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An Eye on the Law

• Oct 31, 2022
• Latest Journal

by Anna Kwartz MSc PhD DipTP(IP) MCOptom

Spending time writing medico-legal reports is not the natural default for a clinician, whose day-to-day life is generally spent patient-facing and very hands on. However, the medico-legal world offers an opportunity for an investigative mind to be inquisitive and analytical. Further, as an optometrist with an academic background, I feel perfectly placed to utilise my clinical experience and writing skills to author medico-legal reports.

I think many people are unsure what an optometrist actually does. Optometrist is the contemporary term for ophthalmic optician, which was traditionally a clinician who performed sight tests and fitted contact lenses. However, there have been significant developments in recent years in widening the scope of optometric practice. I, like many others, have an independent prescribing qualification, which means that I can write prescriptions for medications to treat eye conditions, without recourse to a doctor. Whilst most optometrists are involved in provision of core services in primary care (ie on the high street), others are involved in managing eye diseases such as glaucoma, retinal pathology, red eye etc.

The vast majority of optometric medico-legal work involves patients who have visited their high street optometrist and been reassured that their eyes are healthy, but actually have undiagnosed eye disease. I regularly write reports where conditions such as glaucoma, retinal detachment, ocular malignancy, macula disease and neurological conditions have not been detected by the claimant’s primary care optometrist.

The first report I wrote involved a young patient who suffered from very severe eczema. They had visited a dermatologist at their local hospital who had prescribed a potent steroid to be used short-term around the eyes to bring their skin condition under control with a plan to use a gentler treatment thereafter. Due to multiple breakdowns in communication between the hospital and the GP and also between the GP and the patient, the latter continued using the treatment long term; in fact they were very happy, as their skin was in better condition than ever before. However, unbeknown to the patient and their doctors, the steroid cream actually led to irreversible blindness in both eyes. The underlying reason was that the patient was a significant ‘steroid responder’ which describes the fact that in some people, steroids can cause a large rise in the pressure within the eye. Raised pressure in the eye can cause glaucoma which can lead to painless, gradual, irreversible visual loss. Typically, patients do not notice visual symptoms until a considerable amount of their visual function has been lost.

During the period of steroid treatment, the patient had visited their high street optometrist for a new pair of glasses. The optometrist had enquired if they used any medication, and the patient informed them about their eczema treatment. Neither the GP nor the dermatologist had recommended that the pressure within the eyes should be measured and the optometrist did not perform the test, primarily because the patient was younger than the standard age of 40 or so when routine screening for glaucoma typically commences and they did not consider the possibility of them being a steroid responder. Several years later, when the glaucoma was eventually diagnosed and the patient had been given the devastating news that there was no chance of regaining their lost vision, the patient claimed against the hospital, the GP and the optometrist. Ultimately, liability was shared between the three.

Another case on which I gave an opinion involved an older patient who developed a brain tumour which involved their pituitary gland. The patient made multiple visits to their optometrist with non-specific complaints of visual loss and considered that there may have been a problem with their glasses. The optometrist took the correct approach of performing a visual field test (an assessment of the ‘all round’ vision) to establish if there was loss consistent with neurological disease. A visual field test lasts a number of minutes and requires the patient to be able to maintain very steady fixation on a screen and make accurate observations of small stimuli. The elderly patient found the test incredibly difficult to perform, which is not an unusual scenario. Consequently, the results were equivocal and not repeatable and were discounted as clinically not significant. The optometrist made a referral to the hospital for the patient to have cataract removal (where the cloudy lens of the eye is removed and replaced with a plastic implant). The cataracts were subsequently removed and the patient was discharged back to the care of the optometrist. However, their visual problems persisted and it was some time before a further referral for a suspected pituitary tumour was made. Due to surgical complications during removal of the tumour, the patient was rendered profoundly visually impaired. Liability was shared  between the optometrist and the hospital.

As well as dealing with civil cases, I also act as an expert witness for my regulatory body, the General Optical Council, and have regularly given evidence in fitness to practice hearings. The General Optical Council has a strong system of acceptance criteria and a well-defined route for case progression. Many of the cases are similar to those I see from civil work eg glaucoma, retinal detachment etc but there are additional issues of patient communication and record keeping.

Away from the medico-legal arena, I work part-time as a hospital optometrist in paediatric, retinal, anterior eye and glaucoma clinics and also as a core skills primary care optometrist, as well as volunteering at a clinic for the homeless. I definitely believe that my expert witness work has made me a better clinician and has certainly taught me to keep incredibly thorough patient records.