Retinal detachment on a wet AMD patient Photo: Retina Gallery
Team Leader, Claims, Avant Mutual Group Limited
Ms Jones had been practising for 13 years. The patient, Mr Smith, was a 65-year-old with a history of hypertension and diabetes. A smoker who wore prescription glasses for distance and reading, Mr Smith wrote to the complaints body in his state alleging Ms Jones failed to diagnose a detached retina. As a result, he required extensive surgery to repair it.
Had the retinal tear or detachment been diagnosed earlier, Mr Smith believed he could have undergone laser treatment rather than surgery. He not only made allegations regarding the standard of care, but sought $6,000 compensation for the cost of his surgery plus compensation for ‘pain and suffering’.
Mr Smith had been a patient of the practice since 2004. He had had cataract surgery on his right eye in 2002 and four years later, on his left eye. He noted on numerous occasions that his right eye’s vision never returned to the same extent as vision in the left eye had post-operatively, yet both were historically measured at 6/6=.
On 12 June 2009, Mr Smith attended a consultation for a routine diabetic review after receiving a recall letter two weeks before, which recommended he make an appointment for a routine check-up.
Mr Smith had no presenting complaints, but as a diabetic patient he required six-monthly check-ups. Less than four months later, on 2 October, he presented at a review with the following complaints:
- intermittent, variable temporal blur in both eyes
- something blurred in the superior and temporal field
- recent headaches
- onset three weeks with intermittent clear and blurred vision
- no flashes, no floaters, only the blur noted mostly left eye temporarily
Ms Jones examined Mr Smith thoroughly. All of the clinical findings were normal, with no abnormalities detected. The examinations performed included:
- Best corrected vision Right 6/9= and Left 6/6=
- Visual field test: both full to confrontation and computerised perimetry (central threshold)
- Pupils: PERRLA/No RAPD
- Anterior segment examination revealed that the tear break-up time was low, unstable and less than the inter-blink interval. Ms Jones determined that this could have been a possible factor in addressing the presenting complaint on intermittent blurred vision. There was mild posterior capsular opacification/fibrosis (right > left), IOL noted.
- A posterior segment test by conducting a dilated pupil examination to exclude retinal involvement plus the underlying diabetic and hypertensive risk factors was normal
- Binocular indirect ophthalmoscopy with a 20 D lens, slitlamp fundoscopy with a 90 D lens, digital retinal imaging and optical coherence tomography all returned normal findings and a thorough examination of the temporal and inferior retinal periphery did not find any breaks or tears in the retina of either eye. There was no pigment noted in the posterior segment and periphery was noted to be intact.
- Intraocular pressure was measured at 15 mmHg, in both eyes both pre- and post-pupil dilation
- Corneal thickness was measured at 530 µm
- Monocular colour vision and red desaturation tests were fine
- Motility or eye movements were recorded as being full and pain free.
Importantly, the results of these tests were clearly documented in the clinical record by Ms Jones.
On 2 October, there was no evidence of retinal detachment or a tear in the retina in the right eye. The examinations found nothing significant to explain Mr Smith’s complaints. He was told his symptoms could be diabetic or cardiovascular in nature and Ms Jones recommended he consult his GP with a view to having a head CT or MRI scan to exclude other causes.
Ms Jones also recommended Mr Smith use Genteal eye drops to assist his unstable tear film and relieve his dry eyes, as he also had an ongoing intermittent history of ocular surface disruption.
Finally, the optometrist told Mr Smith that if his symptoms changed he should return for review. A week later, he did return, complaining he was still experiencing intermittent temporal bilateral visual field disturbance and wanted further investigation.
At this consultation Mr Smith said he had seen his GP, who referred him for a brain CT, the results of which were clear. He also reported using Genteal drops four-plus times a day.
A week later, Ms Jones measured Mr Smith’s vision as 6/6= in both eyes. She also performed a sodium fluorescein stain test, which produced minimal corneal surface staining. The mild posterior capsular opacification (PCO) did not explain the intermittent blurring symptoms.
There was no evidence of retinal detachment or a tear in the retina in the right eye.
They discussed the unexplained intermittent variable temporal bilateral visual field disturbance and the inconclusive diagnosis for his symptoms, and both felt they warranted investigation by a specialist ophthalmologist.
An appointment was arranged for Mr Jones to see an ophthalmologist on 17 October. Ms Jones also advised Mr Smith he should return to see her if there were any further changes.
After Mr Smith attended the specialist appointment, Ms Jones received a letter from the ophthalmologist dated 22 October stating: ‘Mr Smith’s vision has deteriorated over the last 24 hours and, on examination, he has a shallow inferior right retinal detachment. I have referred him urgently for a retinal detachment repair. Thank you for sending Mr Smith quickly.’
Mr Smith had undergone a right retinal detachment repair on 19 October, and it was understood from the ophthalmologist’s further reports that he had done extremely well following surgery.
A good result
The following February, Ms Jones received a copy of Mr Smith’s complaint from the complaints body. She appropriately sought advice from Avant, her professional indemnity insurer, which provided assistance.
Avant representatives met her and assisted with her submissions to the complaints body, which were lodged on 30 April. Almost a month later, Ms Jones was advised by the complaints body that they had decided not to take further action because they believed the matter had been dealt with adequately.
This good result was due not only to Ms Jones providing appropriate treatment but also importantly, documentation of this treatment, which enabled Avant to defend her appropriately.
From Avant’s experience we know disease-related litigation and complaints against optometrists appear to follow three common threads:
- failure to perform a thorough examination
- failure to follow up on suspicious findings
- failure to document tests performed and patient management.
In order to minimise the likelihood of failing to detect existing or developing pathology, optometrists are advised to regularly assess whether they are adhering to accepted standards of practice, such as:
- obtaining an adequate patient history
- performing the necessary diagnostic tests
- initiating an appropriate management plan, which should include patient education
- following up sufficiently to rule out errors and complications
- documenting adequately to show that these four steps were followed
- documentation is key.
Documentation is particularly important. Generally, the claimant assumes that ‘if you did not record it, you did not perform it’. Optometrists Association has comprehensive guidelines on record card content, particularly regarding the recording of examination findings. It is important to not only perform an appropriate examination, but also to record your findings, including negative or normal findings. These become significant if there is an allegation, such as failure to diagnose a retinal detachment.
It is very common for a patient who has developed a retinal detachment to allege that on the previous visit to the optometrist, he or she was experiencing flashes or floaters or some other visual disturbance that the optometrist had failed to recognise.
If a test is not recorded and interpreted, it may be difficult for the optometrist to later establish it had been performed. An optometrist who has made a reasonably detailed record of the patient’s symptoms and has recorded all results of specific examinations, including negative and normal results, is in a better position to defend a claim. Ms Jones’s case is an excellent example of this.
The use of recognised abbreviations or acronyms can facilitate quick and accurate record-taking. Abbreviations should be consistent with no ambiguity of meaning. Optometrists Association provides a list of common abbreviations and acronyms. Using them is not obligatory but does encourage consistency in records and lessens the likelihood of misinterpretation.
A consistent approach to assessing patients and keeping good records are essential to ensuring optometrists continue to enjoy a low incidence of professional negligence claims.
* This scenario is based on a real case. Names have been changed and identifying features have been removed to protect the practitioner’s identity.
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