Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
Mr A Consumer
Ms B Optometrist / Provider
Dr C Ophthalmologist
On 27 September 2000 the Commissioner received a complaint from the consumer, Mr A, about services provided by optometrist Ms B. The complaint was that:
- On 4 September 2000, Mr A consulted Ms B, optometrist, as he noticed a grey 'part-disc' shape in his peripheral vision. Ms B incorrectly diagnosed a floater, when in fact retinal detachment had occurred some time previously.
- Ms B did not refer Mr A to an ophthalmologist for assessment on this date.
- Ms B examined Mr A's eyes without dilatation drops.
- In a letter to Mr A on 14 September 2000, Ms B incorrectly advised that she questioned him about flashes of light on 4 September 2000, because they were a symptom of retinal detachment. This symptom was not mentioned to Mr A during his appointment on 4 September 2000.
- In her letter of 14 September, Ms B incorrectly advised that on 4 September 2000, she offered Mr A the option of attending an ophthalmologist for a second opinion.
An investigation was commenced on 29 November 2000.
- Mr A's optometry records from Ms B
- Medical records from a public hospital
- Mr A's records from Dr C
- Report from an independent optometrist, Mr Desmond Moss
Information gathered during investigation
On 4 September 2000 at 4.30pm, Mr A consulted optometrist Ms B, with what he described as a grey "part-disc" shape in the peripheral vision of his left eye. Mr A's records indicate that he had not had an eye examination for two years and over the previous year or so his reading vision had deteriorated, but his distant vision was unchanged. He did not experience any double vision or headaches. He had a history of vitreous floaters and had been seeing Dr C, an ophthalmologist, for 15 years. He told Ms B that he had seen Dr C about a year before this appointment because his floaters had been getting worse, but there was nothing that could be done for them.
Ms B advised me that this was the first time she had examined Mr A. Mr A told her that he had always had floaters, but they had been getting worse over the previous month or so. Two hours before his appointment he became aware of a black disc shape in the lower area of his left eye. During the examination he told Ms B that he had not experienced any flashes and had not suffered any sudden jarring or knocks to his head. He was aware that this black disc floater was new.
Ms B advised me that she checked Mr A's level of vision and visual acuity, and then looked inside his eyes. Ms B could see floaters in both eyes, including the floater he was referring to. Ms B said that she explained to Mr A that she could see the floater, but could not see any holes, tears or haemorrhages. Mr A asked Ms B if she intended to dilate his eyes and she explained that, if there was any concern, it is her practice to refer patients requiring dilatation to an ophthalmologist.
In Ms B's opinion Mr A's floater appeared to be a posterior vitreous detachment. Ms B said that she explained to him that these are generally benign, but can go on to form a retinal detachment. Ms B stressed to him that there were no signs that would lead her to suspect retinal detachment at this examination (signs of retinal detachment are flashes or a curtain of visual loss). Ms B said that she discussed the symptoms of retinal detachment with Mr A and offered him the option of a second opinion and dilatation by Dr C. Ms B said that Mr A chose not to seek a second opinion from Dr C. In part Ms B's documentation of the consultation stated:
" ... Warned re symptoms of retinal detachment. Offered option referral for second opinion. To see [Dr C] if floaters change."
Ms B advised me that if he had requested a second opinion it would not have been an urgent referral. She stressed to Mr A that if his floater changed he should contact Dr C urgently. Ms B completed a full evaluation of Mr A's visual status, checking both his distant and reading prescriptions. His current spectacles were slightly off alignment in the right eye and Ms B adjusted the lens in his frame, which he said improved his vision. Ms B checked his eye pressure for glaucoma. Mr A had a family history of glaucoma and Ms B recommended that he have his visual fields checked at her practice. Ms B advised me that she explained the results of these tests to Mr A. Ms B also discussed with Mr A the change in his spectacle prescription. He was to let her know if he had any change in his eyes or if he wanted to put new lenses into his current frames. She completed the examination at 5.40pm.
Mr A said that Ms B did not tell him about the symptoms of detached retina; he was given no indication by Ms B that the sudden onset of floaters is a warning sign for retinal tear or retinal detachment. Mr A advised me that Ms B did not mention flashes of light as a sign of retinal detachment; the only advice Ms B gave him about detached retina was a curtain coming up from the sides of his peripheral vision.
Mr A stated that Ms B did not offer him a second opinion from Dr C. Ms B was clear and confident in her diagnosis of a floater. Mr A stated that he was given no indication that it would be prudent to seek ophthalmologic evaluation. He advised me that Ms B totally convinced him that to seek another opinion was to express disbelief in her diagnosis.
On Wednesday 6 September 2000, Mr A telephoned Ms B to say that the floater had become bigger and was now in a more central position. Ms B advised him that if it was the same floater as before it was unlikely to have changed in size but, since there had been a change, she wanted him to contact Dr C urgently. Mr A consulted Dr C at 11.30am that day. Dr C examined Mr A's eyes, with the aid of dilatation drops, and diagnosed a large retinal tear and retinal detachment. Dr C immediately contacted the surgeon on call at the public hospital and arranged immediate hospital admission for Mr A. He was admitted at 1.30pm and underwent surgery to repair his detached retina at 5.00pm on Thursday 7 September.
