THIRD DIVISION

[G.R. No. 178763. April 21, 2009.]

PETER PAUL PATRICK LUCAS, FATIMA GLADYS LUCAS,

ABBEYGAIL LUCAS AND GILLIAN LUCAS , petitioners, vs. DR.
PROSPERO MA. C. TUAÑO, respondent.

DECISION

CHICO-NAZARIO, J : p

In this petition for review on certiorari 1 under Rule 45 of the Revised

Rules of Court, petitioners Peter Paul Patrick Lucas, Fatima Gladys Lucas,
Abbeygail Lucas and Gillian Lucas seek the reversal of the 27 September
2006 Decision 2 and 3 July 2007 Resolution, 3 both of the Court of Appeals in
CA-G.R. CV No. 68666, entitled "Peter Paul Patrick Lucas, Fatima Gladys
Lucas, Abbeygail Lucas and Gillian Lucas v. Prospero Ma. C. Tuaño".
In the questioned decision and resolution, the Court of Appeals
affirmed the 14 July 2000 Decision of the Regional Trial Court (RTC), Branch
150, Makati City, dismissing the complaint filed by petitioners in a civil case
entitled, "Peter Paul Patrick Lucas, Fatima Gladys Lucas, Abbeygail Lucas
and Gillian Lucas v. Prospero Ma. C. Tuaño", docketed as Civil Case No. 92-
2482.
From the record of the case, the established factual antecedents of the
present petition are:
Sometime in August 1988, petitioner Peter Paul Patrick Lucas (Peter)
contracted "sore eyes" in his right eye.
On 2 September 1988, complaining of a red right eye and swollen
eyelid, Peter made use of his health care insurance issued by Philamcare
Health Systems, Inc. (Philamcare), for a possible consult. The Philamcare
Coordinator, Dr. Edwin Oca, M.D., referred Peter to respondent, Dr. Prospero
Ma. C. Tuaño, M.D. (Dr. Tuaño), an ophthalmologist at St. Luke's Medical
Center, for an eye consult.
Upon consultation with Dr. Tuaño, Peter narrated that it had been nine
(9) days since the problem with his right eye began; and that he was already
taking Maxitrol to address the problem in his eye. According to Dr. Tuaño, he
performed "ocular routine examination" on Peter's eyes, wherein: (1) a gross
examination of Peter's eyes and their surrounding area was made; (2)
Peter's visual acuity were taken; (3) Peter's eyes were palpated to check the
intraocular pressure of each; (4) the motility of Peter's eyes was observed;
and (5) the ophthalmoscopy 4 on Peter's eyes was used. On that particular
consultation, Dr. Tuaño diagnosed that Peter was suffering from
conjunctivitis 5 or "sore eyes". Dr. Tuaño then prescribed Spersacet-C 6 eye
drops for Peter and told the latter to return for follow-up after one week.
As instructed, Peter went back to Dr. Tuaño on 9 September 1988.
Upon examination, Dr. Tuaño told Peter that the "sore eyes" in the latter's
right eye had already cleared up and he could discontinue the Spersacet-C.
However, the same eye developed Epidemic Kerato Conjunctivitis (EKC), 7 a
viral infection. To address the new problem with Peter's right eye, Dr. Tuaño
prescribed to the former a steroid-based eye drop called Maxitrol, 8 a dosage
of six (6) drops per day. 9 To recall, Peter had already been using Maxitrol
prior to his consult with Dr. Tuaño.
TDAHCS

On 21 September 1988, Peter saw Dr. Tuaño for a follow-up

consultation. After examining both of Peter's eyes, Dr. Tuaño instructed the
former to taper down 10 the dosage of Maxitrol, because the EKC in his right
eye had already resolved. Dr. Tuaño specifically cautioned Peter that, being
a steroid, Maxitrol had to be withdrawn gradually; otherwise, the EKC might
recur. 11
Complaining of feeling as if there was something in his eyes, Peter
returned to Dr. Tuaño for another check-up on 6 October 1988. Dr. Tuaño
examined Peter's eyes and found that the right eye had once more
developed EKC. So, Dr. Tuaño instructed Peter to resume the use of Maxitrol
at six (6) drops per day.
On his way home, Peter was unable to get a hold of Maxitrol, as it was
out of stock. Consequently, Peter was told by Dr. Tuano to take, instead,
Blephamide 12 another steroid-based medication, but with a lower
concentration, as substitute for the unavailable Maxitrol, to be used three (3)
times a day for five (5) days; two (2) times a day for five (5) days; and then
just once a day. 13
Several days later, on 18 October 1988, Peter went to see Dr. Tuaño at
his clinic, alleging severe eye pain, feeling as if his eyes were about to "pop-
out", a headache and blurred vision. Dr. Tuaño examined Peter's eyes and
discovered that the EKC was again present in his right eye. As a result, Dr.
Tuaño told Peter to resume the maximum dosage of Blephamide.
Dr. Tuaño saw Peter once more at the former's clinic on 4 November
1988. Dr. Tuaño's examination showed that only the periphery of Peter's
right eye was positive for EKC; hence, Dr. Tuaño prescribed a lower dosage
of Blephamide.
It was also about this time that Fatima Gladys Lucas (Fatima), Peter's
spouse, read the accompanying literature of Maxitrol and found therein the
following warning against the prolonged use of such steroids:

WARNING:

Prolonged use may result in glaucoma, with damage to the optic

nerve, defects in visual acuity and fields of vision, and posterior,
subcapsular cataract formation. Prolonged use may suppress the host
response and thus increase the hazard of secondary ocular infractions,
in those diseases causing thinning of the cornea or sclera, perforations
have been known to occur with the use of topical steroids. In acute
 purulent conditions of the eye, steroids may mask infection or enhance
existing infection. If these products are used for 10 days or longer,
intraocular pressure should be routinely monitored even though it may
be difficult in children and uncooperative patients.

Employment of steroid medication in the treatment of herpes

simplex requires great caution.

xxx xxx xxx

ADVERSE REACTIONS:

Adverse reactions have occurred with steroid/anti-infective

combination drugs which can be attributed to the steroid component,
the anti-infective component, or the combination. Exact incidence
figures are not available since no denominator of treated patients is
available.

Reactions occurring most often from the presence of the anti-

infective ingredients are allergic sensitizations. The reactions due to
the steroid component in decreasing order to frequency are elevation
of intra-ocular pressure (IOP) with possible development of glaucoma,
infrequent optic nerve damage; posterior subcapsular cataract
formation; and delayed wound healing.

Secondary infection: The development of secondary has occurred

after use of combination containing steroids and antimicrobials. Fungal
infections of the correa are particularly prone to develop coincidentally
with long-term applications of steroid. The possibility of fungal invasion
must be considered in any persistent corneal ulceration where steroid
treatment has been used.

Secondary bacterial ocular infection following suppression of host

responses also occurs.

