Assessment by optometrist

Names have been removed (except the expert who advised on this case) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.

Optometrist, Ms B 

Optometry Clinic

 

A Report by the Deputy Health and Disability Commissioner

 

Table of Contents

Executive summary
Complaint and investigation
Information gathered during investigation
Opinion: Ms B - Breach
Opinion: The Clinic - Adverse Comment
Follow-up actions
Appendix A - Independent optometry advice to the Commissioner

 

Executive summary

1. On 20 December 2012, Master A, who was four years old at the time, was examined by optometrist Ms B at an optometry clinic (the Clinic). Ms B advised HDC that Master A's mother explained to her that the main reason for their visit was because Master A failed his B4 School Check, and because she had noticed that occasionally he had a "wandering eye". 
2. Ms B told HDC that during this appointment she carried out retinoscopy, an Ishihara colour vision test, and pupil reactions to assess Master A's ocular health.
3. Ms B also tested Master A's eye alignment and arranged a further appointment for 21 December 2012, so that she could test further for amblyopia with the aid of cycloplegic drops.
4. On 21 December 2012, Master A attended his second optometrist appointment with Ms B. Ms B re-examined Master A's eyes using cycloplegic drops to obtain a more accurate prescription. The results, as documented in Master A's notes, showed that Master A was somewhat hypermetropic (long sighted) with a low degree of astigmatism. Ms B recommended that Master A wear single vision distance spectacles full time and return for a review in six weeks' time.
5. Very little of this appointment is recorded in Master A's notes, including what was discussed or regarding any management plan. 
6. On 20 May 2013, Master A's parents made an appointment for him with a consultant ophthalmic surgeon Dr C. Dr C diagnosed an alternating exotropia (divergent squint, where the direction of the eye deviates), and advised that glasses were unnecessary to treat Master A's condition.

Findings 

7. By not carrying out a thorough and appropriate eye health assessment at the appointment on 21 December 2012, for not repeating the measurements of vision, and for prescribing spectacles to Master A when they were unnecessary, Ms B was found to have failed to provide services to Master A with reasonable care and skill and, therefore, breached Right 4(1)  of the Code of Health and Disability Services Consumers' Rights 1996 (the Code). 
8. Ms B failed to comply with Master A's right to the information that he could be expected to receive. Ms B did not fully inform Master A's parents of Master A's diagnosis and prognosis, including the reasoning behind why spectacles were prescribed, or of the plan to manage his condition. Accordingly, Ms B was found to have breached Right 6(1)  of the Code. 
9. It was also found that without this information (as outlined above), Master A's parents were not in a position to make an informed choice or give informed consent for their son regarding an agreed course of management, including the prescribing of spectacles. Accordingly, Ms B was found to have breached Right 7(1)  of the Code. 
10. By not following the professional standards relating to documentation, Ms B breached Master A's right to services that complied with those standards and, accordingly, breached Right 4(2)  of the Code. 
11. The Clinic was not found liable for Ms B's breaches of the Code. 

 

Complaint and investigation

12. The Commissioner received a complaint from Mrs A about the services provided to her son, Master A, by optometrist Ms B and the Clinic. The following issues were identified for investigation: 

• Whether the Clinic provided an appropriate standard of care to Master A in December 2012.
• Whether Ms B provided an appropriate standard of care to Master A in December 2012.

13. An investigation was commenced on 26 May 2014. This report is the opinion of Deputy Commissioner Ms Theo Baker, and is made in accordance with the power delegated to her by the Commissioner.
14. The parties directly involved in the investigation were:

Mrs A Complainant

Ms B Provider

The Clinic Provider

Also mentioned in this report:

Dr C Consultant ophthalmic surgeon

 

15. Independent expert advice was obtained from optometrist Mr Geraint Phillips (Appendix A). 

 

Information gathered during investigation

B4 School Check

16. On 29 November 2012, Master A, aged 4 years, had his vision and hearing tested. This was completed as part of a B4 School Check.  The vision/hearing technician found that Master A's hearing was not of concern, but recommended that his vision be reviewed by an optometrist or ophthalmologist, as his vision test results showed slightly diminished vision in his left eye, and he had a possible lazy eye. Out of concern for his lazy eye, Master A's parents made an appointment for him to be reviewed by an optometrist at the Clinic.

