ablasio retina

Retinal Detachment

Failure to diagnose retinal detachment is the second most common cause of large liability claims involving optometrists.

. or if a reasonable optometrist would suspect that the symptoms indicate the risk of a retinal detachment.If a patient presents with symptoms indicative of retinal detachment. a dilated fundus examination must be performed.

About 4 months later she suddenly began seeing light flashes in the eye. and a retinal exam revealed detachment affecting the macula.An elderly woman who had been the longterm patient of an optometrist complained of suddenly seeing a “spot” in the field of vision of one eye. . He told the patient she had a PVD and described the symptoms of retinal detachment. The optometrist found acuity in the eye to be 20/20 and observed no pathology when examining the posterior pole through an undilated pupil.

For asymptomatic patients who are at risk for retinal detachment. a dilated fundus examination should be performed at the first examination and periodically thereafter. Common risk factors include: • history of past retinal detachment • myopia (-6 diopters or more) • open-angle glaucoma in myopic patients treated with strong miotic agents • aphakia or pseudophakia (especially the 6 months following cataract surgery). and capsulotomy (especially the 6 months following the laser procedure) • lattice degeneration • blunt ocular trauma (especially the year following the trauma) • proliferative retinopathies (e. proliferative stage of diabetes.g. branch retinal vein occlusion) • retinal detachment in fellow eye .. sickle cell.

Demarcation lines (below) indicate there is slowly progressive detachment . there may be a significant risk of detachment in the fellow eye.History of previous detachment—if the detachment is from a non-traumatic cause.

. 5% risk). stretched retina of high myopic eyes is at risk for tears (greater than 5 diopters 2% risk. greater than 10 diopters.High myopia—the thin.

which had been present for more than the 2 weeks. .A severely myopic man (-18 D) complained of seeing numerous small spots and specks in one eye. which the optometrist attributed to refractive amblyopia. About 2 weeks after the exam acuity in the eye was reduced to hand motion. Evaluation revealed a retinal detachment. Fundus exam was through an undilated pupil and was unremarkable. A retinal tear was also found in the fellow eye (-7 D). Best acuity was 20/400. No information was provided concerning the symptoms of retinal detachment or the need for a follow-up examination.

. YAG capsulotomy also creates up to a 3% risk of detachment. depending on the technique used. The 6 months following surgery is when the eye is most at risk.Pseudophakia—cataract surgery results in detachment in up to 2% of cases.

Lattice degeneration—is thinning of the retina with liquified vitreous above the retina and adhesion to the retina at the lattice margins. which can result in detachment if there are holes at the lattice margins or a tear caused by posterior vitreous detachment. .

.Open-angle glaucoma treated with strong miotics—high drug concentrations (6% pilocarpine) may cause intense miosis that leads to retinal stretching in high myopic eyes and a resultant tear.

which occurs at the ora serrata and is slowly progressive. taking an average of 4 months to involve the macula. .Blunt trauma—the most common detachment is retinal dialysis.

sickle cell.Proliferative retinopathy—diabetes. fibrosis. and ultimately a tractional retinal detachment. which results in bleeding. vein occlusion. . and other conditions cause neovascularization.

the most important type of detachment is acute onset. .For purposes of litigation. symptomatic posterior vitreous detachment.

because between 8% and 15% of cases have a retinal tear. symptomatic posterior vitreous detachment (PVD) require a dilated fundus examination. approximately one-third will develop into a retinal detachment.Patients with an acute onset. . of these.

.Retinal detachment may occur (from an incompletely separated PVD) even though no tear is found at the time of examination. the 2 months following the onset of symptoms is the most likely period for a detachment to occur.

If a patient with acute onset. Patients should not be dismissed from care until full separation of the vitreous has occurred (which can be as long as several months). . symptomatic PVD does not have a tear or detachment at the time of examination. a warning describing the symptoms of detachment must be given and the patient scheduled for a follow-up examination in 2 to 4 weeks.

Referral for retinal evaluation is necessary.A finding of vitreous hemorrhage with symptoms of acute PVD indicates there is a 70% to 80% likelihood of an underlying retinal break. .

. Handwritten entries do not need to be lengthy. but must describe the risk (“warned patient of the signs and symptoms of retinal detachment”). and the consent obtained (“patient understood and agreed”).All warnings should be noted in the patient record or documented through the use of a signed form. what to do if the risk occurs (“patient to RTC immediately for DFE if S & S occur”).

Retinal detachment involving the macula was found. A dilated fundus exam with BIO revealed PVD. but for 6 days later. with the patient averring he had not been warned of the symptoms of detachment. RTC PRN”. He called and made an appointment. alleging negligence and breach of informed consent. the doctor’s records were the key: he had written “PVD. . Seven weeks after the exam while climbing a ladder the man experienced a bright flash in the eye. At the trial.A military retiree in his 60s was examined by the base OD because of the acute onset of “spots” in one eye. A lawsuit was filed. Reassure.

Note how the doctor is trapped into admitting that telling the patient about the symptoms of retinal detachment was necessary if the PVD was incomplete. . and that failure to bring the patient back in 2-4 weeks breaches the standard of care in such a situation.

warnings and rescheduling are required • If fully separated. make it clear that any warning to the patient about the symptoms of detachment applies to a future PVD in the fellow eye .CLAP Traps • The record must reflect whether the PVD is fully separated • If not separated.

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