On 26 November 1988, Peter returned to Dr. Tuaño's clinic,

complaining of "feeling worse". 14 It appeared that the EKC had spread to the
whole of Peter's right eye yet again. Thus, Dr. Tuaño instructed Peter to
resume the use of Maxitrol. Petitioners averred that Peter already made
mention to Dr. Tuaño during said visit of the above-quoted warning against
the prolonged use of steroids, but Dr. Tuaño supposedly brushed aside
Peter's concern as mere paranoia, even assuring him that the former was
taking care of him (Peter).
Petitioners further alleged that after Peter's 26 November 1988 visit to
Dr. Tuaño, Peter continued to suffer pain in his right eye, which seemed to
"progress", with the ache intensifying and becoming more frequent.
Upon waking in the morning of 13 December 1988, Peter had no vision
in his right eye. Fatima observed that Peter's right eye appeared to be
bloody and swollen. 15 Thus, spouses Peter and Fatima rushed to the clinic of
Dr. Tuaño. Peter reported to Dr. Tuaño that he had been suffering from
constant headache in the afternoon and blurring of vision.
Upon examination, Dr. Tuaño noted the hardness of Peter's right eye.
With the use of a tonometer 16 to verify the exact intraocular pressure 17
(IOP) of Peter's eyes, Dr. Tuaño discovered that the tension in Peter's right
eye was 39.0 Hg, while that of his left was 17.0 Hg. 18 Since the tension in
Peter's right eye was way over the normal IOP, which merely ranged from
10.0 Hg to 21.0 Hg, 19 Dr. Tuaño ordered 20 him to immediately
discontinue the use of Maxitrol and prescribed to the latter Diamox 21 and
Normoglaucon, instead. 22 Dr. Tuaño also required Peter to go for daily
check-up in order for the former to closely monitor the pressure of the
latter's eyes.
TAHcCI

On 15 December 1988, the tonometer reading of Peter's right eye

yielded a high normal level, i.e., 21.0 Hg. Hence, Dr. Tuaño told Peter to
continue using Diamox and Normoglaucon. But upon Peter's complaint of
"stomach pains and tingling sensation in his fingers", 23 Dr. Tuaño
discontinued Peter's use of Diamox. 24
Peter went to see another ophthalmologist, Dr. Ramon T. Batungbacal
(Dr. Batungbacal), on 21 December 1988, who allegedly conducted a
complete ophthalmological examination of Peter's eyes. Dr. Batungbacal's
diagnosis was Glaucoma 25 O.D. 26 He recommended Laser Trabeculoplasty
27 for Peter's right eye.

When Peter returned to Dr. Tuaño on 23 December 1988, 28 the

tonometer measured the IOP of Peter's right eye to be 41.0 Hg, 29 again,
way above normal. Dr. Tuaño addressed the problem by advising Peter to
resume taking Diamox along with Normoglaucon.
During the Christmas holidays, Peter supposedly stayed in bed most of
the time and was not able to celebrate the season with his family because of
the debilitating effects of Diamox. 30
On 28 December 1988, during one of Peter's regular follow-ups with Dr.
Tuaño, the doctor conducted another ocular routine examination of Peter's
eyes. Dr. Tuaño noted the recurrence of EKC in Peter's right eye.
Considering, however, that the IOP of Peter's right eye was still quite high at
41.0 Hg, Dr. Tuaño was at a loss as to how to balance the treatment of
Peter's EKC vis-Ã -vis the presence of glaucoma in the same eye. Dr. Tuaño,
thus, referred Peter to Dr. Manuel B. Agulto, M.D. (Dr. Agulto), another
ophthalmologist specializing in the treatment of glaucoma. 31 Dr. Tuaño's
letter of referral to Dr. Agulto stated that:

Referring to you Mr. Peter Lucas for evaluation & possible

management. I initially saw him Sept. 2, 1988 because of
conjunctivitis. The latter resolved and he developed EKC for which I
gave Maxitrol. The EKC was recurrent after stopping steroid drops.
Around 1 month of steroid treatment, he noted blurring of vision & pain
on the R. however, I continued the steroids for the sake of the EKC. A
month ago, I noted iris atrophy, so I took the IOP and it was definitely
elevated. I stopped the steroids immediately and has (sic) been
treating him medically.

It seems that the IOP can be controlled only with oral Diamox,
and at the moment, the EKC has recurred and I'm in a fix whether to
 resume the steroid or not considering that the IOP is still uncontrolled.
32

On 29 December 1988, Peter went to see Dr. Agulto at the latter's

clinic. Several tests were conducted thereat to evaluate the extent of Peter's
condition. Dr. Agulto wrote Dr. Tuaño a letter containing the following
findings and recommendations:

Thanks for sending Peter Lucas. On examination conducted

vision was 20/25 R and 20/20L. Tension curve 19 R and 15 L at 1210 H
while on Normoglaucon BID OD & Diamox 1/2 tab every 6h po.

Slit lamp evaluation 33 disclosed subepithelial corneal defect

outer OD. There was circumferential peripheral iris atrophy, OD. The
lenses were clear.

Funduscopy 34 showed vertical cup disc of 0.85 R and 0.6 L with

temporal slope R>L.

Zeiss gonioscopy 35 revealed basically open angles both eyes

with occasional PAS, 36 OD.

Rolly, I feel that Peter Lucas has really sustained significant

glaucoma damage. I suggest that we do a baseline visual fields and
push medication to lowest possible levels. If I may suggest further, I
think we should prescribe Timolol 37 B I D 38 OD in lieu of
Normoglaucon. If the IOP is still inadequate, we may try D'epifrin 39 BID
OD (despite low PAS). I'm in favor of retaining Diamox or similar CAI. 40

If fields show further loss in say — 3 mos. then we should

consider trabeculoplasty.

I trust that this approach will prove reasonable for you and Peter.
41

Peter went to see Dr. Tuaño on 31 December 1988, bearing Dr.