Visit to the Clinic - 20 December 2012

17. On 20 December 2012, Master A was examined by optometrist Ms B at the Clinic. Ms B advised HDC that she asked Master A's mother about her son's case history. Ms B documented in Master A's notes that the main reason for the visit to her was because Master A failed his B4 School Check, and because occasionally his mother had noticed that he had a wandering eye. 
18. Ms B examined Master A's vision and recorded normal vision for his right eye and slightly reduced vision for his left eye. The results matched the B4 School Check.
19. Ms B tested Master A's eye alignment. It is recorded in Master A's notes that he had a medium sized exotropia  and medium sized exophoria  at distance in his left eye. 
20. Ms B also documented that she assessed Master A's stereopsis (depth perception) and his refractive status.  
21. Ms B documented "no" beside each of the listed methods for examining ocular health, such as direct and indirect ophthalmoscopy.  However, she told HDC that she carried out an Ishihara colour vision test and pupil reactions to assess Master A's ocular health. Although it is recorded in the notes that an Ishihara colour vision test was performed, there is no record of how it was conducted. It is recorded that Ms B tested Master A's pupil reactions. 
22. Ms B advised HDC that she carried out a dry retinoscopy,  which showed an asymmetrical prescription. Ms B said that this is usually an indication for further assessment using cycloplegic drops, as there may be a risk of amblyopia, a condition where one eye has decreased vision. Ms B advised that visual development in this eye may be permanently stunted without intervention. There is no record in the notes that a retinoscopy was performed.
23. Ms B told HDC that her examinations showed that Master A's eyes turned slightly outward, and that his left eye showed a tendency to want to diverge in the distance. Ms B arranged a further appointment for 21 December 2012, so that she could test for amblyopia  with the aid of cycloplegic drops.  

Visit to the Clinic - 21 December 2012

24. On 21 December 2012, Master A attended his second optometrist appointment with Ms B. The notes from this appointment were entered into the same electronic notes from the previous appointment (20 December 2012). 
25. It is recorded in the notes that at this appointment Ms B re-examined Master A's refractive status using cycloplegic drops. 
26. The results were documented as showing that Master A was somewhat long-sighted with a low degree of astigmatism.  Ms B stated to HDC that she discussed with Master A's parents that she considered that the small amount of long-sightedness in the one eye might have been causing slightly blurred vision and "encouraging [Master A's] eyes to occasionally dissociate". As is recorded in the notes, Ms B recommended that Master A wear single vision distance spectacles  full time and return for a review in 6 weeks' time. Ms B said that she told Master A's parents that she wanted Master A to trial the spectacles until the review appointment. She advised HDC: 

"[T]he spectacle correction is on the lower end of hyperopic correction for a child with exotropia, however I hoped that the correction would help to eliminate the slight blurred vision which in turn could have encouraged better ocular alignment."

27. Master A's notes have no record of any further assessments or measurements undertaken on 21 December. Ms B stated to HDC that she believed the minimum level of ocular assessment to rule out sight and life-threatening conditions had already been conducted, and that she had enough information to prescribe glasses to help correct the asymmetrical visual acuity,  and that she "did not manage to complete further testing due to other constraints". She also said:

"While I appreciate there is no clear documentation on why ocular health was not recorded … The process of [using] eyedrops can be distressing for a child and for [Master A] I decided to delay this part of the examination until the following visit because I judged that he had had enough that day." 

28. Ms B stated that, "as written in the clinical records", she wished to see Master A again within six weeks to complete the visual examination. She advised: "[A]s intended at the review appointment a comprehensive ocular health check would have been completed." She told HDC that she discussed with Master A's parents her intentions to complete the rest of the ocular examination at the review appointment, and she would have completed the ocular health assessment by performing fundoscopy (another word for ophthalmoscopy). She planned to, if necessary, discuss with Master A's parents at the review appointment the steps to manage his ocular misalignment. 
29. Ms B told HDC that she felt that Master A's eye misalignment might require closer monitoring and referral. She said that her plan for the next appointment, "as discussed with his parents", was to re-measure Master A's vision and assess whether the glasses had improved the vision in his left eye. She stated: "If the spectacles were found to result in little or no improvement to his vision and if his ocular alignment was not improving, I would have referred [Master A] to a paediatric ophthalmologist for further assessment." She said that she told Master A's parents that she would discuss other options with them, including referral, at the review appointment. She also stated that the spectacles had a three-month satisfaction guarantee, so that "if at the review appointment the spectacles were found to have not improved [Master A's] vision, [the family] would have been provided with a full refund, unfortunately because the review was not attended we never had the opportunity to follow through with this process". In response to my provisional opinion, Master A's parents stated: "There was never any discussion about further checks and a possible referral." 
30. The records document that spectacles were prescribed, and that Ms B would review Master A in six weeks' time. However, there is no evidence in the records that Ms B discussed any plan for the review appointment, or the possibility of referral, with Master A's parents. Mr and Mrs A advised that they were "never told that the glasses were only a 6 week trial or test".
31. Master A's parents told HDC that Ms B told them that if Master A got glasses and wore them straight away, his eye condition had a good chance of "coming right". They said that they asked a lot of questions about how the glasses would correct Master A's eyes from drifting, but they were not given a "straight answer". They also said that they asked what Master A's prescription was, and requested a copy "multiple times" after his appointment, but were not provided with a copy. They purchased two pairs of glasses and ensured that Master A wore them "all the time".
32. Ms B told HDC that she had no further contact with Master A and his family despite sending two recall letters on 1 March and 13 June 2013 reminding Master A's parents of his review appointment. 

