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LYNDA MCGIVNEY-NOLAN

Optometrist
Optometric Advisor
Expert Witness

“Remember! Every person who crosses your door is a potential litigant”….advice from my mum the day I qualified!

References used for this lecture are available on request

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MEDICO-LEGAL LITIGATION AGAINST OPTOMETRISTS

On the increase in recent years
Optometrists now being viewed more as “medical professionals”
Members of the public often present to us first
Increasing scope of practice; increased expectations
Increasingly high tech equipment; increasing expectations

Usually results from negligence or perceived negligence

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NEGLIGENCE

“Deviations from the standard of care that results in HARM to the patient”

4 elements

Duty to act; legal requirement to assess and treat a patient
Breech of duty; Negligent action violating standards of care; failing to act
Damage; physical or psychological damage to the patient. No damage=no case
Causation; damage incurred was caused by breech of duty

All 4 must be proven

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ABANDONMENT

Most common reason for negligence
Termination of patient care without ensuring continuation of care or higher level of care

At the root of most cases including Retinal Detachment and Glaucoma litigation

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LEADING CAUSES

Retinal detachment
Glaucoma
AMD
Neuro-ophthalmology

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LEADING REASONS

Failure to recognise risk factors
Failure to record findings
Failure to carry out relevant tests
Poor record keeping
Poor practice protocols
Failure to listen to the patient!

All of the above lead to ABANDONMENT

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CATEGORIES OF RISK

Clinical; arise from the nature of the pathology and associated consequences
Competency; arises from practitioner skills and knowledge
Conduct; behaviour of the practitioner….negligence or inappropriate behaviour
Contextual; working environment increases risk
Systems; poor systems in place to prevent adverse events, poor management

Usually a case will involve a mixture of the above.

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WHAT GOES WHERE?

Clinical risk; always civil case
Competency; can be Coru or Civil or both
Conduct; CORU
Contextual; CORU
Systems; Civil and or CORU

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RISKS IN OPTOMETRY PRACTICE

Adverse Events; competency and clinical risks which present a risk to patients health and safety

Missed RD,

Failure to act on evaluated IOPs,

botched FB removal.

Contextual risk; factors which make adverse events more likely to happen

Busy practice with poor systems in place.

Optometrist does not have access to essential equipment to conduct tests

Optometrists having to do 10 minute eye examinations; difficulty in accessing time to carry out additional tests which may be necessary

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ADVERSE EVENTS

In most legal cases, risk has been clinical
Influenced by the nature of the disease
Limits on clinical knowledge

But often linked to contextual risk; busy practice, failure to carry out CPD, poor practice protocols

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CLINICAL RISKS IN OPTOMETRY

Glaucoma
Retinal Detachment
AMD
Diabetes
Non-Tols
Contact Lenses
Paediatrics

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PROTECTING AGAINST LITIGATION; CYA APPROACH

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BEST PROTECTION

Evidence based clinical protocols
Good record keeping
Patient communication

You must be able to substantiate all decisions taken

When caring for your patient.

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GLAUCOMA

A group of eye diseases that damage the optic nerve, often (but not always) associated with elevated IOP.

Main risk is failing to carry out all tests necessary to identify Glaucoma
Other risk is failing to identify at-risk patients; patient profiling
Clinical risk high due to the nature of the disease

(slow onset, low prevalence)

Carry all tests necessary; IOPs, Fields and disc evaluation
Fundus photography essential

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GLAUCOMA MANAGEMENT

Repeat IOPs
Repeat Fields
Ability to interpret fields
Ability to analyse discs

OCT if available
Measure central corneal thickness
Knowledge of Ocular Hypertension versus Glaucoma

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RETINAL DETACHMENT

Sight threatening event when retina separates from underlying tissue

Risks include
Not taking careful symptoms and history
Failing to identify at-risk patients
Inadequate/incomplete clinical examination

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RETINAL DETACHMENT

Second only to DR as cause of Retinal vascular disease

Major cause of visual function impairment
Leading cause of litigation against Optometrists in Ireland
Biggest settlements

One of the most common ocular emergencies

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PATIENT PROFILE

Prevalence rating; 0.01%
Middle age myopes
Over -1.00 risk is there; increases dramatically over -3.00
Previous history of RD in partner eye
Recent history of head/eye trauma
Laser surgery (rare)
Cataract surgery, tumour, diabetic eye disease, blood pressure

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PATIENT SYMPTOMS

Photopsia; mechanical stimulation of the retina
May be isolated episode or repeated, may be single flash due to localised traction or arc of light due to traction on the retinal base
May increase on eye movement
Floaters; may be numerous or isolated, but of recent onset or change to existing
Field defect; shadow, veil etc noted
Metamorphopsia
Loss of vision; macula off

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CLINICAL SIGNS

Floaters; you want to find the floaters and evaluate them; are they normal or are they typical of PVD or retinal detachment. Beware of single recent onset floater.