Agulto's aforementioned letter. Though Peter's right and left eyes then had
normal IOP of 21.0 Hg and 17.0 Hg, respectively, Dr. Tuaño still gave him a
prescription for Timolol B.I.D. so Peter could immediately start using said
medication. Regrettably, Timolol B.I.D. was out of stock, so Dr. Tuaño
instructed Peter to just continue using Diamox and Normoglaucon in the
meantime.
Just two days later, on 2 January 1989, the IOP of Peter's right eye
remained elevated at 21.0 Hg, 42 as he had been without Diamox for the
past three (3) days.
On 4 January 1989, Dr. Tuaño conducted a visual field study 43 of
Peter's eyes, which revealed that the latter had tubular vision 44 in his right
eye, while that of his left eye remained normal. Dr. Tuaño directed Peter to
religiously use the Diamox and Normoglaucon, as the tension of the latter's
right eye went up even further to 41.0 Hg in just a matter of two (2) days, in
the meantime that Timolol B.I.D. and D'epifrin were still not available in the
market. Again, Dr. Tuaño advised Peter to come for regular check-up so his
IOP could be monitored.
Obediently, Peter went to see Dr. Tuaño on the 7th, 13th, 16th and
20th of January 1989 for check-up and IOP monitoring.
In the interregnum, however, Peter was prodded by his friends to seek
a second medical opinion. On 13 January 1989, Peter consulted Dr. Jaime
Lapuz, M.D. (Dr. Lapuz), an ophthalmologist, who, in turn, referred Peter to
Dr. Mario V. Aquino, M.D. (Dr. Aquino), another ophthalmologist who
specializes in the treatment of glaucoma and who could undertake the long
term care of Peter's eyes.
According to petitioners, after Dr. Aquino conducted an extensive
evaluation of Peter's eyes, the said doctor informed Peter that his eyes were
relatively normal, though the right one sometimes manifested maximum
borderline tension. Dr. Aquino also confirmed Dr. Tuaño's diagnosis of
tubular vision in Peter's right eye. Petitioners claimed that Dr. Aquino
essentially told Peter that the latter's condition would require lifetime
medication and follow-ups. EHSTcC

In May 1990 and June 1991, Peter underwent two (2) procedures of
laser trabeculoplasty to attempt to control the high IOP of his right eye.
Claiming to have steroid-induced glaucoma 45 and blaming Dr. Tuaño
for the same, Peter, joined by: (1) Fatima, his spouse; 46 (2) Abbeygail, his
natural child; 47 and (3) Gillian, his legitimate child 48 with Fatima, instituted
on 1 September 1992, a civil complaint for damages against Dr. Tuaño,
before the RTC, Branch 150, Quezon City. The case was docketed as Civil
Case No. 92-2482.
In their Complaint, petitioners specifically averred that as the "direct
consequence of [Peter's] prolonged use of Maxitrol, [he] suffered from
steroid induced glaucoma which caused the elevation of his intra-ocular
pressure. The elevation of the intra-ocular pressure of [Peter's right eye]
caused the impairment of his vision which impairment is not curable and
may even lead to total blindness". 49
Petitioners additionally alleged that the visual impairment of Peter's
right eye caused him and his family so much grief. Because of his present
condition, Peter now needed close medical supervision forever; he had
already undergone two (2) laser surgeries, with the possibility that more
surgeries were still needed in the future; his career in sports casting had
suffered and was continuing to suffer; 50 his anticipated income had been
greatly reduced as a result of his "limited" capacity; he continually suffered
from "headaches, nausea, dizziness, heart palpitations, rashes, chronic
rhinitis, sinusitis," 51 etc.; Peter's relationships with his spouse and children
continued to be strained, as his condition made him highly irritable and
sensitive; his mobility and social life had suffered; his spouse, Fatima,
became the breadwinner in the family; 52 and his two children had been
deprived of the opportunity for a better life and educational prospects.
Collectively, petitioners lived in constant fear of Peter becoming completely
blind. 53
 In the end, petitioners sought pecuniary award for their supposed pain
and suffering, which were ultimately brought about by Dr. Tuaño's grossly
negligent conduct in prescribing to Peter the medicine Maxitrol for a period
of three (3) months, without monitoring Peter's IOP, as required in cases of
prolonged use of said medicine, and notwithstanding Peter's constant
complaint of intense eye pain while using the same. Petitioners particularly
prayed that Dr. Tuaño be adjudged liable for the following amounts:

1. The amount of P2,000,000.00 to plaintiff Peter Lucas as and by way

of compensation for his impaired vision.

2. The amount of P300,000.00 to spouses Lucas as and by way of

actual damages plus such additional amounts that may be
proven during trial.

3. The amount of P1,000,000.00 as and by way of moral damages.

4. The amount of P500,000.00 as and by way of exemplary damages.

5. The amount of P200,000.00 as and by way of attorney's fees plus

costs of suit. 54
TAIEcS

In rebutting petitioners' complaint, Dr. Tuaño asserted that the

"treatment made by [him] more than three years ago has no causal
connection to [Peter's] present glaucoma or condition". 55 Dr. Tuaño
explained that "[d]rug-induced glaucoma is temporary and curable, steroids
have the side effect of increasing intraocular pressure. Steroids are
prescribed to treat Epidemic Kerato Conjunctivitis or EKC which is an
infiltration of the cornea as a result of conjunctivitis or sore eyes". 56 Dr.
Tuaño also clarified that (1) "[c]ontrary to [petitioners'] fallacious claim, [he]
did NOT continually prescribe the drug Maxitrol which contained steroids for
any prolonged period" 57 and "[t]he truth was the Maxitrol was discontinued .
. . as soon as EKC disappeared and was resumed only when EKC
reappeared;" 58 (2) the entire time he was treating Peter, he "continually
monitored the intraocular pressure of [Peter's eyes] by palpating the eyes
and by putting pressure on the eyeballs", and no hardening of the same
could be detected, which meant that there was no increase in the tension or
IOP, a possible side reaction to the use of steroid medications; and (3) it was
only on 13 December 1988 that Peter complained of a headache and blurred
vision in his right eye, and upon measuring the IOP of said eye, it was
determined for the first time that the IOP of the right eye had an elevated
value.
But granting for the sake of argument that the "steroid treatment of
[Peter's] EKC caused the steroid induced glaucoma", 59 Dr. Tuaño argued
that:

[S]uch condition, i.e., elevated intraocular pressure, is

temporary. As soon as the intake of steroids is discontinued, the
intraocular pressure automatically is reduced. Thus, [Peter's] glaucoma
can only be due to other causes not attributable to steroids, certainly
not attributable to [his] treatment of more than three years ago . . . .
 From a medical point of view, as revealed by more current
examination of [Peter], the latter's glaucoma can only be long standing
glaucoma, open angle glaucoma, because of the large C:D ratio. The
steroids provoked the latest glaucoma to be revealed earlier as [Peter]
remained asymptomatic prior to steroid application. Hence, the steroid
treatment was in fact beneficial to [Peter] as it revealed the incipient
open angle glaucoma of [Peter] to allow earlier treatment of the same.
60

In a Decision dated 14 July 2000, the RTC dismissed Civil Case No. 92-
2482 "for insufficiency of evidence". 61 The decretal part of said Decision
reads:

Wherefore, premises considered, the instant complaint is

dismissed for insufficiency of evidence. The counter claim (sic) is
likewise dismissed in the absence of bad faith or malice on the part of
plaintiff in filing the suit. 62

The RTC opined that petitioners failed to prove by preponderance of

evidence that Dr. Tuaño was negligent in his treatment of Peter's condition.
In particular, the record of the case was bereft of any evidence to establish
that the steroid medication and its dosage, as prescribed by Dr. Tuaño,
caused Peter's glaucoma. The trial court reasoned that the "recognized
standards of the medical community has not been established in this case,
much less has causation been established to render [Tuaño] liable". 63
According to the RTC:

