The Role of Optometrists and Ophthalmologists

In the UK, eyecare is mostly dealt with by optometrists and ophthalmologists, with a small contribution from GPs and pharmacists.

Optometrists generally work in high street settings offering sight tests, provision of contact lenses and sales of glasses. Detection of eye disease is also a large part of the role of optometrists, who are often the first port of call when a patient develops an eye problem.

Ophthalmologists are doctors who specialise in eyes; they tend to work in hospital settings and deal with diagnosis of eye disease together with medical and surgical management.

In recent years, optometrists have become more involved in treating eye conditions, and some practitioners have earned independent prescribing qualifications, which allows them to prescribe drug treatments for eye conditions. Some optometrists work within the hospital eye service or the independent sector where they diagnose and manage eye disease either independently or in conjunction with their ophthalmology colleagues.

Common Optometry Negligence Claims

The majority of optometry medical negligence claims arise from high street optometry. Typically, cases involve a patient visiting their optometrist with a complaint such as blurred vision or of particular symptoms, for example flashes of light and/or floaters. If the causative condition is not identified by the optometrist and an appropriate referral is not made, there may well be a breach of duty on behalf of the optometrist.

Typical cases of breach are a failure to detect conditions such as retinal detachments, glaucoma and brain tumours. In these situations, the optometrist has either failed to ascertain the patient’s symptoms or has not acted on issues mentioned to them.

Retinal Detachment: Symptoms and Referral

For instance, in retinal detachment, patients often complain of flashes of light and/or floaters. On hearing these symptoms, the optometrist should perform an examination of the retina with the benefit of pupil dilation, where the pupil is dilated using eye drops. Doing so significantly increases the extent of the retina that can be examined. In a patient with symptoms suggestive of retinal detachment, it is a breach of duty not to perform dilated examination. If a patient is found to have a retinal detachment, the optometrist should make a same day referral to the hospital eye service, as delays in treatment can result in permanent visual loss.

Glaucoma: Clinical Data and Missed Signs

When a patient develops glaucoma, there are often no particular symptoms, as the condition causes painless gradual visual loss. The clinician needs to perform a careful analysis of the clinical data and consider the pressure inside the eye, the appearance of the optic nerve and whether or not the patient has a defect in their visual field, which is their peripheral vision.

On the whole, glaucoma can progress quite slowly, so comparing a patient’s results over multiple examinations is important. A breach of duty can occur when a patient has an evident feature of glaucoma, such as glaucomatous changes to the optic nerve recorded in retinal photographs, but a referral has not been made. In some cases, delayed referral may allow further irreversible deterioration in vision before treatment begins.

Brain Tumours and Full Clinical Assessment

Detection of brain tumours by optometrists can involve them joining up the dots between various symptoms and multiple clinical findings. For example, patients can complain of symptoms such as headaches, reduced vision or blank patches in their visual field. The optometrist needs to perform a variety of clinical assessments including a check of the eye movements, analysis of colour vision and pupil reactions, assessment of the optic nerve and a visual field test. Omission of these examinations and/or a failure to make a referral would constitute a breach of duty, particularly where concerning neurological or visual symptoms were present and required urgent escalation.

How an Optometry Expert Can Assist Solicitors

There are multiple ways an optometrist’s expert opinion can assist the solicitor. First, by reviewing the quality of the history that was taken from the patient to ascertain if the relevant details had been established by the optometrist. Second, by reviewing the clinical examination to determine if the appropriate assessments were performed. Third, in considering the advice that was given to the patient and whether it was appropriate for their condition. Fourth, by giving their opinion on whether a referral should have been made and, if so, with what degree of urgency. Reference may be made to the various forms of professional guidance on which optometrists rely.

The opinion of an optometry expert tends to be confined to breach of duty. In clinical negligence cases, there will generally also be an ophthalmologist who provides an opinion on causation, condition and prognosis. Cases very much benefit from a conference where the experts can share their opinions.

The Importance of Digital Imaging and Complete Records

Contemporary optometry practice often involves the use of digital imaging: retinal photographs and optical coherence tomography, which provides very detailed analysis of the layers of the retina. These images are very useful to the expert as they provide an objective and permanent record of the examination and can be the basis of the expert’s opinion in considering whether or not there was a breach of duty. In some cases, the imaging may demonstrate abnormalities that were present but not acted upon at the time of the consultation.

When sending instructions to an expert, it is vitally important that all the digital images, together with any supplementary results, such as visual field tests, are included in the bundle.

Extended Roles and Emerging Medico-Legal Issues

In addition to clinical negligence involving high street optometrists, there are also cases involving optometrists working in extended roles. Some optometrists work in refractive surgery clinics when they provide pre and post operative care of patients who wish to reduce their reliance on spectacles and contact lenses. Optometrists are employed in increasing frequency by independent sector providers of eye surgery, for example cataract surgery.

Consequently, there is an emerging area of expert witness work involving giving an opinion on their actions in these environments, which often includes an analysis of pre operative counselling and educating the patient about surgical options to allow optometrists to give informed consent. These additional roles have widened the scope of an optometry expert witness. It is important that an appropriate expert is instructed whose experience is relevant to the particular case, particularly where issues of referral urgency, informed consent, image interpretation or clinical escalation are being considered.