Visit to another clinic for a second opinion

33. Master A's parents said that they "started researching the different types of eye movement conditions" and "read enough to suspect that glasses would be doing nothing" for Master A. They decided to seek a second opinion, and made an appointment for Master A at another clinic.
34. On 28 April 2013, the optometrist at the second clinic examined Master A's eyes and diagnosed an alternating exotropia. She advised Master A's parents that this condition cannot be treated with glasses, and that the glasses were unnecessary. She referred Master A to consultant ophthalmic surgeon Dr C to assess the exotropia further.

Visit to consultant ophthalmic surgeon

35. On 20 May 2013, Master A had an appointment with Dr C. Dr C found that Master A had "excellent unaided acuity … in each eye" and agreed with the second optometrist's findings and diagnosed an alternating exotropia.  He recommended convergence exercises in the hope that they would help Master A regain some control over his eye movement. He further advised Master A's parents that if Master A's ocular alignment deteriorated further and the exotropia remained, they could "consider surgical intervention". 

Complaint laid

36. On 31 May 2013, Master A's parents complained on the Clinic's Facebook page about Ms B's care of Master A. The store director contacted them that day to discuss the complaint, and a full refund of the purchase price of the glasses was made.

Further information provided to HDC

Changes to current practice 

37. Ms B advised HDC that she knows she needs to improve her note-taking "to ensure no ambiguities are present in the interpretation of my records". She also advised that she now tries her best to "ensure that the management plan is clearly understood by the patient and family before prescribing glasses or taking other actions". Furthermore, she advised that she has sought mentoring on paediatric and binocular vision abnormalities from her colleague, the Optometrist Director at the Clinic, and that she has organised with a paediatric specialist to sit in and observe during his paediatric/squints clinics. 

The Clinic's lack of policies and guidelines

38. The Clinic advised this Office: 

"[A]ll [of our] optometrists are required to hold the relevant registration in New Zealand to enable them to conduct eye examinations. They have complete professional freedom to act in the best interest of their patients and are expected to follow current accepted industry standards for optometric care. [The Clinic] does not provide any guidelines or have any policy surrounding the prescribing of glasses and of the examination of patients other than that provided by the profession."

 

Responses to provisional opinion

39. Mr and Mrs A, Ms B and the Clinic were given the opportunity to respond to relevant sections of my provisional opinion. 

Mr and Mrs A

40. Mr and Mrs A's response has been incorporated into the report where relevant. 

Ms B

41. Ms B advised that she has taken steps to initiate her own programme for skills improvement, through mentoring and supplementary clinical exposure. Ms B advised that the Optometrists and Dispensing Opticians Board requested that she complete a self-audit relating to her management, examination routine and record keeping. Ms B did so, and based on this audit, the Optometrists and Dispensing Opticians Board formed the view that Ms B appears to be practising at the required standard.
42. Ms B provided a letter of apology for Master A and his parents. This has been forwarded on to them by this Office. 

The Clinic

43. The Clinic advised that it had no comment to make in response to my provisional opinion.

 

Opinion: Ms B - Breach

Visit to the Clinic 20 December 2012

44. On 20 December 2012, Master A was examined by optometrist Ms B, at the Clinic. Ms B examined Master A's vision and carried out several tests. She recorded normal vision for his right eye and slightly reduced vision for his left eye. She told HDC that Master A's eyes turned slightly outward, and that his left eye showed a tendency to want to diverge in the distance. There was some indication that he might be at risk of developing a lazy eye, so she wanted to perform further tests using cycloplegic drops, and therefore arranged a further appointment for 21 December 2012.
45. HDC's expert adviser, optometrist Mr Geraint Phillips, advised me that at that visit, the important tests for a four-year-old were undertaken. These were case history, vision, eye alignment, stereopsis, and an assessment of refractive status. I note that Master A's ocular health was not assessed thoroughly at this appointment, and an examination using cycloplegic drops was not performed. However, as advised by Mr Phillips, it would have been appropriate for these tests to have been undertaken at the appointment the following day. In my view, Ms B's care of Master A on 20 December 2012 was reasonable.