[Petitioners] failed to establish the duty required of a medical

practitioner against which Peter Paul's treatment by defendant can be
compared with. They did not present any medical expert or even a
medical doctor to convince and expertly explain to the court the
established norm or duty required of a physician treating a patient, or
whether the non taking (sic) by Dr. Tuaño of Peter Paul's pressure a
deviation from the norm or his non-discovery of the glaucoma in the
course of treatment constitutes negligence. It is important and
indispensable to establish such a standard because once it is
established, a medical practitioner who departed thereof breaches his
duty and commits negligence rendering him liable. Without such
testimony or enlightenment from an expert, the court is at a loss as to
what is then the established norm of duty of a physician against which
defendant's conduct can be compared with to determine negligence.
64

The RTC added that in the absence of "any medical evidence to the
contrary, this court cannot accept [petitioners'] claim that the use of steroid
is the proximate cause of the damage sustained by [Peter's] eye". 65
Correspondingly, the RTC accepted Dr. Tuaño's medical opinion that
"Peter Paul must have been suffering from normal tension glaucoma,
meaning, optic nerve damage was happening but no elevation of the eye
pressure is manifested, that the steroid treatment actually unmasked the
condition that resulted in the earlier treatment of the glaucoma. There is
nothing in the record to contradict such testimony. In fact, plaintiff's Exhibit
'S' even tends to support them".
Undaunted, petitioners appealed the foregoing RTC decision to the
Court of Appeals. Their appeal was docketed as CA-G.R. CV No. 68666. CcSEIH

On 27 September 2006, the Court of Appeals rendered a decision in

CA-G.R. CV No. 68666 denying petitioners' recourse and affirming the
appealed RTC Decision. The fallo of the judgment of the appellate court
states:

WHEREFORE, the Decision appealed from is AFFIRMED. 66

The Court of Appeals faulted petitioners because they —

[D]id not present any medical expert to testify that Dr. Tuano's
prescription of Maxitrol and Blephamide for the treatment of EKC on
Peter's right eye was not proper and that his palpation of Peter's right
eye was not enough to detect adverse reaction to steroid. Peter
testified that Dr. Manuel Agulto told him that he should not have used
steroid for the treatment of EKC or that he should have used it only for
two (2) weeks, as EKC is only a viral infection which will cure by itself.
However, Dr. Agulto was not presented by [petitioners] as a witness to
confirm what he allegedly told Peter and, therefore, the latter's
testimony is hearsay. Under Rule 130, Section 36 of the Rules of Court,
a witness can testify only to those facts which he knows of his own
personal knowledge, . . . . Familiar and fundamental is the rule that
hearsay testimony is inadmissible as evidence. 67

Like the RTC, the Court of Appeals gave great weight to Dr. Tuaño's
medical judgment, specifically the latter's explanation that:

[W]hen a doctor sees a patient, he cannot determine whether or

not the latter would react adversely to the use of steroids, that it was
only on December 13, 1989, when Peter complained for the first time
of headache and blurred vision that he observed that the pressure of
the eye of Peter was elevated, and it was only then that he suspected
that Peter belongs to the 5% of the population who reacts adversely to
steroids. 68

Petitioners' Motion for Reconsideration was denied by the Court of

Appeals in a Resolution dated 3 July 2007.
Hence, this Petition for Review on Certiorari under Rule 45 of the
Revised Rules of Court premised on the following assignment of errors:

I.

THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN

AFFIRMING THE DECISION OF THE TRIAL COURT DISMISSING THE
PETITIONERS' COMPLAINT FOR DAMAGES AGAINST THE RESPONDENT
ON THE GROUND OF INSUFFICIENCY OF EVIDENCE;

II.
 THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN
DISMISSING THE PETITIONERS' COMPLAINT FOR DAMAGES AGAINST
THE RESPONDENT ON THE GROUND THAT NO MEDICAL EXPERT WAS
PRESENTED BY THE PETITIONERS TO PROVE THEIR CLAIM FOR
MEDICAL NEGLIGENCE AGAINST THE RESPONDENT; AND

III.

THE COURT OF APPEALS COMMITTED GRAVE REVERSIBLE ERROR IN

NOT FINDING THE RESPONDENT LIABLE TO THE PETITIONERS' FOR
ACTUAL, MORAL AND EXEMPLARY DAMAGES, ASIDE FROM ATTORNEY'S
FEES, COSTS OF SUIT, AS A RESULT OF HIS GROSS NEGLIGENCE. 69

A reading of the afore-quoted reversible errors supposedly committed

by the Court of Appeals in its Decision and Resolution would reveal that
petitioners are fundamentally assailing the finding of the Court of Appeals
that the evidence on record is insufficient to establish petitioners'
entitlement to any kind of damage. Therefore, it could be said that the sole
issue for our resolution in the Petition at bar is whether the Court of Appeals
committed reversible error in affirming the judgment of the RTC that
petitioners failed to prove, by preponderance of evidence, their claim for
damages against Dr. Tuaño.
Evidently, said issue constitutes a question of fact, as we are asked to
revisit anew the factual findings of the Court of Appeals, as well as of the
RTC. In effect, petitioners would have us sift through the evidence on record
and pass upon whether there is sufficient basis to establish Dr. Tuaño's
negligence in his treatment of Peter's eye condition. This question clearly
involves a factual inquiry, the determination of which is not within the ambit
of this Court's power of review under Rule 45 of the 1997 Rules Civil
Procedure, as amended. 70
Elementary is the principle that this Court is not a trier of facts; only
errors of law are generally reviewed in petitions for review on certiorari
criticizing decisions of the Court of Appeals. Questions of fact are not
entertained. 71CcAESI

Nonetheless, the general rule that only questions of law may be raised
on appeal in a petition for review under Rule 45 of the Rules of Court admits
of certain exceptions, including the circumstance when the finding of fact of
the Court of Appeals is premised on the supposed absence of evidence, but
is contradicted by the evidence on record. Although petitioners may not
explicitly invoke said exception, it may be gleaned from their allegations and
arguments in the instant Petition.
Petitioners contend, that "[c]ontrary to the findings of the Honorable
Court of Appeals, [they] were more than able to establish that: Dr. Tuaño
ignored the standard medical procedure for ophthalmologists, administered
medication with recklessness, and exhibited an absence of competence and
skills expected from him". 72 Petitioners reject the necessity of presenting
expert and/or medical testimony to establish (1) the standard of care
respecting the treatment of the disorder affecting Peter's eye; and (2)
whether or not negligence attended Dr. Tuaño's treatment of Peter,
because, in their words —

That Dr. Tuaño was grossly negligent in the treatment of Peter's

simple eye ailment is a simple case of cause and effect. With mere
documentary evidence and based on the facts presented by the
petitioners, respondent can readily be held liable for damages even
without any expert testimony. In any case, however, and contrary to
the finding of the trial court and the Court of Appeals, there was a
medical expert presented by the petitioner showing the recklessness
committed by [Dr. Tuaño] — Dr. Tuaño himself. [Emphasis supplied.]

