Health and Disability Commissioner rules missed diagnosis left patient blind in one eye

The patient was prescribed eye drops and sent home.

A woman who is now blind in one eye after two optometrists failed to identify the signs of a severe eye condition says she wishes she sought a second opinion.

“After the two operation[s] I suffered anxiety, often feeling dizzy,” she said.

“I wish I had got a second opinion at another optometrist, but at the time trusted the medical professionals. This still plays on my mind, especially when my eye is all red and stinging an[d] [I] know it will never get any better.”

The elderly woman, who wasn’t named in a Health and Disability Commissioner’s report released today, was seen at an optometry clinic in late 2017 and told staff she had black and grey spots in her vision.

She was prescribed glasses and told to come back in two years. However, within 10 months she claimed her eyesight had only gotten worse and this time complained of dark and blurred vision.

A retinal scan was taken and she was prescribed eye drops but five days later she was back with pain in her right eye.

An eye specialist then found her retina had detached and the woman underwent two unsuccessful surgeries in an attempt to reattach it. She is now permanently blind in that eye.

Following those unsuccessful surgeries the Accident Compensation Corporation referred the optometrists to the Health and Disability Commissioner for a delay in diagnosis of the woman’s detached retina.

They said that given how quickly the woman’s vision had deteriorated over five days after being given eye drops it should have raised alarm bells at the clinic.

One of the optometrists who saw the woman at the clinic said he didn’t undertake a full dilation test because she’d already had one recently and the deterioration of her vision was only mild.

“I did not feel [Ms A’s] symptoms or her clinical results indicated that she was possibly undergoing or in obvious risk of developing a retinal detachment,” he told the commissioner.

The clinic itself acknowledged the “awful ordeal” the woman had been through and assured the commissioner that it wouldn’t happen again.

It also found the optometrist at fault was not performing at an acceptable level and had him complete a series of training programmes as well as have his work supervised. He completed this in 2022.

An independent adviser to the commissioner said there was enough information in the scans the optometrists took, as well as the woman’s symptoms, to at least warrant further investigation.

That specialist was critical of the lack of notes taken by the optometrist during the woman’s visits and there was no record about the advice she was given in regards to the “dry eye” she was diagnosed with.

He described those notes as “brief, at best” and there was a significant difference between what was documented and what the optometrist was legally required to.

Photographs were also taken of the woman’s eye which the adviser said showed an inferior retinal detachment, and the second optometrist should have diagnosed it.

Deputy Health and Disability Commissioner Dr Vanessa Caldwell was critical in her report that a retinal examination was not performed at earlier appointments when it should have, which delayed the diagnosis of the woman’s condition.

Caldwell was also critical of their poor documentation and commented that the note-taking of one of the optometrists fell far short of the required professional standards.

Since the incident, both optometrists have undertaken training to improve their practise and the clinic has made a number of changes to improve communication between staff and update its technology.

Caldwell ordered the two staff members and the clinic to apologise to its patient and that an audit of similar cases at the clinic be undertaken.

Jeremy Wilkinson is an Open Justice reporter based in Manawatū covering courts and justice issues with an interest in tribunals. He has been a journalist for nearly a decade and has worked for NZME since 2022.