Visit to the Clinic - 21 December 2012

Assessment and prescription - Breach

46. On 21 December 2012, Master A attended his second optometrist appointment with Ms B, who re-examined Master A's refractive status using cycloplegic drops and recommended he wear single vision distance spectacles and return for a review in six weeks' time.
47. The only documented eye health assessments were Master A's pupil reactions and an Ishihara colour vision test, performed the previous day. Mr Phillips advised that Master A's eye misalignment and slightly reduced vision in the left eye required a thorough eye health assessment, and that it would have been appropriate to repeat the measurements of vision at this appointment. I accept this advice.
48. Ms B advised this Office that she "did not manage to complete further testing due to other constraints". She also told HDC that the process of using eye drops can be distressing for a child, and so she decided to delay that part of the examination until the following visit because she judged that Master A had had enough that day. Ms B acknowledged to this Office that there was no clear documentation as to why further ocular health assessment was not carried out.
49. Ms B advised HDC that, "as written in her clinical records", she wished to see Master A again within six weeks to complete the visual examination, and that "as intended at the review appointment a comprehensive ocular health check would have been completed". However, the clinical records state only that she prescribed spectacles and would review Master A in six weeks' time. There is no record of her intention to complete the visual examination at that time, or how she intended to do it.
50. Mr Phillips advised me that Master A's ocular health was not assessed appropriately at this appointment. In particular, Ms B should have assessed Master A's internal eye health. I accept this advice. I further accept Mr Phillips' advice that it was not appropriate for Ms B to rely on a follow-up appointment, in six weeks' time, to continue such testing, as there are "many reasons why a patient might not return for a six week follow-up".
51. Mr Phillips also advised this Office that the prescribing of spectacles was not likely to help Master A's problem, and therefore was unnecessary. He stated that "the prescribing of a relatively low amount of hyperopia  and minimal astigmatism was very unlikely to have any significant effect on the eye misalignment, especially at distance". 

Conclusion

52. By not carrying out a thorough and appropriate eye health assessment at the appointment on 21 December 2012, for not repeating the measurements of vision, and for prescribing spectacles to Master A when they were unnecessary, Ms B failed to provide services to Master A with reasonable care and skill and, therefore, breached Right 4(1) of the Code. 

 

Information provided - Breach

53. Ms B advised this Office that she discussed with Master A's parents that she considered that the small amount of hyperopia in one eye might have been causing slightly blurred vision and encouraging Master A's eyes to dissociate occasionally, and she told Master A's parents that she wanted Master A to trial spectacles. She also advised HDC that her plan "as discussed with [Master A's] parents" for the next review appointment was to re-measure Master A's vision, complete the rest of the ocular examination, and assess whether the glasses improved the vision in his left eye. She advised that she also told Master A's parents that they would discuss other options, including referral, at the review appointment.
54. Master A's parents advised this Office that they were unclear as to why the spectacles were prescribed, and had no understanding of their likely success as a treatment in this case. They also complained that they were not aware of a management plan. 
55. As stated by Mr Phillips, there are many reasons why a patient might not return for a six-week follow-up, and therefore there should have been discussion at the 21 December 2012 appointment with Master A's parents about Master A's misalignment and the plan for its management. 
56. The importance of optometrists communicating advice and information to patients and their caregivers is covered in detail by the Opticians and Dispensing Opticians Board's standards of clinical competence for Optometrists ("Optometrists Standards"). The standards state that optometrists must agree a course of management with the patient, including likely management and prognosis.  
57. Standard 5.1 of the Optometrists Standards outlines the criteria for developing a management plan for each patient that is implemented in agreement with the patient/carer. The optician must address "the importance of the presenting problems and findings in the management plan and [discuss] options to address the patient's needs".  
58. Standard 7.1.1 of the Optometrists Standards states that the optometrist "[p]romptly records all relevant information pertaining to the patient in a separate record and in a format which is understandable and useable by any optometrist and his/her colleagues (including … patient history, diagnoses, management strategies, summary of advice given to patient …)". 
59. However, there is no documentation of a management plan or of one being discussed with Master A's parents. There is also no documentation of any discussion with Master A's parents that the spectacles were part of a trial, or that any plan was discussed in the event that the spectacles made no improvement. As they were not aware of what the plan was going forward, Master A's parents felt the need to carry out their own research into Master A's eye condition, and sought a second opinion. 
60. I have decided, therefore, that it is unlikely that Ms B fully informed Master A's parents of Master A's diagnosis and prognosis, including the reasoning behind why spectacles were prescribed, or of the plan to manage his condition. 