They insist that Dr. Tuaño himself gave sufficient evidence to establish
his gross negligence that ultimately caused the impairment of the vision of
Peter's right eye, 73 i.e., that "[d]espite [Dr. Tuaño's] knowledge that 5% of
the population reacts adversely to Maxitrol, [he] had no qualms whatsoever
in prescribing said steroid to Peter without first determining whether or not
the (sic) Peter belongs to the 5%". 74
We are not convinced. The judgments of both the Court of Appeals and
the RTC are in accord with the evidence on record, and we are accordingly
bound by the findings of fact made therein.
Petitioners' position, in sum, is that Peter's glaucoma is the direct
result of Dr. Tuaño's negligence in his improper administration of the drug
Maxitrol; "thus, [the latter] should be liable for all the damages suffered and
to be suffered by [petitioners]". 75 Clearly, the present controversy is a
classic illustration of a medical negligence case against a physician based on
the latter's professional negligence. In this type of suit, the patient or his
heirs, in order to prevail, is required to prove by preponderance of evidence
that the physician failed to exercise that degree of skill, care, and learning
possessed by other persons in the same profession; and that as a proximate
result of such failure, the patient or his heirs suffered damages.
For lack of a specific law geared towards the type of negligence
committed by members of the medical profession, such claim for damages is
almost always anchored on the alleged violation of Article 2176 of the Civil
Code, which states that:

ART. 2176. Â Whoever by act or omission causes damage to

another, there being fault or negligence, is obliged to pay for the
damage done. Such fault or negligence, if there is no pre-existing
contractual relation between the parties, is called a quasi-delict and is
governed by the provisions of this Chapter.

In medical negligence cases, also called medical malpractice suits,

there exist a physician-patient relationship between the doctor and the
victim. But just like any other proceeding for damages, four essential (4)
elements i.e., (1) duty; (2) breach; (3) injury; and (4) proximate causation, 76
must be established by the plaintiff/s. All the four (4) elements must co-exist
in order to find the physician negligent and, thus, liable for damages.
When a patient engages the services of a physician, a physician-
patient relationship is generated. And in accepting a case, the physician, for
all intents and purposes, represents that he has the needed training and skill
possessed by physicians and surgeons practicing in the same field; and that
he will employ such training, care, and skill in the treatment of the patient. 77
Thus, in treating his patient, a physician is under a duty to [the former] to
exercise that degree of care, skill and diligence which physicians in the same
general neighborhood and in the same general line of practice ordinarily
possess and exercise in like cases. 78 Stated otherwise, the physician has the
duty to use at least the same level of care that any other reasonably
competent physician would use to treat the condition under similar
circumstances.
This standard level of care, skill and diligence is a matter best
addressed by expert medical testimony, because the standard of care in a
medical malpractice case is a matter peculiarly within the knowledge of
experts in the field. 79
There is breach of duty of care, skill and diligence, or the improper
performance of such duty, by the attending physician when the patient is
injured in body or in health [and this] constitutes the actionable
malpractice. 80 Proof of such breach must likewise rest upon the testimony of
an expert witness that the treatment accorded to the patient failed to meet
the standard level of care, skill and diligence which physicians in the same
general neighborhood and in the same general line of practice ordinarily
possess and exercise in like cases. DaIACS

Even so, proof of breach of duty on the part of the attending physician
is insufficient, for there must be a causal connection between said breach
and the resulting injury sustained by the patient. Put in another way, in order
that there may be a recovery for an injury, it must be shown that the "injury
for which recovery is sought must be the legitimate consequence of the
wrong done; the connection between the negligence and the injury must be
a direct and natural sequence of events, unbroken by intervening efficient
causes"; 81 that is, the negligence must be the proximate cause of the
injury. And the proximate cause of an injury is that cause, which, in the
natural and continuous sequence, unbroken by any efficient intervening
cause, produces the injury, and without which the result would not have
occurred. 82
Just as with the elements of duty and breach of the same, in order to
establish the proximate cause [of the injury] by a preponderance of the
evidence in a medical malpractice action, [the patient] must similarly use
expert testimony, because the question of whether the alleged professional
negligence caused [the patient's] injury is generally one for specialized
expert knowledge beyond the ken of the average layperson; using the
specialized knowledge and training of his field, the expert's role is to present
to the [court] a realistic assessment of the likelihood that [the physician's]
alleged negligence caused [the patient's] injury. 83
From the foregoing, it is apparent that medical negligence cases are
best proved by opinions of expert witnesses belonging in the same general
neighborhood and in the same general line of practice as defendant
physician or surgeon. The deference of courts to the expert opinion of
qualified physicians [or surgeons] stems from the former's realization that
the latter possess unusual technical skills which laymen in most instances
are incapable of intelligently evaluating; 84 hence, the indispensability of
expert testimonies.
In the case at bar, there is no question that a physician-patient
relationship developed between Dr. Tuaño and Peter when Peter went to see
the doctor on 2 September 1988, seeking a consult for the treatment of his
sore eyes. Admittedly, Dr. Tuaño, an ophthalmologist, prescribed Maxitrol
when Peter developed and had recurrent EKC. Maxitrol or
neomycin/polymyxin B sulfates/dexamethasone ophthalmic ointment is a
multiple-dose anti-infective steroid combination in sterile form for topical
application. 85 It is the drug which petitioners claim to have caused Peter's
glaucoma.
However, as correctly pointed out by the Court of Appeals, "[t]he onus
probandi was on the patient to establish before the trial court that the
physicians ignored standard medical procedure, prescribed and
administered medication with recklessness and exhibited an absence of the
competence and skills expected of general practitioners similarly situated".
86 Unfortunately, in this case, there was absolute failure on the part of
petitioners to present any expert testimony to establish: (1) the standard of
care to be implemented by competent physicians in treating the same
condition as Peter's under similar circumstances; (2) that, in his treatment of
Peter, Dr. Tuaño failed in his duty to exercise said standard of care that any
other competent physician would use in treating the same condition as
Peter's under similar circumstances; and (3) that the injury or damage to
Peter's right eye, i.e., his glaucoma, was the result of his use ofMaxitrol, as
prescribed by Dr. Tuaño. Petitioners' failure to prove the first element alone
is already fatal to their cause.
HScaCT

