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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. . a dilated fundus examination must be performed.If a patient presents with symptoms indicative of retinal detachment.

He told the patient she had a PVD and described the symptoms of retinal detachment. About 4 months later she suddenly began seeing light flashes in the eye. The optometrist found acuity in the eye to be 20/20 and observed no pathology when examining the posterior pole through an undilated pupil. .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. and a retinal exam revealed detachment affecting the macula.

g.. a dilated fundus examination should be performed at the first examination and periodically thereafter. and capsulotomy (especially the 6 months following the laser procedure) • lattice degeneration • blunt ocular trauma (especially the year following the trauma) • proliferative retinopathies (e.For asymptomatic patients who are at risk for retinal detachment. sickle cell. proliferative stage of diabetes. 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). branch retinal vein occlusion) • retinal detachment in fellow eye .

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.

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

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

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

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

.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. .Blunt trauma—the most common detachment is retinal dialysis. taking an average of 4 months to involve the macula.

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

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

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

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.

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

. 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. what to do if the risk occurs (“patient to RTC immediately for DFE if S & S occur”). .All warnings should be noted in the patient record or documented through the use of a signed form. but must describe the risk (“warned patient of the signs and symptoms of retinal detachment”). and the consent obtained (“patient understood and agreed”).

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

and that failure to bring the patient back in 2-4 weeks breaches the standard of care in such a situation. .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.

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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