Retinal Tear; You want to look at retina carefully, look for signs of tear or disturbance in blood vessel pattern. Need to pay attention to temporal retina in particular.

Best way is dilation and Volk

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MYOPIA AND RD

Any age at risk
Lattice degeneration increases risk further
Myopia -1 to -3 have 4 times the risk of emmetrope of developing RD
Myopia over -3.00 risk is 10 times

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CLINICAL EXAMINATION

Visual acuities
Anterior seg exam (shaeffers sign)
Dilation
Volk exam
Fundus photo; will not protect; too narrow field of view

You MUST dilate; if you decide not to; you must refer
If you dilate; you must carry out all tests until you reach a decision
Refer or recall (with warning letter)

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CLINICAL EXAMINATION

First; visual acuity
Change in rx (look for shift in plus)
External examination; trauma etc
Pupil reactions; RAPD
Amsler grid
Field test
Dilation
Slit lamp; anterior exam
Volk Lens
Fundus photo; as far out into periphery

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EXAMINATION TECHNIQUES

Direct ophthalmoscopy no longer considered adequate
Fundus photography alone of central retina not adequate; no stereo and not peripheral enough
Best practice; dilate with 90D Volk lens (pref superfield)

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RETINAL DETACHMENTS

Recent RD appear as white membrane with tiny folds and blood vessels which floats on eye movement.
To differentiate RD vs Retinoschisis; ask px to move eye and re-fixate; movement indicated RD
Most retinal tears occur in the upper temporal arcades or out in the periphery. Small tear may not be visible while patient is symptomatic
Fluid gets in behind tear and travels down behind the retina towards the macula
Vision may not be affected until end stage

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CLASSIFICATION

Retinal Detachment

Rhegmantogenous

Break

Tear

Hole

Non-Rhegmantogenous

Tractional

Serous

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WHAT ABOUT PVD RISK?

PVD

10% Present with retinal break

High risk-46% detach within 6 weeks

Low risk of detachment

90% present without complications

96% stay uncomplicated

3.4% Break 4 to 6 weeks

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MAIN PIT FALLS

Failure to recognise symptoms; can occur in isolation of one another
No time; come back later
Phone call; any advice given to patient puts practitioner at risk;
Front of desk staff must know routine; how to advise patient ringing up with symptoms
Failure to invite patient back to review (within 6 weeks) and issue RD warning letter in meantime.

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KNOW THE RISK FACTORS!

Risk Factors for RD

Risk sports

Family History

RD fellow eye

Systemic disease

Myopia

Aphakia

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MANAGEMENT STRATEGY

Px presenting with flashes an floaters should be presumed to have retinal tear unless demonstrated otherwise
New or changed symptom especially when combined with risk factor; obligation to conduct mydriatic exam with volk
If this cannot be done; refer as urgent suspected detachment

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RD PRACTICE POLICY

Once you have commenced examination, you must not cease until you have made a decision or a diagnosis
Telephone conversations; patients telephoning with symptoms must be advised that full exam is necessary and diagnosis CANNOT be given over phone
Clinically relevant phone conversations should be noted in patient record
Reception staff must be appraised of this policy for phone calls or drop-ins
Reception staff must record this info and advice given

This can be applied to all areas of clinical risk!

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RECENT TRAUMA

Any patient presenting with trauma; give RD warning if complete exam with dilation and Volk reveals no anomaly.
If patient symptomatic (has had flash, floater), refer even if you can see nothing.
Review any patient presenting with trauma as RD can occur weeks/months even years after

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RECORDS

Write down EVERYTHING
Record negative as well as positive findings
Record all patient encounters; phone/drop-in/brief visit etc
Note all advice/info/written material
Medico-legal; if examination undertaken with dilated volk and detachment occurs thereafter..onus to prove detachment present at time. If direct method used; no defence!

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REMEMBER

Not all detachments are accompanied by flashing lights, floaters etc, symptoms can be isolated; look at the risks versus the probability
There may be one episode of flashing light
Any flashing light or floater in any myope even under 50 should be considered highly suspicious
Always give warning letter even if you are confident you can find no anomlaies
Don’t look at the macula; if they can still see, its just because macula not affected

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NON-TOLS

Spec Rx is incorrect
Not serious health risk but can have consequences
Practice audit should be regularly carried out to evaluate numbers, reasons and management
Most legal cases involve small claims or solicitors letter and out of court settlement

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SYMPTOMS

Headaches
Blurred vision
Diplopia or BV issues
Annoyance

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CAUSES

Dispensing; incorrect Rx dispensed, incorrect frame fitting, centration problems with PD, heights etc, discomfort from weight of lenses, cosmetic reasons, miscommunication