Petitioners maintain that Dr. Tuaño failed to follow in Peter's case the
required procedure for the prolonged use of Maxitrol. But what is actually the
required procedure in situations such as in the case at bar? To be precise,
what is the standard operating procedure when ophthalmologists prescribe
steroid medications which, admittedly, carry some modicum of risk?
Absent a definitive standard of care or diligence required of Dr. Tuaño
under the circumstances, we have no means to determine whether he was
able to comply with the same in his diagnosis and treatment of Peter. This
Court has no yardstick upon which to evaluate or weigh the attendant facts
of this case to be able to state with confidence that the acts complained of,
indeed, constituted negligence and, thus, should be the subject of pecuniary
reparation.
Petitioners assert that prior to prescribing Maxitrol, Dr. Tuaño should
have determined first whether Peter was a "steroid responder". 87 Yet again,
petitioners did not present any convincing proof that such determination is
actually part of the standard operating procedure which ophthalmologists
should unerringly follow prior to prescribing steroid medications.
In contrast, Dr. Tuaño was able to clearly explain that what is only
required of ophthalmologists, in cases such as Peter's, is the conduct of
standard tests/procedures known as "ocular routine examination", 88
composed of five (5) tests/procedures — specifically, gross examination of
the eyes and the surrounding area; taking of the visual acuity of the patient;
checking the intraocular pressure of the patient; checking the motility of the
eyes; and using ophthalmoscopy on the patient's eye — and he did all those
tests/procedures every time Peter went to see him for follow-up consultation
and/or check-up.
We cannot but agree with Dr. Tuaño's assertion that when a doctor
sees a patient, he cannot determine immediately whether the latter would
react adversely to the use of steroids; all the doctor can do is map out a
course of treatment recognized as correct by the standards of the medical
profession. It must be remembered that a physician is not an insurer of the
good result of treatment. The mere fact that the patient does not get well or
that a bad result occurs does not in itself indicate failure to exercise due
care. 89 The result is not determinative of the performance [of the physician]
and he is not required to be infallible. 90
Moreover, that Dr. Tuaño saw it fit to prescribe Maxitrol to Peter was
justified by the fact that the latter was already using the same medication
when he first came to see Dr. Tuaño on 2 September 1988 and had exhibited
no previous untoward reaction to that particular drug. 91
Also, Dr. Tuaño categorically denied petitioners' claim that he never
monitored the tension of Peter's eyes while the latter was on Maxitrol. Dr.
Tuaño testified that he palpated Peter's eyes every time the latter came for
a check-up as part of the doctor's ocular routine examination, a fact which
petitioners failed to rebut. Dr. Tuaño's regular conduct of examinations and
tests to ascertain the state of Peter's eyes negate the very basis of
petitioners' complaint for damages. As to whether Dr. Tuaño's actuations
conformed to the standard of care and diligence required in like
circumstances, it is presumed to have so conformed in the absence of
evidence to the contrary. HSCATc

Even if we are to assume that Dr. Tuaño committed negligent acts in

his treatment of Peter's condition, the causal connection between Dr.
Tuaño's supposed negligence and Peter's injury still needed to be
established. The critical and clinching factor in a medical negligence case is
proof of the causal connection between the negligence which the evidence
established and the plaintiff's injuries. 92 The plaintiff must plead and prove
not only that he has been injured and defendant has been at fault, but also
that the defendant's fault caused the injury. A verdict in a malpractice action
cannot be based on speculation or conjecture. Causation must be proven
within a reasonable medical probability based upon competent expert
testimony. 93
The causation between the physician's negligence and the patient's
injury may only be established by the presentation of proof that Peter's
glaucoma would not have occurred but for Dr. Tuaño's supposed negligent
conduct. Once more, petitioners failed in this regard.
Dr. Tuaño does not deny that the use of Maxitrol involves the risk of
increasing a patient's IOP. In fact, this was the reason why he made it a point
to palpate Peter's eyes every time the latter went to see him — so he could
monitor the tension of Peter's eyes. But to say that said medication
conclusively caused Peter's glaucoma is purely speculative. Peter was
diagnosed with open-angle glaucoma. This kind of glaucoma is characterized
by an almost complete absence of symptoms and a chronic, insidious
course. 94 In open-angle glaucoma, halos around lights and blurring of vision
do not occur unless there has been a sudden increase in the intraocular
vision. 95 Visual acuity remains good until late in the course of the disease.
96 Hence, Dr. Tuaño claims that Peter's glaucoma "can only be long standing

. . . because of the large C:D 97 ratio", and that "[t]he steroids provoked the
latest glaucoma to be revealed earlier" was a blessing in disguise "as [Peter]
remained asymptomatic prior to steroid application".
Who between petitioners and Dr. Tuaño is in a better position to
determine and evaluate the necessity of using Maxitrol to cure Peter's EKC
vis-Ã -vis the attendant risks of using the same?
That Dr. Tuaño has the necessary training and skill to practice his
chosen field is beyond cavil. Petitioners do not dispute Dr. Tuaño's
qualifications — that he has been a physician for close to a decade and a
half at the time Peter first came to see him; that he has had various medical
training; that he has authored numerous papers in the field of
ophthalmology, here and abroad; that he is a Diplomate of the Philippine
Board of Ophthalmology; that he occupies various teaching posts (at the
time of the filing of the present complaint, he was the Chair of the
Department of Ophthalmology and an Associate Professor at the University
of the Philippines-Philippine General Hospital and St. Luke's Medical Center,
respectively); and that he held an assortment of positions in numerous
medical organizations like the Philippine Medical Association, Philippine
Academy of Ophthalmology, Philippine Board of Ophthalmology, Philippine
Society of Ophthalmic Plastic and Reconstructive Surgery, Philippine Journal
of Ophthalmology, Association of Philippine Ophthalmology Professors, et al.
It must be remembered that when the qualifications of a physician are
admitted, as in the instant case, there is an inevitable presumption that in
proper cases, he takes the necessary precaution and employs the best of his
knowledge and skill in attending to his clients, unless the contrary is
sufficiently established. 98 In making the judgment call of treating Peter's
EKC with Maxitrol, Dr. Tuaño took the necessary precaution by palpating
Peter's eyes to monitor their IOP every time the latter went for a check-up,
and he employed the best of his knowledge and skill earned from years of
training and practice.
In contrast, without supporting expert medical opinions, petitioners'
bare assertions of negligence on Dr. Tuaño's part, which resulted in Peter's
glaucoma, deserve scant credit.
 Our disposition of the present controversy might have been vastly
different had petitioners presented a medical expert to establish their theory
respecting Dr. Tuaño's so-called negligence. In fact, the record of the case
reveals that petitioners' counsel recognized the necessity of presenting such
evidence. Petitioners even gave an undertaking to the RTC judge that Dr.
Agulto or Dr. Aquino would be presented. Alas, no follow-through on said
undertaking was made. DCaEAS

