Welcome to question of the day #79

Welcome to question of the day #79

Should I conduct visual field testing on all my patients?

Some of my colleagues perform every test on every patient (patient ability permitting) in order to practice defensively and avoid being sued for missing something. This takes time, money and effort and it’s not something I do myself. I have the clinical decision making skills, experience and the confidence to be able to conduct the tests that are necessary; the tests that each individual patient needs and deserves according to their particular circumstances. And, the UK optical regulator agrees with me:

GOC Standard 7.6

‘Only provide or recommend examinations, treatments, drugs or optical devices if these are clinically justified and in the best interests of the patient.’

My colleagues tell me that there are medico-legal benefits, in showing that something was not present when the patientwas examined. Suppose a young person is discovered to have a pituitary tumour some months after they had an eye examination. Having a visual field result on record shows that signs were not ‘missed’ at the point of the test and you are in the clear. I disagree. If the test was not required by law, you could be criticised for not doing a test that was not clinically necessary but it would not stand up to even the mildest clinical and legal scrutiny.

There is a large down side to carrying out blanket visual fields screening;false-positive referrals. The danger of performing visual fields on people who would not normally need them is that a clinically insignificant field defect may be found. This creates a diagnostic dilemma and the optometrist has to make a clinical decision; is this an artefact or it is a genuine visual field defect.

In my experience, many patients miss a few points on visual field testing and although this might be clinically insignificant, the optometrist may feel (for defensive practice reasons) that the patient needs to be referred for further investigation with all the worry that causes the patient. There’s also the time needed to explain it and write the referral, as well as the cost of a hospital appointment. People with a more urgent need for hospital appointments may be delayed.

Eye specialists with good training, should have confidence in their clinical decision making skills and conduct needs-led examinations.