Prescription; unable to adapt to prescription change

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RISKS

Impact on critical tasks
Falls
Inability to job

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DIABETIC EYE DISEASE

Despite RetinaScreen; onus still on optometrists to identify and evaluate ocular related complications of diabetes
Not just retina; lens, extra-ocular muscles, glaucoma etc
Not 100% take up in screening; still see patients with diabetes who need their eyes checked
Diabetic patients should have dilated exam, not just retinal blood vessels, macula, disc and lens need to be viewed as well
Usually asymptomatic until advanced

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CLINICAL EXAM

Visions
Refractive changes
Amsler grid
BV work up; muscle palsies (3^rd or 6^th)
IOPs
Dilated fundus exam
Fundus photography

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AMD

Leading cause of vision loss in over 50’s
Main risk; Wet AMD only 10-15% of AMD cases but consequences more severe
Cannot screen; does not meet WHO criteria for screening programme

No one diagnostic test

Cannot be prevented

Cannot always be treated

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AMD

Symptoms
Reduced night vision
Difficulties reading
Metamorphopsia

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RISK FACTORS

Strong	Weak
Age Genetic Smoking Diet Weight/Lifestyle	Race Alcohol BP and Cholesterol Cardiovascular disease Kidney disease Post-Cat op UV exposure

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AREDS CLASSIFICATION

Stage	Classification	Characteristics
No AMD	1	Few small drusen <63 microns
Early	2	Multiple Medium drusen and/or RPE abnormalities
Intermediate	3	Extensive Medium Drusen , 1 large .125 microns, with or without geog atrophy not at fovea
Late	4	Geographic atrophy of RPE and chorio-capillaris involving fovea Neovascular changes, CNV Serous/haemorrhagic det of RPE Hard Exudates Fibrovascular proliferations sub RPE/retinal Disciform scarring

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Well-demarcated Geographic atrophy
Degeneration of overlying photoreceptors,

thinning of RPE and increased visibility of choroid

Areas of clumped pigmentation around area

of atrophy

Early atrophy fovea spared;

cannot use VA as guide to disease progression

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CLINICAL INVESTIGATION

Appears as green-grey lesion
Sub-retinal or intra-retinal haemorrhages
Exudates
Intra-retinal fluid
Pigment epithelial detachment (PED)
Hospital clinic; fluoroscein angiography

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MANAGEMENT OF DRY AMD PATIENT

Monitor every 6 months
Give Amsler Grid (essential)
Lifestyle advice re diet, exercise and smoking
Nutritional supplements

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PRACTITIONER RISK

Failure to make timely diagnosis
Failure to recognise clinical signs and symptoms
Failure to carry out relevant tests
Failure to interpret test results correctly
Failure to give appropriate advice to patient

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CLINICAL EXAM

Patient profiling; age, family history, smoker, systemic disease
Visual acuities
Amsler grid
Ophthalmoscopy
Fundus photography
OCT if available, if not and wet AMD suspected; refer

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CONTACT LENSES

Numerous risks; increase with lens modality
Risks identified with poor patient hygiene
Tap water
Swimming
Incorrect care solutions
Failure to follow care regimen
Ortho-K
Extended and overnight wear

Important to document and flag patients with poor compliance!!!

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PRACTITIONER RISK

Low; main issues with patient non-compliance
Important to take systemic health into consideration; risk factor. Ex diabetes or arthritis

Good communication skills
Record keeping
Instructions in writing
Routine check ups; review compliance

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PAEDIATRICS

Higher risk than adults
Importance of relevant upskilling
Experience critical; less experience; higher risk
Correct equipment
Prescribing guidelines; evidence based
Recognising risk factors; amblyopia etc
Need to refer when appropriate, need to know our scope of practice
Good communication skills
Good practice protocols

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RECORD KEEPING

Main pitfall
Misreporting findings or advice given
Not recording tests undertaken;
Legibility
Lack if clarity
E-records…fields not entered, or single word used “yes” or “no”; says nothing to expert witness
Under-reporting; giving more advice than recorded on file

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COMMUNICATION

“The single biggest problem with Communication is the illusion that it has taken place!”George Bernard Shaw
Gather as much information as possible!

Contributing factor to risk management
Contact lenses…hygiene and care
Paediatrics…..parents
Non-tols…….accurate information from patient re lifestyle,

daily visual requirements

Retinal detachments…patient history and follow up action

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USE OF OPTOMETRIC ASSISTANTS

Identified in studies as risk
Delegation of automated tests
Poor supervision
Poor communication
Poor training
……………………..errors made!
Leaves Optometrist wide open as most highly qualified member of staff, must take the hit.

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CAUSATION

Poor outcome is not always malpractice; diagnosis of bilateral amblyopia in a patient with reduced VAs. Px goes on to receive RP diagnosis. You did not cause. Outcome would be the same.

Child comes in with reduced vision in one eye; no fields, dilated exam or pupils examined. Child has tumour. You didn’t cause the tumour but delayed treatment. You are liable. Causation.

34 year old myope comes in complaining of isolated flash of light in one eye. No dilated exam done and no RD warning given, Goes on to have RD. You didn’t cause RD but delayed treatment. Causation.

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