AFFIRM; and Opinion Filed April 16, 2019.




                                            In The
                               Court of Appeals
                        Fifth District of Texas at Dallas
                                    No. 05-17-01464-CV

  JMA PARTNERS, INC. D/B/A GUARDIAN PHARMACY SERVICES AND JACK R.
                            MUNN, Appellants
                                  V.
                         JESUS GUZMAN, Appellee

                          On Appeal from the 95th District Court
                                  Dallas County, Texas
                           Trial Court Cause No. DC-17-06313

                            MEMORANDUM OPINION
                      Before Justices Brown, Schenck, and Pedersen, III
                                  Opinion by Justice Brown
       In this interlocutory appeal, we consider whether expert reports filed by appellee Jesus

Guzman to support his health care liability claims against appellants JMA Partners, Inc. d/b/a

Guardian Pharmacy Services and its president Jack R. Munn (together, Guardian) meet the

requirements of chapter 74 of the civil practice and remedies code, the Texas Medical Liability

Act (TMLA). See TEX. CIV. PRAC. & REM. CODE ANN. § 74.351. We conclude they do and affirm

the trial court’s order overruling Guardian’s objections to the reports and denying Guardian’s

motion to dismiss.

                                        BACKGROUND

       In February 2017, Guzman underwent a routine cataract surgery during which the surgeon,

Jeffrey Whitman, M.D. of the Key-Whitman Eye Center (Key-Whitman), injected a
triamcinolone/moxifloxacin with Pluronic antibiotic and steroid medication (Tri-Moxi) into

Guzman’s eye. Guzman alleges the Tri-Moxi, which was compounded by Guardian, caused

permanent damage to his eye. Guzman sued Guardian, alleging strict liability in tort, negligence,

and gross negligence, and served expert reports by John Scott Karolchyk, MS, RPh, FIACP, and

Wesley K. Herman, M.D.

           Guardian moved to dismiss Guzman’s claims, arguing the expert reports did not satisfy the

TMLA requirement for a fair summary of the experts’ opinions regarding the applicable standards

of care, the failure to meet those standards, and the causal relationship between the failure and

Guzman’s injury. See CIV. PRAC & REM. § 74.3351(r)(6). Following a hearing, the trial court

denied Guardian’s motion, and Guardian filed this interlocutory appeal. In two issues, Guardian

contends the trial court abused its discretion in overruling its objections to the expert reports and

denying its motion to dismiss or, alternatively, should have provided a thirty-day extension for

Guzman to attempt to cure the deficiencies in the reports.

                                                              APPLICABLE LAW

           A plaintiff who files a health care liability claim must serve an expert report on each

defendant early in the proceedings. CIV. PRAC. & REM. § 74.351(a).1 An expert report is sufficient

if it “provides a fair summary of the expert’s opinions . . . regarding applicable standards of care,

the manner in which the care rendered . . . failed to meet the standards, and the causal relationship

between the failure and the injury, harm, or damages claimed.” Id. § 74.351(r)(6). A trial court

should grant a motion challenging the adequacy of a report “only if it appears to the court, after

hearing, that the report does not represent an objective good faith effort to comply with the

definition of an expert report in Subsection (r)(6).” Id. § 74.351(l).



      1
        “In a health care liability claim, a claimant shall, not later than the 120th day after the date each defendant's original answer is filed, serve
on that party or the party’s attorney one or more expert reports, with a curriculum vitae of each expert listed in the report for each physician or
health care provider against whom a liability claim is asserted.” CIV. PRAC. & REM. § 74.351(a).

                                                                         –2–
       The report need not marshal all of a plaintiff’s proof, but must include the expert’s opinions

on the standard of care, breach, and causation. Baty v. Futrell, 543 S.W.3d 689, 693–94 (Tex.

2018) (citing Am. Transitional Care Ctrs. of Tex., Inc. v. Palacios, 46 S.W.3d 873, 877–79 (Tex.

