Welcome to question of the day #223

Eyetools question of the day #223 

I prescribed a new patient with varifocals. He had no general health problems, no suspicious symptoms or signs had 6/6 in each eye with -4.00 DS in each eye. It was his third pair of varifocals and he was an experienced varifocal wearer. He knew how to use them so I was not particularly concerned that he wouldn’t be able to get on with them. He came back a week after collecting his new pair complaining that the vision in his right eye was blurry with the new varifocals. One of my optical assistants adjusted the fit of the frames. He came back a week later still complaining of blurry vision. Again, one of my assistants adjusted the frame fit. He came back again about a week later still complaining of blurred vision in his right eye. He was offered further frame adjustment but refused. The practice manager gave him a refund.

I have just received a complaint letter from him saying that he went to another practice the day he received the refund and a macular-off retinal detachment was discovered. He has since had two operations on his right retina but these have been unsuccessful and the sight in his right eye is very poor. In his letter he asks why didn’t I detect the retinal detachment? What went wrong?

It is difficult to know whether the patient had a retinal tear and/or a retinal detachment when you first examined him. It sounds like there was three-week period between him collecting the new varifocals and the occurrence of the retinal detachment. It doesn’t sound like there were any symptoms or signs to put you on alert for a retinal tear and/or retinal detachment when you examined him.

It is typical practice to adjust the frame when a person complains of blurry vison with new varifocals even with experienced varifocal wearers. The one slight issue is that the patient was complaining of blurred vision in one eye and in my experience a person with visual symptoms due to poor fitting frames typically, but not always, complains of problems seeing with both eyes.

In my opinion when he came back the second time to complain about blurry vision in his right eye he should have been advised to see you for a refraction re-check and also another examination of the retina of the right eye. It is difficult to say whether he had a retinal tear and/or detachment but it would have been reasonable clinical practice to examine his right retina again.

The same goes for the third return. As he was later on that day diagnosed with a retinal detachment he must have had it when he was in your practice and given a refund by the practice manager. It would have been reasonable for the optical assistant or practice manager to advise the patient to see you for a refraction recheck and a retinal examination. Better for you to detect the retinal detachment than another optometrist.

It will be difficult to prove that the patient had the retinal detachment when you first examined him and it was reasonable to try frame adjustment once but probably not twice or even a third time.

I suggest you train your optical assistants to alert you to patients who return complaining of visual problems especially when frame adjustment has failed to solve the visual problem.