It was only after she went to a different optometry clinic that she was referred to see an ophthalmologist and then urgently referred to hospital, where she underwent laser treatments to both eyes.
"This has been such a stressful, exhausting, confusing, expensive part of my life," the woman was quoted as saying in the report.
The woman visited Specsavers Silverdale five times for sight tests and routine eye exams between 2014 and 2019, where she complained of various symptoms in her left eye.
The first optometrist she saw had referred her to hospital to investigate her blurry vision and intense pressure in the left eye, but an appointment did not take place.
Neither Specsavers nor the District Health Board has the referral in their records, but the woman had a copy.
Assessments were done at the other visits but the optometrists who attended to her did not notice anything abnormal, and she was given spectacle prescriptions.
After the woman's fifth and final visit to Specsavers on January 6, 2019, she went to a different optometry clinic the same day and was immediately referred to see an ophthalmologist.
One week later, the ophthalmologist diagnosed her with bilateral subacute angle-closure glaucoma, noting she had been symptomatic for as long as five years.
Subacute angle-closure glaucoma is a type of glaucoma where the eye's drainage channels become blocked by the iris, affecting fluid drainage and increasing pressure in the eye.
The ophthalmologist urgently referred her to hospital, where she was seen that day and underwent laser treatments to both eyes. She was likely to need further treatment for her left eye.
She was told she could have gone blind in her left eye if she had not pursued her investigation at another clinic.
The Specsavers optometrists had poor listening skills, and did not take correct notes on all the symptoms she mentioned at appointments, she told the HDC.
Commissioner Morag McDowell said the three optometrists and Specsavers Silverdale had breached the Code of Health and Disability Services Consumers' Rights for failing to provide their services with reasonable care and skill.
"The multiple failures by the optometrists employed by Specsavers Silverdale indicated a pattern of poor care, for which Specsavers Silverdale ultimately was responsible," she said.
She found that the optometrists failed to carry out a comprehensive assessment, which should have included gonioscopy, a method of examining a specific part of the eye.
The optometrists also failed to fully and properly document their assessment of the woman, and one presented information incorrectly.
"Careful consideration and further investigation of potentially concerning symptoms is crucial for timely detection and treatment of eye diseases such as glaucoma," the Commissioner said.
She recommended the optometrists and Specsavers Silverdale each write a written apology to the woman, and also asked the Optometrists and Dispensing Opticians Board to consider reviewing the competence of the three individual optometrists.
The clinic was asked to provide a report on remedial actions, provide relevant training for staff, and consider requiring optometrists to review and discuss previous visit records at every consultation with customers.
Specsavers Silverdale said they regretted their customer felt "let down" by the store, but it has made changes and now requires staff to document all assessment findings, and optometrists have gone for training on gonioscopy.
On whether the woman required the glasses she was prescribed at each appointment, Specsavers said their decisions were based on examination findings and in consultation with the customer.
"We believe that [she] would have felt her prescription was of benefit to her or otherwise she would have availed herself of our 90-day warranty period."