Mr A said that Dr C told him he had had the retinal tear for some time. The registrar at the Outpatients Department Eye Clinic at the public hospital, told Mr A at his outpatient appointment on 11 September that she estimated that the tear had occurred about two weeks prior to his consultation with Ms B.
On 12 September Mr A wrote to Ms B to complain about the services she had provided. The nature of his complaint was that she failed to recognise and diagnose a retinal tear and detachment, failed to immediately refer him for ophthalmologic evaluation, and failed to fully warn him of other signs of detachment. Ms B responded on 14 September and denied Mr A's allegations.
Independent advice to Commissioner
The following expert advice was obtained from an independent optometrist, Mr Desmond Moss:
"It would be fair to say that eliminating the possibility of retinal detachment is not an easy task, and failing to diagnose one is every eye professional's worst nightmare. No matter how thorough and searching the examination of the fundi, there is still the possibility that a subtle tear may go undetected, but proceed to detachment over even a short period of time. Symptoms and history help with diagnosis of course, but probably no protocol is ever totally foolproof.
That said, this was a situation where there was certainly something to be seen in the complainant, [Mr A's] eye. The optometrist he consulted, [Ms B], believed what she saw to be a vitreous floater, and she felt sufficiently secure in her diagnosis to reassure [Mr A]. As it later emerged, this reassurance was not well founded, and the retina proceeded to detach as has been outlined in the history available to me.
I will address the matter under the headings you require on page 3.
Overall, I believe [Ms B] provided [Mr A] with services with reasonable care and skill. Her examination records show the detail and caring attention one would expect of any eyecare professional.
* It may be that opinions on the thoroughness and appropriateness of [Ms B's] examination of [Mr A] on 4th September 2000 could vary. But I am bound to say that, given [Mr A's] history of floaters, his report of a recent increase in floaters, and a significant part-disc shaped disturbance in his vision, I would regard it as essential that a dilated examination be carried out. In the event that [Ms B] felt uncomfortable doing this, I believe she should have referred [Mr A] for this to be done, presumably by an ophthalmologist. Her diagnosis was, I suppose, reasonable, given the evidence she had gathered, but I believe her failure to dilate gave rise to an insufficiency in the evidence.
* With the benefit of hindsight, it is obvious that [Mr A] would have been better served with urgent ophthalmological assessment when [Ms B] saw him. However, this was not apparent to [Ms B] on the basis of the information she had before her, and she states she would have regarded referral as comparatively non-urgent. Whether immediate referral was feasible, it then being 5.30pm, it is impossible to say, and it is possible that this might not have affected the eventual outcome given that the retina proceeded to detach over a relative short period. It is also noted that [Mr A] received ophthalmological assessment, on [Ms B's] advice some 40 hours later, arguably a comparatively short interval in the circumstances.
* The use of dilatation drops - I believe that examination with a dilated pupil would have given [Ms B] additional information about the presence, or likelihood, of a detachment. It is, of course, the choice of an individual practitioner to use or not to use drops, according to their comfort level with this procedure. However, as I have said above, I believe that [Mr A] should have been referred if [Ms B] chose not to dilate.
* It is somewhat difficult in hindsight to decide positively whether or not the detachment had occurred before [Ms B] examined [Mr A], but I would have to regard it as highly likely that at least some degree of detachment had occurred.
There is an obvious difference of opinion between [Ms B] and [Mr A] regarding whether he was advised about the symptoms of retinal detachment, and offered a second opinion. It is idle to speculate who was right and who was wrong, but I would have to say that, having listened to patients' versions of the advice I have offered over the years, the balance of possibilities probably rests favourably with [Ms B]. ... "
Response to provisional opinion
In response to my provisional opinion, Ms B provided me with reports from an ophthalmologist, and an optometrist about the use of dilation drops in eye examinations and referral to an ophthalmologist. The ophthalmologist noted the following:
"Thank you for asking me to review the documentation on this case. It is an area of difficulty and of great interest to me, having done retinal detachment operations for over 25 years.
I will not repeat what has already been stated. The important question here seems to be whether or not [Ms B] should have insisted on immediate referral because of the possibility of retinal detachment, or whether her explanation of the symptoms of retinal detachment and her offer of referral were sufficient.
[Ms B] said that she asked [Mr A] if he had had flashes in the vision and he denied any flashes, although I do not know whether this was documented in her record. Flashes are an important symptom of retinal tear and detachment.
Floaters are a very common symptom and it would be impossible for every patient who visits an optometrist with floaters to be seen by an ophthalmologist. However, [Mr A] had a grey part-disc shape in the lower field which would increase one's suspicion of retinal problems. Whether this alone, in the absence of flashes, is enough to insist on immediate referral rather than just warning of detachment and offering referral is debatable. On balance, I believe [Ms B] gave appropriate care with the evidence she had at the time.