Conclusion

61. I find that Ms B failed to comply with Master A's right to the information that he could be expected to receive. Ms B did not fully inform Master A's parents of Master A's diagnosis and prognosis, including the reasoning behind why spectacles were prescribed, or of the plan to manage his condition. Therefore, Ms B breached Right 6(1) of the Code. 
62. As set out above, I do not consider that Master A's parents received sufficient information about the diagnosis and intended management of their son's condition. Without this information, Master A's parents were not in a position to make an informed choice or give informed consent for their son regarding an agreed course of management, including the prescribing of spectacles. Accordingly, Ms B also breached Right 7(1) of the Code. 

 

Documentation - Breach

63. Ms B failed to document: 

• what her ocular assessment of Master A consisted of and why it was not completed;
• what she discussed with Master A's parents; and 
• her reasoning behind the prescribing of the spectacles, and her management plan going forward.

64. Standard 7.1.1 of the Optometrists Standards states that the optometrist:

"Promptly records all relevant information pertaining to the patient in a separate record and in a format which is understandable and useable by any optometrist and his/her colleagues (including … patient history, diagnoses, management strategies, summary of advice given to patient …)." 

65. Ms B acknowledged to this Office that she needs to improve her note-taking in order to "ensure no ambiguities are present in the interpretation of [her] records". I note that those ambiguities occurred because Ms B documented her notes for the second appointment into the same electronic notes from the previous appointment. In addition, there was also very little documentation overall, particularly relating to the reasoning behind her diagnoses, management strategies, and what was discussed with Master A's parents. 
66. By not following the professional standards relating to documentation, Ms B breached Master A's right to services that complied with those standards and, accordingly, breached Right 4(2) of the Code. 

 

Opinion: The Clinic - Adverse Comment

67. The Clinic had a duty to provide services that complied with the Code. In addition, under section 72(2) of the Health and Disability Commissioner Act 1994 (the Act), employers can be found vicariously liable for any breach of the Code by an employee. However, under section 72(5) of the Act, it is a defence for an employing authority to prove that it took such steps as were reasonably practicable to prevent the act or omission of employees who breached the Code. 
68. This Office has previously found providers not liable for the acts or omissions of staff, when those acts or omissions clearly relate to an individual clinical failure made by the staff member.  I consider that Ms B's failure to carry out a thorough and appropriate eye health assessment for Master A, her failure to fully inform Master A's parents of his diagnosis and prognosis, and her failures in documentation, were individual failures. Ms B also failed to follow the standards outlined by the Opticians and Dispensing Opticians Board. However, I do not consider that the Clinic is liable for those failures. 
69. I note, however, that the Clinic does not provide any guidelines or have any policy surrounding the examination of patients. While I acknowledge the Clinic's response to this Office that all of its optometrists "are expected to follow current accepted industry standards for optometric care", in this instance (as discussed above), Ms B did not follow all of the industry's standards. Although I consider this an individual failure in clinical judgement, I do consider that it would be helpful for the Clinic to develop its own written policies to assist in ensuring that processes are clear, which, in turn, will support its optometrists in providing good care.

 

Recommendations

70. With regard to Ms B, I recommend the Optometrists and Dispensing Opticians Board undertake a review of Ms B's competence, in regard to her diagnostic skills, communication and record-keeping and report back to this Office on this recommendation within six months of this report.
71. With regard to the Clinic, I recommend it develop and implement a policy regarding communication and record-keeping, for the use of optometrists providing services at the Clinic, and implement training in this area. The Clinic should provide evidence of this within three months of this report.

 

 

Follow-up actions

72. • A copy of this report with details identifying the parties removed, except the expert who advised on this case, will be sent to the Optometrists and Dispensing Opticians Board, and it will be advised of Ms B's name. 

• A copy of this report with details identifying the parties removed, except the expert who advised on this case, will be placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.

 

Appendix A - Independent optometry advice to the Commissioner

The following expert advice was obtained from Mr Geraint Phillips, optometrist: 

"I have been asked to provide advice to the Commissioner on case number C13HDC00696 concerning the care provided by [the Clinic] to [Master A].

I can confirm I have no personal or professional conflict of interest in this case.

[Master A] consulted [the Clinic] on two occasions, as follows. The words in italics are my interpretation of the meaning of the abbreviation or word(s) that are before them.