2001)). The report must (1) inform the defendant of the specific conduct the plaintiff has called

into question, and (2) provide a basis for the trial court to conclude the claims have merit. Palacios,

46 S.W.3d at 880 (although a fair summary “is something less than a full statement of the

applicable standard of care and how it was breached,” it must “set out what care was expected, but

not given”). A report “must make a good-faith effort to explain, factually, how proximate cause

is going to be proven,” although the report need not use the words “proximate cause,”

“foreseeability,” or “cause in fact.” Columbia Valley Healthcare Sys., L.P. v. Zamarripa, 526

S.W.3d 453, 460 (Tex. 2017).      “A conclusory statement of causation is inadequate; instead, the

expert must explain the basis of his statements and link conclusions to specific facts.” Id.

       The trial court must consider an expert report in its entirety, rather than isolating specific

portions or sections, to determine whether it includes the required information. See Van Ness v.

ETMC First Physicians, 461 S.W.3d 140, 144 (Tex. 2015) (per curiam); see also Austin Heart,

P.A. v. Webb, 228 S.W.3d 276, 282 (Tex. App.—Austin 2007, no pet.) (“The form of the report

and the location of the information in the report are not dispositive.”). Additionally, one expert

need not address the standard of care, breach, and causation; multiple expert reports may be read

together to determine whether the requirements have been met. See CIV. PRAC. & REM. § 74.351(i).

       We review a trial court’s ruling on a motion to dismiss under section 74.351 for an abuse

of discretion. Baty, 543 S.W.3d at 693 n.4; Children’s Med. Ctr. of Dall. v. Durham, 402 S.W.3d

391, 395 (Tex. App.—Dallas 2013, no pet.). A trial court abuses its discretion when it acts

arbitrarily and without reference to guiding rules or principles. Nexion Health at Duncanville, Inc.

v. Ross, 374 S.W.3d 619, 622 (Tex. App.—Dallas 2012, pet. denied). In analyzing a report’s

                                                 –3–
sufficiency, we consider only the information contained within the four corners of the report. See

Palacios, 46 S.W.3d at 878.

                                           ANALYSIS

        Guzman served Guardian with two expert reports. One report was prepared by John Scott

Karolchyk, MS, RPh, FIACP, a formulation developer and compounding pharmacist who

developed the “true” Tri-Moxi injectable formulation with Jeffrey Liegner, M.D., and patented it

with Imprimis Pharmaceuticals in 2013. Liegner contacted Karolchyk on Dr. Whitman’s behalf

about potential retinal toxicity associated with a version of the formulation compounded by

Guardian, and Karolchyk agreed to consult for Key-Whitman. Karolchyk evaluated and tested

Guardian’s version of the formulation, and his report contains the opinions he formed during his

consultation.

        Wesley K. Herman, M.D., an ophthalmic microsurgeon certified as a laser vision correction

specialist in corneal and cataract surgery, prepared Guzman’s second expert report. Herman has

used injectable formulations, including compounded Tri-Moxi, as part of his daily practice and

regularly examines patients with environmentally toxic and chemical issues, including patients on

prescribed medications potentially toxic to ocular tissues and patients who have experienced

retinal toxic events.

1. Standard of Care and Breach

        Guardian complains Karolchyk’s report, prepared as a Key-Whitman consultant, does not

offer an opinion on the standard of care applicable to a compounding pharmacy or even indicate

Karolchyk was asked to opine on the standard of care. Guardian maintains Karolchyk’s report

does not satisfy section 74.351’s requirements because it simply compares the Guardian

formulation to the patented formulation without identifying the patented formulation as the only

acceptable formulation and fails to address any specific action or inaction by Guardian in

                                               –4–
compounding the formulation, i.e., how to properly formulate the compound, sonicate it, test it,

and what caused the pH to be too high. According to Guardian, Herman’s report also does not

adequately establish a standard of care and, as a physician, Herman is not qualified to offer an

opinion on the standard or care for, or breach by, a compounding pharmacy or pharmacist.