Regarding dilation of the pupil, in the year 2000 it would have been very uncommon for an optometrist to do so. Normal practice would have been to refer to an ophthalmologist for further examination if it was considered necessary."
The optometrist advised:
"Practice Policy regarding Floaters
Floaters are a very common occurrence.
In this practice I would always recommend an eye examination. This would involve assessment of vision and visual activity and direct ophthalmoscopy initially.
Further investigation would depend on the onset, duration, severity and other symptoms, e.g. dilation would be done in cases of recent trauma (head or eye injury), when floater in association with flashing lights and in some systemic diseases e.g. diabetes.
Risks are discussed with patients and an opportunity to consult with a specialist if there is any doubt. If the patient chooses not to do this then they are asked to report any changes or new symptoms and return for reassessment."
In view of the information raised by their reports, I asked my expert advisor, Mr Desmond Moss, to review his original advice. Mr Moss advised me that he could not recall exactly when the legislation that enabled optometrists to use dilation drops came into effect. He agreed that once legislation comes into force it does take some time to become common practice. In his view, if Ms B did not feel confident in using dilation drops she could have referred Mr A to a specialist. The fact that the use of dilation drops was a new practice does not completely excuse her not using the drops or making a specialist referral.
Code of Health and Disability Services Consumers' Rights
The following Rights in the Code of Health and Disability Services Consumers' Rights are applicable to this complaint:
Right to Services of an Appropriate Standard
1) Every consumer has the right to have services provided with reasonable care and skill.
Right to be Fully Informed
1) Every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive, including -
a) An explanation of his or her condition; and
b) An explanation of the options available, including an assessment of the expected risks, side effects, benefits, and costs of each option; ...
Opinion: No breach
In my opinion Ms B did not breach Right 4(1) or Right 6(1)(a) or 6(1)(b) of the Code of Health and Disability Services Consumers' Rights.
Mr A had the right to receive optometry services provided with reasonable care and skill.
Incorrect diagnosis and failure to use dilatation drops
My independent optometrist advised me that eliminating the possibility of retinal detachment is not an easy task. No matter how far and searching the examination of the fundi, there is still the possibility that a subtle tear may go undetected and proceed to detachment. I accept my expert advice that Ms B's diagnosis was reasonable on the evidence she had.
However, my independent optometrist advised that there was "something" in Mr A's eye which required further examination. Ms B believed that she saw a vitreous floater and felt sufficiently secure in her diagnosis to reassure Mr A. Given Mr A's history of floaters, his report of recent increase in floaters, and a significant part-disc- shaped disturbance in his vision, it was essential that a dilated examination be undertaken. If Ms B felt uncomfortable doing this, she should have referred Mr A to an ophthalmologist.
Ms B advised me that at the time she examined Mr A very few optometrists in her city used dilation drops because provision under the Medicines Act did not come into force until mid-1990. It has taken some time for optometrists to begin carrying out dilations during examination. My advisor confirmed that this was the case. Ms B did not see any holes or tears and stressed to Mr A that if there was any change with the floaters he should see a specialist immediately. The moment Mr A reported changes she referred him to Dr C.
My advisor said that it is difficult to determine whether the detachment had occurred before Ms B examined Mr A's eye, but that it is highly likely that at least some degree of detachment had occurred. Appropriate investigation is an integral part of diagnosis and the use of dilation drops may have assisted Ms B to make a diagnosis. However, I accept that the use of dilation drops was not common practice at that time. In my opinion Ms B's failure to use dilation drops in making a diagnosis did not amount to a breach of Right 4(1) of the Code.
Rights 6(1)(a) and 6(1)(b)
Mr A had the right to information that a reasonable consumer, in his circumstances, would need in order to make an informed choice about his optometry treatment. This included information about his condition, the risks he faced, and the options available to him.
Symptoms of retinal detachment and offer of a second opinion
Mr A told me that Ms B did not advise him about the symptoms of retinal detachment and did not offer to refer him for a second opinion. Ms B said that she did provide this information. There is no independent witness to substantiate the content or nature of Ms B's conversation with Mr A, although his advice to me suggests that there was some discussion about a second opinion. Ms B documented the outcome of her consultation with him. The notes clearly document that she discussed the symptoms of retinal detachment with Mr A, and offered him referral for a second opinion.
I have no reason to believe that Mr A's medical record is not a true record of Ms B's consultation with him. Although Ms B has not included the content of her discussions, she obviously discussed referring him for a second opinion. It is probable that Ms B also discussed her reasons for suggesting it. I conclude that Ms B explained the symptoms of retinal detachment, advised Mr A what he should do if his eyes altered, and offered him a second opinion. Accordingly, in my opinion Ms B provided Mr A with information that enabled him to make an informed choice about optometry services and did not breach Right 6(1)(a) or 6(1)(b) of the Code.
- A copy of this report will be sent to the Opticians Board.
- A copy of this report with identifying features removed will be sent to the New Zealand Association of Optometrists, and the New Zealand College of Optometrists, and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.