The plaintiff in a civil case has the burden of proof as he alleges the
affirmative of the issue. However, in the course of trial in a civil case, once
plaintiff makes out a prima facie case in his favor, the duty or the burden of
evidence shifts to defendant to controvert plaintiff's prima facie case;
otherwise, a verdict must be returned in favor of plaintiff. 99 The party
having the burden of proof must establish his case by a preponderance of
evidence. 100 The concept of "preponderance of evidence" refers to evidence
which is of greater weight or more convincing than that which is offered in
opposition to it; 101 in the last analysis, it means probability of truth. It is
evidence which is more convincing to the court as worthy of belief than that
which is offered in opposition thereto. 102 Rule 133, Section 1 of the Revised
Rules of Court provides the guidelines for determining preponderance of
evidence, thus:

In civil cases, the party having the burden of proof must establish
his case by a preponderance of evidence. In determining where the
preponderance or superior weight of evidence on the issues involved
lies the court may consider all the facts and circumstances of the case,
the witnesses' manner of testifying, their intelligence, their means and
opportunity of knowing the facts to which they are testifying, the
nature of the facts to which they testify, the probability or improbability
of their testimony, their interest or want of interest, and also their
personal credibility so far as the same legitimately appear upon the
trial. The court may also consider the number of witnesses, though the
preponderance is not necessarily with the greater number.

Herein, the burden of proof was clearly upon petitioners, as plaintiffs in

the lower court, to establish their case by a preponderance of evidence
showing a reasonable connection between Dr. Tuaño's alleged breach of
duty and the damage sustained by Peter's right eye. This, they did not do. In
reality, petitioners' complaint for damages is merely anchored on a
statement in the literature of Maxitrol identifying the risks of its use, and the
purported comment of Dr. Agulto — another doctor not presented as witness
before the RTC — concerning the prolonged use of Maxitrol for the treatment
of EKC.
It seems basic that what constitutes proper medical treatment is a
medical question that should have been presented to experts. If no standard
is established through expert medical witnesses, then courts have no
standard by which to gauge the basic issue of breach thereof by the
physician or surgeon. The RTC and Court of Appeals, and even this Court,
could not be expected to determine on its own what medical technique
should have been utilized for a certain disease or injury. Absent expert
medical opinion, the courts would be dangerously engaging in speculations.
All told, we are hard pressed to find Dr. Tuaño liable for any medical
negligence or malpractice where there is no evidence, in the nature of
expert testimony, to establish that in treating Peter, Dr. Tuaño failed to
exercise reasonable care, diligence and skill generally required in medical
practice. Dr. Tuaño's testimony, that his treatment of Peter conformed in all
respects to standard medical practice in this locality, stands unrefuted.
Consequently, the RTC and the Court of Appeals correctly held that they had
no basis at all to rule that petitioners were deserving of the various damages
prayed for in their Complaint.
WHEREFORE, premises considered, the instant petition is DENIED for
lack of merit. The assailed Decision dated 27 September 2006 and
Resolution dated 3 July 2007, both of the Court of Appeals in CA-G.R. CV No.
68666, are hereby AFFIRMED. No cost.
SO ORDERED.
Ynares-Santiago, Austria-Martinez, Nachura and Peralta, JJ., concur.
Â
Footnotes

1. Rollo, pp. 9-48.

2. Penned by Court of Appeals Associate Justice Marina L. Buzon with Associate
Justices Regalado E. Maambong and Japar B. Dimaampao concurring; Annex
"A" of the Petition; id. at 49-69.

3. Annex "B" of the Petition; id. at 70-72.

4. Ophthalmoscopy is a test that allows a health professional to see inside the
back of the eye (called the fundus) and other structures using a magnifying
instrument (ophthalmoscope) and a light source. It is done as part of an eye
examination and may be done as part of a routine physical examination
(http://www.webmd.com/eye-health/ophthalmoscopy). aSTECI

5. Conjunctivitis, also known as pinkeye, is an inflammation of the conjunctiva, the

thin, clear tissue that lies over the white part of the eye and lines the inside
of the eyelid (http://www.webmd.com/eye-health/eye-health-conjunctivitis).

6. The generic name of Spersacet-C ophthalmic drops is Sulfacetamide. It is

prescribed for the treatment and prophylaxis of conjunctivitis due to
susceptible organisms; corneal ulcers; adjunctive treatment with systemic
sulfonamides for therapy of trachoma
(http://www.merck.com/mmpe/lexicomp/sulfacetamide.html).

7. Epidemic kerato conjunctivitis is a type of adenovirus ocular infection.

(http://emedicine.medscape.com/article/1192751-overview).

8. Neomycin/polymyxin B sulfates/dexamethasone is the generic name of Maxitrol

Ophthalmic Ointment. It is a multiple dose anti-infective steroid combination
in sterile form for topical application
(http://www.druglib.com/druginfo/maxitrol/).
9. Exhibit "A"; records, p. 344.

10. Apply 5-6 drops for 5 days; then 3 drops for 3 days; and then a minimum of 1
drop per day.

11. TSN, 27 September 1993, pp. 18-19.

12. Blephamide Ophthalmic Suspenion contains Sulfacetamide/Prednisolone. This

medication contains an antibiotic (sulfacetamide) that stops the growth of
bacteria and a corticosteroid (prednisolone) that reduces inflammation
(http://www.webmd.com/drugs/drug-6695-Blephamide+Opht.aspx?
drugid=6695&drugname=Blephamide+Opht).

13. Exhibit "H"; records, p. 346.

14. TSN, 27 September 1993, p. 40.

15. TSN, 3 May 1995, p. 14.

16. A tonometer is an instrument for measuring the tension or pressure,

particularly intraocular pressure (http://medical-
dictionary.thefreedictionary.com/tonometer).

17. Intraocular Pressure (IOP) is the pressure created by the continual renewal of
fluids within the eye (http://www.medterms.com/script/main/art.asp?
articlekey=4014).

18. Exhibit "1-a"; records, p. 618-A.

19. Normal IOP is measured in millimeters of Mercury (Hg).

20. See note 19.

21. The generic name of Diamox, for oral administration, is acetazolamide. This
medication is a potent carbonic anhydrase inhibitor, effective in the control
of fluid secretion (http://www.drugs.com/pro/diamox.html).

22. The active ingredient of Normoglaucon is Metipranolol hydrochloride. It is

used for the reduction of intraocular pressure in patients with glaucoma
(open, closed angle) in situations in which monotherapy with pilocarpine or
beta-blockers are insufficient
(http://www.angelini.it/public/schedepharma/normoglaucon.htm).

23. TSN, 11 October 1993, p. 7.

24. Exhibit "1-a"; records, p. 618-A. ECaITc

25. Glaucoma is an eye condition which develops when too much fluid pressure
builds up inside of the eye. The increased pressure, called the intraocular
pressure, can damage the optic nerve, which transmits images to the brain.
If the damage to the optic nerve from high eye pressure continues, glaucoma
will cause loss of vision (http://www.webmd.com/eye-health/glaucoma-eyes).