          Karolchyk, as a developer of the “true” patented Tri-Moxi injectable formulation, has been

involved in testing the formulation and is familiar with its components and pharmaceutical

parameters. To evaluate Guardian’s Tri-Moxi formulation, Karolchyk reviewed documents,

including the Guardian formulations, emails from Guardian and Key-Whitman, and formulation

test results by DynaLabs. He also tested six vials from two different lots of the Guardian

formulation. Karolchyk consulted with Imprimis Pharmaceuticals, confirming the true, original

patented formulation and its manufacturing process.

          According to Karolchyk’s report, the Tri-Moxi formulation is “a sophisticated delivery

system involving complex, multistep preparation, with significant potential for error” and only

highly specialized, highly trained and knowledgeable professionals should prepare the injection

following very strict procedures.2                     Karolchyk concluded with a reasonable degree of

pharmaceutical certainty that Guardian’s formulations were incorrectly formulated and not similar

in any way to the tested, patented formulation. He further concluded the formulation was

compounded improperly and in an unsafe manner, untested, and prepared outside the standard of

care.

          In support of his opinion, Karolchyk described the specific deficiencies in Guardian’s

formulation and processes:




      2
        Karolchyk’s report notes the FDA compliance policy guide and Good Compounding Practices do not allow compounding commercially
available, patented drugs.

                                                               –5–
                     The Guardian Tri-Moxi formulation’s concentration pH, which was 7.5 to
                      8.0 as compared to the patented formulation pH of 6.0 to 6.5, was too high
                      for ocular safety. Testing data indicated pH testing had not been
                      completed.3 Karolchyk tested the two lots of Guardian formulation he
                      received and the pH of those lots, at 6.6 and 7.2, was out of specification.

                     The Guardian formulation used poloxamer concentrations of twelve percent
                      and six percent (unlike the less than three percent poloxamer concentration
                      of the patented formulation). Further, Guardian’s use of sonication and
                      double sonication resulted in changes of viscosity, which can result in
                      known degradation of components. Research studies have shown
                      “sonication of poloxamer above concentrations of 5% . . . to degrade into
                      toxic products.” Poloxamer concentrations about five percent also “form
                      bioadhesive gels when exposed to body temperature, resulting in gel
                      expansion and a depot effect off the gel whenever it adheres in the ocular
                      space after injection.”

                     Guardian did not test or analyze particle size distributions prior to
                      dispensing to Key-Whitman. The patented Tri-Moxi formulation has
                      ninety-eight percent of its triamcinolone acetonide particles less than five
                      microns, confirming an “involved and tested pharmaceutical process which
                      allows for reliable and reproducible injection and dispersion of the actives
                      during injection.”

                     Guardian’s in-house testing, when performed, used a “QT Micro” method
                      in which the test solution is filtered into sample media. Suspension
                      formulations, however, cannot be filtered. Guardian used a different test
                      media, “TuffTest,” for subsequent formulations, but did not provide
                      validation of any media fills. Guardian also did not report any quarantine,
                      which adds to patient safety before outside lab testing is completed.

           The report does not include a section explicitly setting out a standard of care, but,

considered in its entirety, Karolchyk makes clear that, in his expert opinion, the standard of care

related to formulating, preparing, and testing a Tri-Moxi formulation is that used for the patented

formulation. And, the report identifies Guardian’s specific deficiencies in meeting that standard

of care, including a formulation pH too high and dangerous to the human eye, a formulation

improperly compounded based on testing showing the pH was out of specification, poloxamer

concentrations well above the three percent used in the patented formulation, and improper testing


       3
          Karolchyk’s report also states that three items were out of specification in Guardian’s quality control testing performed by DynaLabs, but
it is unclear what those items are from the report.