20/12/12 

The clinical records from [the Clinic] for this appointment state:

- Reason for Visit:

o Routine check (no symptoms) failed kindy screening mum has noticed a wandering eye

LEE (last eye examination) never before

 

- General Health:

o No health issues

o Tonsillisitis and adenoids

o BHx (birth history) 'c section, 37 weeks, no major illnesses'

The answers to other History and Symptoms questions were 'none' or 'no'

- Objective and lOP Time: 12.22

o RE:+0.25/-0.75 x 115

o LE:+0.50/-0.50 x xl75

These above findings would suggest that an objective measure of [Master A's] refractive error was obtained but there is no indication of what method or instrumentation was used. There are no recordings of IOP (intra-ocular pressure).

- Refracted Rx

o Vision: RE:6/6 LE 6/9

o RE: Sph 0.00 LE Sph +0.75

- Prescribed Rx

o RE: +1.00/-0.25 x 180 LE: + 1.25/-0.25 x 18

o Recall period 2

There is no date on the Prescribed Rx entry but it would be reasonable to assume it was made following the second visit. There is no indication what a recall period of '2' means.

- Muscle Balance Tests

o DV Cover s Rx (distance cover test without an optical correction): LXOT Medium

o NV Cover s Rx (near cover test without an optical correction): Medium Quick Recovery XOP

 

There are no other Muscle Balance Test results. There is no indication as to the meaning or quantitative measure of 'Medium'.

 

- Accommodation and Pupils

o Motility: full and Smooth

o NPC: IOCM

o Accommodation: Normal for age

o Pupils: PERRLA

 

- Additional Tests

o Ishihara pass with 2 errors

o Stereopsis 400 secs of arc

 

There is no record of any examination findings for External Eye and Ophthalmoscopy. The records state:

- Direct (Ophthalmoscopy) - No

- Indirect (Ophthalmoscopy) - No

- VOLK - No

- Dilated - No

- Slit lamp - No

As the above are all methods for examining the health of the eyes and all are recorded as No, it would be assumed that the ocular health was not assessed.

- Advice given/Action taken

o Cyclo required - completed 21/12/2012

o Pres (prescribe) SVD (single vision distance) specs and review in 1.5 months  time

o Discussed patching and process involved - this is handwritten

 

It can reasonably be assumed that the cycloplegic examination was undertaken at the second visit (next day).

There is no record of the drug used or the number of drops instilled.

 

- Refracted/Prescribed/Dispense notes

o -/cyclo rx R +1.75/-O.50x 180 L +1.75/-050x1 21/12/2012 [Ms B]/-

It can reasonably be assumed that these are the refractive findings found during the cycloplegic examination.

In summary, the two visits to [the Clinic] for this 4 yr old boy were one day apart and were because of a concern from the mother regarding an eye misalignment. There is no record of how long this had been noticed or whether it had been noticed to be constant or occasional.

The optometric examination on the first visit identified a 'medium' (LXOT) strabismic misalignment when looking in the distance, with the left eye turned out relative to the right eye. A 'medium' (XOP) exophoria misalignment was identified when looking at near. An exophoria is where the eyes are able to be aligned but showed a tendency to want to diverge. The recovery from any divergence at near was recorded as 'Quick' which indicates [Master A] was able to align his eyes at near at either the first or second appointment. No assessment of the ocular health of the child is recorded. The recorded vision was as expected and normal in the right eye and slightly reduced in the left.

The care provided by [the Clinic] at this first appointment was reasonable as the important and prioritised tests for a 4 yr old were undertaken. These were case history, visions, eye alignment, stereopsis and an assessment of refractive status. If not able to be performed at the first visit, re-booking [Master A] for a cycloplegic examination was appropriate and, in fact required. The main omission was any assessment of ocular health but this could have been undertaken at the next appointment, especially as cycloplegia has the effect of dilating the pupils, thereby making internal eye health assessment easier.

The second visit involved an examination under cycloplegia, whereby drops were instilled to eliminate the effect of the eye's accommodative mechanism to allow a more baseline measurement of the refractive error. The drops would also have dilated the pupils. Under cycloplegia, the refractive status was assessed to be somewhat long sighted (hypermetropic) with a low degree of astigmatism. The amount of hypermetropia found was more than that found the day before but it is common to find more hypermetropia after instilling cycloplegic drops than without drops. Again, there are no records of any assessment of ocular health relating to this second appointment.

The outcome following the second appointment was the prescribing of single vision distance glasses and to review [Master A] in 1.5 months. There are hand written notes that patching and the process involved was discussed.

