When Two Ophthalmologists Disagree on the Same Record
Two board-certified ophthalmologists can read the same chart and reach different conclusions without either one being dishonest or incompetent. Most of the time, the divergence traces to something identifiable: they assumed different facts, they weighted the same findings differently, they were asked different questions, or they are disagreeing about what a reasonable practitioner could do rather than about what the eye shows. Locating the actual source of a disagreement is more useful to counsel than assuming the other side's expert is wrong — and it is usually achievable from the two reports themselves.
Start From the Right Premise
The instinct on receiving an adverse expert report is to look for what is wrong with it — occasionally correct, frequently unproductive. Medicine is not a domain where a fixed rule generates one answer from one set of inputs; it is probabilistic inference under incomplete information, where trained practitioners legitimately differ. An opposing opinion is more useful treated as a hypothesis with a derivation you can trace, test, and either dismantle or accommodate.
Source One: They Assumed Different Facts
This is the most common cause and the easiest to miss, because both reports describe themselves as based on "the medical records." In practice, experts are given different materials. One received the complete optometry file establishing baseline acuity; the other did not. One reviewed the native optical coherence tomography (OCT) data; the other worked from printed summary pages. One had the treating technician's deposition; the other had only the chart. Experts also receive different factual premises from counsel — an assumed symptom onset date, an assumed exposure duration — and an opinion is a function of its premises. A causation conclusion premised on symptoms beginning the day of an incident will differ from one premised on symptoms beginning three weeks later, and neither expert is being unreasonable.
How to test it: set the two records-reviewed inventories side by side and identify every item on one list absent from the other, then extract each report's stated assumptions of fact. Differences traceable to inputs are often resolved by giving both experts the same complete set — and if the opposing opinion changes when a missing document is supplied, that is a stronger cross-examination point than any attack on qualifications.
Source Two: They Weighted the Same Findings Differently
Where facts are identical, emphasis may not be. Ophthalmic evaluation generates many data points — acuity, refraction, pressures, pupillary findings, imaging, fields, serial notes — and forming an opinion means deciding which carry the most weight when they point in different directions. One evaluator may treat a reproducible visual field defect as the anchor finding and regard a borderline OCT as insufficiently sensitive to exclude it; another may treat the structurally normal OCT as decisive and the field as effort-dependent. Both are applying defensible reasoning to a genuine structure-function tension. Weighting disputes are productive to litigate because they are explicit and testable: ask each expert why the finding emphasized is more probative than the one discounted, and whether any objective evidence could shift the balance.
Source Three: The Range of Reasonable Practice
The standard of care is not a single approved pathway; it is a range of conduct reasonable practitioners may choose among. Ophthalmology contains many decisions on which competent surgeons legitimately differ: whether to operate on a particular cataract now or observe, which intraocular lens formula to favor in an unusual eye, whether to suture a wound that appears sealed, how quickly to escalate postoperative inflammation, whether to refer or manage. When an expert says he would have done something differently, that is a statement about his own practice — meaningful, but not the same as saying the alternative fell outside the acceptable range. Collapsing that distinction is the most frequent overreach in standard-of-care testimony, and it occurs on both sides: the expert who equates preference with the standard, and the expert who treats any choice a physician actually made as necessarily within the range.
Source Four: A Disagreement About Medicine Is Not a Disagreement About Standard of Care
Four distinct questions recur in eye cases, and experts sometimes appear to conflict because they are answering different ones:
- What happened? A diagnostic question: what does the record show about the eye over time?
- Was the care within the standard? A conduct question, judged by what a reasonable ophthalmologist would do under the circumstances then known.
- Did any departure cause the harm? A separate causation question — a departure that changed nothing has no causal effect, and a bad outcome can follow flawless care.
- What is the extent and permanence of the injury? A damages question turning on impairment and prognosis.
Two experts may agree completely on the medicine and disagree only on causation, or agree care was substandard and disagree on whether it mattered. Sorting an apparent conflict into these four buckets often reveals a narrower dispute than the reports suggest. The breach-causation distinction is developed under standard of care and causation.
Source Five: Hindsight
Retrospective review is performed knowing the outcome, and that knowledge distorts judgment predictably: findings ambiguous in real time look obvious once you know what they became. A retinal finding that was minor among many competing possibilities on the day of the visit can seem unmissable to a reviewer who knows a detachment followed. The disciplined evaluator asks what was reasonably knowable at the moment of decision, with the information then available. Whether an opposing expert did so is assessable from the report's own language.