                                                                       –6–
for validation. The report adequately identifies the standard of care by setting forth “specific

information about what the defendant should have done differently.” See Abshire v. Christus

Health SE Tex., 563 S.W.3d 219, 226 (Tex. 2018) (quoting Palacios, 46 S.W.3d at 880);

Zamarripa, 526 S.W.3d at 450 (an expert report’s “adequacy does not depend on whether the

expert uses any particular ‘magical words’”); see, e.g., Baty, 543 S.W.3d at 695 (expert’s opinion

that anesthetist breached standard of care by sticking optic nerve with retrobulbar needle

sufficiently, although not explicitly, identified standard of care as not sticking optic nerve with

retrobulbar needle).

          We disagree that more detail was required. An expert need not conclusively establish a

standard of care; indeed, the parties to a medical malpractice claim often disagree over what the

standard of care requires. See Baty, 543 S.W.3d at 695–96; Certified EMS, Inc. v. Potts, 392

S.W.3d 625, 630–31 (Tex. 2013). Because Karolchyk’s report advises Guardian of the specific

conduct in formulating, preparing, and testing its Tri-Moxi injectable formulation that Guzman,

through Karolchyk, has called into question and provides the trial court a sufficient basis to

reasonably conclude that Guzman’s claims against Guardian have merit, the report satisfies section

74.351(r)(6)’s standard of care and breach requirements.4 See Baty, 543 S.W.3d at 697.

2. Causation

          Guardian contends the expert reports fail to adequately establish causation and,

specifically, Herman’s opinions on causation are conclusory and not linked to the alleged breach

of the standard of care. Specifically, Guardian complains Herman neither explained what caused

the pH level to become “too high” nor was able to state what the pH was in the medication that

was injected into Guzman’s eye.



      4
         Accordingly, we need not address Guardian’s arguments regarding whether Herman is qualified to opine on standard of care or breach in
this case and the related opinions in his report.

                                                                    –7–
       According to his report, Herman’s opinions are based upon his education, training,

experience, pertinent medical literature, review of relevant medical records, Karolchyk’s expert

report and testing, and Herman’s personal examination of Guzman. Herman’s report sets out the

following facts:

              Whitman performed cataract surgery on Guzman’s left eye on February 16,
               2017.

              At the conclusion of the procedure, Whitman injected a Tri-Moxi
               formulation into the vitreous of Guzman’s eye to provide post-operative
               prophylaxis for ocular inflammation and endophthalmitis. Guardian
               compounded the formulation, which was an attempted copy of the patented
               formulation.

              Whitman noted that Guzman tolerated the procedure well.

              One week after surgery, Guzman’s vision in his left eye was 20/30-2
               without corrective lenses and his best corrected visual acuity was 20/25.

              On March 10, 2017, Guzman was diagnosed with +1 posterior capsule
               opacity and cystoid macular edema. His best corrected visual acuity was
               20/200.

              Guzman was referred to Dr. Ashkan Abbey due to complaints of pain,
               burning, and decreased vision following his surgery. He was diagnosed
               with cystoid macular edema.

              On March 23, 2017, Key-Whitman sent Guzman a letter indicating it had
               become aware of a problem with a compounded medication used at Key-
               Whitman.

       Herman examined Guzman and was familiar specifically with Guzman’s condition and the

cause of his condition. Herman also has treated and managed patients suffering from the same

signs and symptoms as Guzman. Because of Herman’s extensive experience using these injectable

compounds and treating patients with retinal toxic events and their sequalae, Herman is familiar

with the cause of injuries to patients who suffer from retinal toxic events and how such injuries

occur and progress.