The care provided by [the Clinic] at this second appointment is questionable for the following reasons.

- There is no record of whether the vision had been re-measured at the second visit. It would have been appropriate to repeat the measurements of vision at the second appointment as measuring vision in 4yr olds can be challenging and especially in light of the slightly reduced vision recorded for the left eye the day before. It can be seen that the [second optometrist] found slightly better vision in the left eye and [the ophthalmic surgeon] found left eye vision that was better still.

- The prescribing of a relatively low amount of hyperopia and minimal astigmatism in this case was very unlikely to have any significant effect on the eye misalignment, especially at distance. As there were no symptoms recorded, there was no indication to prescribe it for any other reasons.

- The final prescription used was a reduction in hypermetropia from the full amount found under cycloplegia. To reduce the prescription like this is often appropriate but reducing it unequally in this case, with less reduction in the left eye, was inappropriate. Also, as there was a question about whether the left eye's vision was reduced, the amount of astigmatism found under cycloplegia should not have been reduced in the final prescription.

- No assessment of eye health is recorded. This second appointment would have been an ideal opportunity to assess eye health, especially the internal eye health.

- An appropriate management plan would have been to give consideration as to whether a course of eye exercises and/or eye muscle surgery would produce the best outcome, such as the plan following the visits to [the second optometrist] and [the ophthalmic surgeon].

In summary, the prescribing of the spectacles in this case probably did no harm in the short term but was not likely to help and was therefore unnecessary. In my opinion therefore, this was a moderate departure from the expected standards of care. 

While a discussion about patching is mentioned in the records, there is no mention of eye exercises, orthoptic or surgical intervention. This should have been raised with the parents as possible requirements in broader discussions regarding the longer term prognosis. Left without efforts to correct the misalignment, [Master A] might not self-correct, in which case he would remain without binocular vision in the distance. Given that there is no record of any consideration to address the misalignment directly, it is my opinion that this is a moderate departure from the expected standards of care.

With the findings of an eye misalignment and slightly reduced vision in the left eye, an eye health assessment was required. Eye health abnormalities can be a cause of eye misalignments and/or reduced vision in children.

As there is no record of any eye health assessment from either visit, or any mention that any eye health assessment was attempted but failed, such as when a child is uncooperative, it is my opinion that this is at the upper end of a moderate departure from the expected standards of care.

Yours sincerely.

Geraint Phillips"

 

Further expert advice obtained from Mr Geraint Phillips

"18 March 2014

I have been asked to provide advice regarding the response received from [Ms B], dated 25th October 2013 to the preliminary advice I provided, dated 14th October 2013. I can confirm I have no personal or professional conflict of interest in this case. 

I have been asked whether [Ms B's] response (a) changes any of my previous advice, in particular whether it changes my advice in regards to her actions being a mild, moderate or severe departure from expected standards, and (b) raises any other issues. 

I appreciate and accept the clarifications made by [Ms B] in points 1‒4 of her response and I see no issues with them. 

[Ms B] then goes on to discuss the three main areas of concern. These are, (i) the prescribing of the spectacle correction, (ii) no recordings of ocular health assessment and (iii) no recordings of discussion with the parents regarding the nature and longer term implications of the eye misalignment. 

Regarding concern (i), as [Ms B] mentions in her response, the prescribed spectacles were at the lower end of the hyperopic correction range and as such would have been unlikely to 'help to eliminate the slight blurred vision' and 'encouraged better ocular alignment'. Hyperopia is a focussing error whereby the focusing muscles in the eyes are required to contract for the eye to obtain a clear image when looking in the distance. Children usually have a large reserve of this focussing ability and so in this case, with the amount of hyperopia being low meant that correcting it would be likely to have had very little effect on the level of vision or misalignment. 

In the Advice given/Action taken section of the record it states that patching and the process involved was discussed. Patching is not usually part of the treatment for this type of ocular divergence and does not form part of the management plan as per the letter of 20 May 2013 from [Dr C]. The prescribing of spectacles for the low amount of hyperopia is also not part of [Dr C's] management. 

Regarding what plan was envisaged for the six-week review appointment, as there is only the patching mentioned in the records, I cannot comment on what might have been discussed at this review. Therefore, from the information contained in the records, it is still my opinion that the stated management plan is a moderate departure from the expected standard of care. If there was evidence of a discussion with the parents that the prescribing of these spectacles was part of a trial to see if correcting the low levels of hyperopia might benefit the child in some way and that the child would likely require eye exercises and/or surgery, it is my opinion that the standard for informed consent would then have been met for the parents. The parents would then have been part of the decision for the prescribing of the spectacles and have an understanding of the likely success of spectacles as a treatment in this case. 