Distinguishing Reasoned Disagreement From Advocacy
Some opinions are advocacy dressed as analysis, and the markers are visible on the page rather than in the conclusion. A reasoned opinion identifies the evidence cutting against it and explains why it does not control, concedes genuinely uncertain points, states limitations including records not reviewed, describes alternative explanations and the basis for excluding each, distinguishes personal practice from the standard of care, and calibrates confidence to the evidence. An advocacy opinion answers every question in the retaining party's favor with uniform confidence, omits contrary evidence rather than addressing it, substitutes credentials and conclusory phrases for reasoning, and contains no limitations section at all.
Note that none of these markers concerns the conclusion. An expert may reach a conclusion entirely favorable to the retaining party and have reasoned scrupulously to get there — evidence is sometimes one-sided. What is diagnostic is whether the reasoning is exposed to view and whether inconvenient facts are acknowledged, the architecture described in Anatomy of an Ophthalmic Medical-Legal Report.
Practical Questions for Probing an Opposing Opinion
- What records did you review, and what did you not review? Would any bear on your opinions?
- What facts were you asked to assume, and how would your opinion change if an assumption were different?
- Which finding most supports your conclusion, and what evidence is least consistent with it?
- Did you review imaging in native format or from printed summaries, including raw scan data and reliability indices?
- Is your opinion that this care fell outside the range a reasonable ophthalmologist could choose, or that you would have chosen differently? Can you identify practitioners who would reasonably have done what this physician did?
- What alternative explanations did you consider, and what evidence excluded each?
- What did the treating physician reasonably know at the time of the decision, as distinct from now?
- What would change your opinion? Is there any evidence that could?
- Are you opining on breach, on causation, or both — and what is the separate basis for each?
The last two are particularly revealing. An expert who cannot describe any evidence that would alter the opinion has described a position rather than an analysis.
What to Do With a Genuine Disagreement
Some disagreements survive all of this, and they should — they represent real uncertainty in the medicine, and the adversarial process exists to present them. The productive response is to narrow rather than escalate: identify the specific findings or premises on which the opinions diverge, supply both experts with the same complete materials, and frame what remains precisely for the factfinder. California workers' compensation offers a structural answer as well, since an evaluator both parties agree to serve as Agreed Medical Evaluator produces an opinion neither side can dismiss as purchased. In civil litigation the equivalent discipline is an independent case review whose value lies in its willingness to disappoint. An expert whose opinion never varies with the evidence is of limited use to anyone, including the party paying for it.
Frequently Asked Questions
Why do two qualified ophthalmologists reach different conclusions on the same case?
Most often because they were given different materials or different assumed facts, because they weighted the same findings differently where evidence conflicts, or because they were answering different questions — diagnosis, standard of care, causation, or damages. Genuine disagreement within the range of reasonable practice is also common and does not imply that either expert is unqualified or dishonest.
How can counsel tell a reasoned expert opinion from advocacy?
By examining the reasoning rather than the conclusion. Reasoned opinions acknowledge contrary evidence and explain why it does not control, concede uncertainty, state limitations and records not reviewed, address alternative explanations specifically, and vary in confidence across questions. Advocacy opinions answer everything with uniform certainty, omit inconvenient facts, and contain no limitations at all.
Is an expert saying he would have done it differently the same as a standard-of-care opinion?
No. The standard of care is a range of conduct reasonable practitioners may choose among, not a single approved pathway. A statement of personal preference is meaningful testimony about the expert's own practice but does not establish that a different choice fell outside the acceptable range. The distinction is worth probing directly, and the overreach occurs on both sides.
What is the single most useful question to ask an opposing expert?
What evidence would change your opinion. An expert who can identify specific findings or records that would alter the analysis has described a reasoning process; one who cannot identify anything has described a position. The follow-up — what records exist in this case that you did not review — is frequently as productive.
Educational information only. This page provides general information for attorneys and other medical-legal professionals. It is not medical or legal advice, does not address any particular case, and does not create a physician-patient, attorney-client, or expert-client relationship. Opinions in any matter are formed only after review of the specific records, examination findings, and applicable literature. Past engagements do not guarantee any result.
Board-certified ophthalmologist; Adjunct Associate Professor of Ophthalmology, Keck School of Medicine of USC; active California Qualified Medical Evaluator. Full biography · Curriculum vitae
Published August 2, 2026 · Last substantive review August 2, 2026 · Medical reviewer: Marc H. Shomer, MD, PhD, QME
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