                                              –8–
       According to Herman, Guzman had a very specific retinal toxic event in which the retina

was destroyed. The injury to Guzman’s eye is a classic alkaline injury and, in reasonable medical

probability, was caused by moxifloxacin with a pH of greater than 7.0 coming into contact with

his eye. Herman’s report explains that injury will occur if a compound’s pH is not within a

tolerable range for the confined space of the eye. And, for Guzman, too high of a pH caused a

toxic effect on the tissue by restricting the blood supply to the tissue. Once the blood supply is

diminished (due to a shrinking blood vessel), the amount of oxygen traveling to the retina is

reduced, and ischemic injury occurs as a direct result. The toxicity of the formulation caused a

breakdown of the tissue of Guzman’s retina, which is irreversible. The degradation and death of

retinal tissue was a proximate cause of the blindness Guzman has in his left eye. Further, within

reasonable medical probability, Guzman will not regain vision in his left eye. Herman’s report

also excluded other potential causes of Guzman’s injuries, including an infectious or inflammatory

process or a complication from inappropriate or poorly-performed surgery. Instead, the early

presentation of cystoid macular edema so soon after the surgical procedure was a direct result of

the toxic effects of the use of the Guardian medication.

       To satisfy the causation requirement of section 74.351(r)(6), an expert must explain “how

and why” the alleged negligence caused the injury in question. Zamarripa, 526 S.W.3d at 460.

An expert need not prove the plaintiff’s case or account for every known fact; a report is sufficient

if it makes “a good-faith effort to explain, factually, how proximate cause is going to be proven.”

Id. Herman’s report represents a good-faith effort to summarize the causal relationship between

Guardian’s failure to formulate, prepare, and test its Tri-Moxi to meet a safe, nontoxic pH level

and the harm to Guzman. See, e.g., Baty, 543 S.W.3d at 698. Specifically, Herman explained

injury will occur if a compound’s pH is not within a tolerable range for the confined space of the

eye and opined Guzman suffered a classic alkaline injury to his left eye, resulting in vision loss

                                                –9–
that he will not regain, caused by moxifloxacin with a pH greater than 7.0 coming into contact

with his eye. We do not agree more detail, including either the specific pH of the medication

injected into Guzman’s eye or an explanation of what caused the pH to become “too high,” was

required. Herman’s report explains, to a reasonable degree, how and why the alleged breach

caused the injury to Guzman based on the facts presented.

       Guzman’s expert reports represent an objective good faith effort to summarize the experts’

opinions regarding the applicable standards of care, how Guardian failed to meet those standards,

and the causal relationship between the breach and Guzman’s injury. See CIV. PRAC. & REM. §

74.351(l), (r)(6). The reports inform Guardian of the conduct Guzman has called into question

with sufficient specificity and provide a basis for the trial court to conclude that the claims have

merit. See Baty, 543 S.W.3d at 693. Accordingly, the trial court did not abuse its discretion in

overruling Guardian’s objections to the reports or denying its motion to dismiss. See CIV. PRAC.

& REM. § 74.351(l). We overrule Guardian’s first and second issues.

       We affirm the trial court’s order.



                                                      /Ada Brown/
                                                      ADA BROWN
                                                      JUSTICE




171464F.P05




                                               –10–
                               Court of Appeals
                        Fifth District of Texas at Dallas
                                       JUDGMENT

 JMA PARTNERS, INC. D/B/A                              On Appeal from the 95th District Court,
 GUARDIAN PHARMACY SERVICES                            Dallas County, Texas
 AND JACK R. MUNN, Appellants                          Trial Court Cause No. DC-17-06313.
                                                       Opinion delivered by Justice Brown;
 No. 05-17-01464-CV          V.                        Justices Schenck and Pedersen, III
                                                       participating.
 JESUS GUZMAN, Appellee

     In accordance with this Court’s opinion of this date, the judgment of the trial court is
AFFIRMED.

       It is ORDERED that appellee JESUS GUZMAN recover his costs of this appeal from
appellants JMA PARTNERS, INC. D/B/A GUARDIAN PHARMACY SERVICES AND JACK
R. MUNN.


Judgment entered this 16th day of April 2019.




                                                –11–