Regarding concern (ii) that there are no recordings of ocular health assessment, in her response [Ms B] mentions several tests the results of which can help indicate the status of a person's ocular health. These tests are retinoscopy, colour vision assessment and pupil reactions. I can find no mention in the records that retinoscopy was performed, although there are results for 'Objective And IOP'. 

Retinoscopy is an objective test but there are other objective tests that could have been used in this case. Retinoscopy is a test whereby the practitioner estimates the amount of refractive error (refractive error is the amount that the eye is not focussing efficiently or accurately) by shining a light into the eye and judging aspects of the movement of the light that is reflected back out of the eye. Abnormalities within certain structures in the eye can cause alteration in the shape, or cause shadowing of the light reflected back out of the eye but retinoscopy cannot detect many other abnormalities, for instance those of the retina (the light sensitive lining of the back of the eye). 

Retinoscopy is an objective test, meaning that obtaining the results does not rely on any subjective input from the patient. However, there are other possible objective tests that could have been performed, namely the use of an autorefractor which is an automated instrument that does not require the practitioner to gauge the quality of light reflected out of the eye. 

As it is not stated in the records that specifically retinoscopy was performed, I cannot comment as to its use as an ocular health diagnostic tool in this case. 

An Ishihara colour vision assessment was appropriate in this case and can identify some optic nerve abnormalities but only if this test is conducted monocularly ie on each eye separately and not with both eyes open at the same time. If the test is conducted binocularly (both eyes open at the same time) a deficiency in one eye could be compensated for by the other (good) eye and therefore the deficiency could be missed. As there is no mention in the records as to whether the Ishihara test was conducted monocularly or binocularly, I cannot comment as to its use as a diagnostic tool in this case. 

Pupil reactions were recorded as PERRLA (pupils equal, round and reactive to light and accommodation), which usually means that the function of the optic nerves is normal. However, testing pupil function does not give much information about the functioning or abnormalities of the other ocular structures. 

Therefore, from the information contained in the records and from [Ms B's] response that she appreciates there is no clear documentation on why ocular health was not recorded, it is still my opinion that not assessing ocular health with standard assessment methods at one of the two visits is a moderate departure from the expected standard of care. 

Regarding concern (iii), that there were no recordings of discussion with the parents regarding the nature and longer term implications of the eye misalignment, I note [Ms B's] response that it was her intention to make a judgement at the six week follow-up. As only discussion regarding patching was recorded in the records, I cannot comment on what might have been discussed at the six week review. There are many reasons why a patient might not return for a six week follow-up and the standard of care would have been met if there had been discussions with the parents about the misalignment and its management at one of the two initial appointments. 

With this in mind, it is still my opinion that concern (iii) is a moderate departure from the expected standard of care. 

Regarding whether [Ms B's] response raises any other issues, I can confirm that they do not."

 

[1] Every consumer has the right to have services provided with reasonable care and skill.

[2] Every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive.

[3] Services may be provided to a consumer only if that consumer makes an informed choice and gives informed consent, except where any enactment, or the common law, or any other provision of this Code provides otherwise.

[4] Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.

[5] A free health and development check for four-year-olds before they start school.

[6] Also referred to as a divergent squint, where an eye often deviates outward.

⁷ The eyes show a tendency to deviate outwards; however, unlike exotropia, the eye is able to be aligned when visual attention is refocused.

[8] Refracting the eye helps to detect eye problems such as near-sightedness (myopia), far-sightedness (hyperopia) and/or astigmatism. Refractive status affects how clearly you see or how hard you work to see clearly.

[9] A test that looks at the back of the eye; it is usually part of a routine eye test to screen for eye diseases.

[10] A technique to obtain an objective measurement of the refractive error of a patient's eyes. The examiner uses a retinoscope to shine light into the patient's eye, and observes the reflection (reflex) off the patient's retina.

[11] A lazy eye.

[12] Eye drops that dilate the pupils. This enables the refractive status of the eye to be assessed and eliminates the effect of the eye's accommodative mechanism. The examination is commonly referred to as a 'cycloplegia'.

[13] When the eye is not completely round, resulting in objects in the distance sometimes appearing blurry.

[14] Single vision lenses correct for only one distance.

[15] The eyes not focusing on the same thing as each other and therefore not providing clear vision.

[16] A form of eye misalignment where the eyes turn outward.

[17] Long-sightedness.

[18] Standard 5.1.3.

[19] Standard 5.1.2.

[20] Opinion 12HDC01483, available at www.hdc.org.nz.