26. O.D. is the abbreviation for oculus dexter, a Latin phrase meaning "right
eye" (http://medical-dictionary.thefreedictionary.com/O.D).
27. Laser Trabeculoplasty is a kind of surgery which uses a very focused beam of
light to treat the drainage angle of the eye. This surgery makes it easier for
fluid to flow out of the front part of the eye, decreasing pressure in the eye
(http://www.med.nyu.edu/healthwise).

28. According to Peter, after seeing Dr. Tuaño on the 15th of December 1988, he
next saw him on the 17th of the same month. Per Exhibit 1-a, the patient's
index card, however, after the 15th of December 1988, Peter's next visit was
on the 23rd of the same month.

29. Exhibit "1-a"; records, p. 618-A.

30. TSN, 11 October 1993, pp. 16-17.

31. Id. at 18.

32. Exhibit "C"; records, p. 352.

33. The slit-lamp evaluation/examination looks at structures that are at the front
of the eye using a slit-lamp, a low-powered microscope combined with a
high-intensity light source that can be focused to shine in a thin beam
(http://www.nlm.nih.gov/medlineplus/ency/article/003880.htm).

34. Funduscopy is the examination of the back part of the eye's interior (fundus);
also known as ophthalmoscopy.

35. Zeiss Gonioscopy (indirect gonioscopy) is the visualization of the anterior

chamber angle of the eyes undertaken using a Zeiss lens. It is essential to
determine the mechanism responsible for impeding aqueous flow
(http://www.glaucomaworld.net/english/019/e019a01.html).

36. Peripheral Anterior Synechiae.

37. Timolol Maleate is a generic name of a drug in ophthalmic dosage form used
in treatment of elevated intraocular pressure by reducing aqueous humor
production or possibly outflow (http://www.umm.edu/altmed/drugs/timolol-
125400.htm).

38. B.I.D. is the abbreviation of the Latin phrase bis in di'e , meaning "twice a
day" (http://medical-dictionary.thefreedictionary.com/B.I.D).

39. The generic name of the medication D'epifrin is dipivefrin ophthalmic. It is

used to treat open-angle glaucoma or ocular hypertension by reducing the
amount of fluid in the eye thereby decreasing intraocular pressure
(http://www.drugs.com/mtm/dipivefrin-ophthalmic.html).

40. Carbon Anhydrase Inhibitor.

41. Exhibit "D"; records, pp. 356-357.

42. Exhibit "1-a"; id at 618-A.

43. A test to determine the total area in which objects can be seen in the
peripheral vision while the eye is focused on a central point
(http://www.healthline.com/adamcontent/visual-field).
44. A centrally constricted field of vision that is like what you can see through a
tube (http://www.medterms.com/script/main/art.asp?articlekey=24516).

45. A form of open-angle glaucoma that usually is associated with topical steroid
use, but it may develop with inhaled, oral, intravenous, periocular, or
intravitreal steroid administration
(http://emedicine.medscape.com/article/1205298-print).

46. As evidenced by a Marriage Contract between Peter and Fatima; records, p.

340. HEScID

47. As evidenced by the child's Certificate of Live Birth; id. at 341.

48. As evidenced by the child's Certificate of Live Birth; id. at 342.

49. Amended Complaint, p. 4; id. at 79.

50. Peter alleged that due to is impaired vision, he was 'forced' to decline several
opportunities to cover international and regional sports events, i.e., the 1988
and 1992 Olympics as well as various Asian Games; and he could not cover
fast-paced games, i.e., basketball.

51. Amended Complaint, p. 4; records, p. 79.

52. Id.

53. Id.

54. Id. at 82.

55. Answer, p. 6; id. at 38.

56. Id.

57. Id.

58. Id.

59. Answer, p. 13; id. at 45.

60. Id.

61. Id. at 722-734.

62. Id. at 734.

63. Id.

64. Id. at 731.

65. Id.

66. Rollo, p. 68.

67. Id. at 67.

68. Id. at 66.

69. Id. at 23.

70. Civil Service Commission v. Maala, G.R. No. 165253, 18 August 2005, 467
SCRA 390, 398.

71. Alfaro v. Court of Appeals, 416 Phil. 310, 317 (2001).

72. Petition, p. 16; rollo, p. 24.

73. Id.

74. Id. at 26.

75. Amended Complaint, p. 6; records, p. 81.

76. Garcia-Rueda v. Pascasio, et al., 278 SCRA 769, 778 (1997).

77. Id.

78. Snyder v. Pantaleo (1956), 143 Conn 290, 122 A2d 21.

79. Johnson v. Superior Court, 49 Cal. Rptr. 3d 52 (Cal. App. 3d Dist. 2006).

80. Garcia-Rueda v. Pascasio, supra note 76 at 779.

81. Chan Lugay v. St. Luke's Hospital, Inc., 10 CA Reports 415 (1966).

82. Calimutan v. People of the Philippines, G.R. No. 152133, 9 February 2006, 482
SCRA 44, 60, citing Vda. de Bataclan v. Medina, 102 Phil. 181, 186 (1957).

83. Barngrover v. Hins, 657 S.E.2d 14 (Ga. Ct. App. 2008).

84. Dr. Cruz v. Court of Appeals, 346 Phil. 872, 884-885 (1997).

85. http://www.druglib.com/druginfo/maxitrol/.

86. Court of Appeals Decision, p. 17; rollo, p. 66.

87. Steroid responders are people whose intraocular pressure (IOP) goes up very
high when they use steroids
(http://www.willsglaucoma.org/supportgroup/20030827.php).

88. TSN, 7 February 1997, p. 17; rollo, p. 66.

89. Solis, Pedro P., Medical Jurisprudence, 1988, Garcia Publishing, Co.,
Philippines.

90. Domina v. Pratt, 13 A 2d 198 Vt. 1940.

91. TSN, 7 February 1997, pp. 18-19. IHTASa

92. 61 Am. Jur. 2d. §359, p. 527.

93. Id.

94. Newell, Frank W., Ophthalmology, Principles and Concepts, 6th ed., 1986, C.V.
Mosby Company, Missouri.
95. Id.

96. Id.

97. Cup to Disc ratio.

98. Dr. Cruz v. Court of Appeals, supra note 84 at 884-885.

99. Prudential Guarantee and Assurance Inc. v. Trans-Asia Shipping Lines, Inc.,
G.R. No. 151890, 20 June 2006, 491 SCRA 411, 433.

100. Bank of the Philippine Islands v. Royeca, G.R. No. 176664, 21 July 2008, 559
SCRA 207, 215.

101. Jison v. Court of Appeals, 350 Phil. 138, 173 (1998), citing Vicente J.
Francisco, Revised Rules of Court in the Philippines, Evidence (Part II, Rules
131-134).

102. Go v. Court of Appeals, 403 Phil. 883, 890-891 (2001), citing 20 Am. Jur.
1100-1101 as cited in Francisco, Revised Rules of Court.