debris within some of the ethmoid air cells on both sides (1232).

On April 3, 2024 the results of a CT scan of the facial bones was interpreted by Elisa Marie Chen, M.D.  Dr. Chen commented that the bony structures were intact and without evidence of fracture or bone destruction.  There was minimal soft tissue swelling involving the right subcutaneous tissues anterior to the maxillary sinuses.  The globes were intact and there was minimal bilateral maxillary, bilateral sphenoid-ethmoid sinus disease.  Mild degenerative changes of the upper cervical spine were found.

On January 23, 2025, Dr. Berman recorded a diagnosis for Mr. Michel of bilateral hearing nerve loss, slight tinnitus, and dizziness.   Dr.  Berman attributed his hearing and tinnitus issues as being related to labyrinthitis ossificans (1221).

On March 1, 2025, Mr. Michel was seen by Jeffrey Belabin, PA-C complaining of pain.  The assessment reported facial contusion on initial encounter and post-concussion headache (0245),

On March 5, 2025, Mr. Michel was seen by neurologist Andrew Schreiber, M.D.  Dr. Schreiber initially evaluated Mr. Michel on September 24, 2024 (1190).

On March 29, 2024, Mr. Michel was seen by neurologist Frank, Lin, M.D. who diagnosed concussion and post-concussion syndrome (FL, 0974).  Acupuncture and vestibular therapy were ordered.  Mr. Michel’s diagnosis was 1) Closed head trauma with grade I concussion and post concussion injury, 2) Chronic cervical sprain, 3) Headaches, Sleep disturbance, 5) Memory disturbance.

Present Injury Studies
09/04/2024: Radiculopathy (Cervical Region); Skin Paresthesia, Limb pain.
Lisa Kwan, P.T. (1158)

12/27/2024: Nocturnal Polysomnogram showed total Apean index of 79, an Apnea Hypopnea index of 13.4 (1183) .  His study was interpreted by Dr. Schreiber (1191) as normal sleep latency, normal sleep efficiency, and mildly abnormal AHI (1183).

Facial Trauma
In June 2021, Mr. Mical had blunt trauma to the right side of his face. (KP, 170).  Mr. Michael reported that a 60 pound weight dropped on his face (KP, 180). Radiologic studies showed no evidence of fracture. (KP,. 179)

Medications
Lexapro Depo, 5)

Occupation: Sanitation Driver (Depo 16)

Allergy: Penicillin (KP, 685)

Past surgical History
Bilateral Partial Vasectomy, January 10, 2019 (KP, 144)

Past Ocular History
Conjunctivitis, 07/08, 2022 (KP, 299)

Past Medical History

  1. Obesity (KP, 684)
  2. Gastroesophogeal Reflux Disease, 2018 (KP, 118, 680, 123)
  3. Past Surgical History
  4. Shoulder, Right, 2019 (Depo, 9)
  5. Shoulder, Left (Depo, 24)
  6. Cyst removal from left upper eyelid, 1988 (KP, 684)
  7. Cyst removal from left palmar surface 1988 (KP, 694)
  8. Ankle trauma, 2017, (KP, 105)
  9. Melanocytic Nevus, (KP, 205, 745)
  10. Vitiligo, (KP, 205, 745)
  11. Solar Lentigo, KP, 205, 207)
  12. Moderate obstructive sleep apnea, 3/17, 2022, (KP, 238, 239)
  13. Erectile dysfunction, 11/15/2022 (KP, 319)
  14. Dermatits, 9/15/2023, KP, 357)
  15. Acquired penile adhesion, 10/30/2023 (KP, 370)
  16. Overweight, 2/20/2024 (KP, 374, 542)
  17. Scrotal webbing, (KP, 508)
  18. Cervucal Radiculopahy, September 2024, (Haronian, 1144)
  19. Deep vein thrombosis, right lower extremity, May 28, 2015 (KP, 233)
  20. Severe obesity, 2/20/24 (KP 384)

Discussion and Opinions

Based on my review of the available medical records, Mr. Michel’s ocular complaints are not supported by objective ophthalmologic findings and are not medically attributable to the reported head and facial injury of February 1, 2024. The contemporaneous records document a facial contusion, but they do not document a laceration, penetrating injury, orbital fracture, globe injury, retinal injury, optic nerve injury, pupillary abnormality, ocular motility deficit, or visual field defect.

The radiologic studies likewise do not support traumatic ocular injury. The February 1, 2024 CT scan of the head showed no intracranial bleed or bony fracture, and the orbital and facial soft tissues were unremarkable. The April 3, 2024 CT scan of the facial bones showed intact bony structures, intact globes, and no fracture or bone destruction. These findings are inconsistent with an ocular injury sufficient to produce persistent trauma-related visual complaints.

Repeated examinations after the alleged injury were essentially normal. Mr. Michel had normal pupils, full extraocular movements, and no documented visual field defect on multiple examinations. Dr. Schreiber also documented normal visual fields, normal appearing optic nerves, normal extraocular movements, and normal pupil reactions. These findings do not support traumatic optic neuropathy, cranial nerve injury, ocular motility disorder, visual pathway injury, or other objective neuro-ophthalmic injury.

The most direct ophthalmologic examination was performed by Dr. Vu on October 9, 2024. Mr. Michel complained of right-eye light sensitivity and difficulty with ocular movements. However, his visual acuity was essentially normal at 20/20-1 in the right eye and 20/20 in the left eye, with the right eye improving to 20/20 with pinhole correction. Pupils were normal without an afferent pupillary defect. Eye pressures were normal. Extraocular motility was normal. Visual fields were full to confrontation. The corneas and lenses were clear, and the dilated fundus examination was normal in both eyes. The only ophthalmologic diagnosis was bilateral meibomian gland dysfunction, treated conservatively with warm compresses.

To a reasonable degree of medical probability, Mr. Michel’s bilateral meibomian gland dysfunction is a common eyelid-gland and ocular surface condition unrelated to the alleged traumatic injury of February 1, 2024. Meibomian gland dysfunction is not evidence of traumatic injury to the globe, retina, optic nerve, visual pathways, or ocular motor system. Its bilateral nature also weighs against causation by a localized right-sided facial contusion.

Mr. Michel’s complaint of unilateral right-eye photosensitivity is also not medically persuasive as evidence of neurologic dysfunction from the alleged injury. Neurologic light sensitivity from concussion or central nervous system dysfunction would generally be expected to be perceived in both eyes rather than isolated to one eye. In contrast, unilateral photophobia more commonly suggests a local ocular condition; however, Mr. Michel’s right eye showed no corneal injury, uveitis, traumatic iritis, optic nerve injury, pupillary abnormality, visual field loss, or motility abnormality.

To a reasonable degree of medical probability, Mr. Michel’s vision complaints are subjective and are not supported by corroborative ophthalmologic evidence. The objective medical record shows normal visual acuity, normal pupils, normal extraocular movements, normal visual fields, normal optic nerves, normal dilated fundus examinations, intact globes, and no orbital or facial fracture. There is no objective medical basis to attribute Mr. Michel’s claimed visual complaints, unilateral photosensitivity, or bilateral meibomian gland dysfunction to the alleged head and facial injury of February 1, 2024.

The opinions expressed in this case are the opinions of the evaluator based on his training, experience and expertise in the field of ophthalmology.  The conclusions of this report are based in part on the assumption that history provided by the claimant and materials provided for review are true and correct.  I declare that the information contained within this document was prepared by this examiner and is true to the best of my knowledge at the time of issuance of this report.  Opinions are subject to change if more information becomes available at a later date.

Sincerely,

Michael Reynard, M.D.