Identifying red flag symptoms

Listen closely to the patient’s symptoms, don’t be blinkered by the given history, and “have your feelers out for red flags,” were the key takeaways of a session that delved into vitreoretinal presentations at Specsavers Professional Advancement Conference on 13 September.

Ash Sharma, consultant ophthalmologist and clinical director at Newmedica Birmingham, presented the session: The reality of VR: learning from substandard care in vitreoretinal cases to support practitioners building confidence in managing vitreoretinal presentations.

Sharma, who is a medical expert witness, delved into three real cases involving vitreoretinal conditions where patient care fell below expected standards, in order to explore the mistakes and missed opportunities.

Introducing the session, he said: “We want to know we are doing the best for all our patients, but when things go wrong, we do need to focus on how they went wrong and try to learn from that and disseminate those benefits and pitfalls.”

He added: “We need to be responsible enough to know our own weaknesses and limits. This is where we need to reflect on practice, and where practice has not been the standard we expect it to be.”

Optometrists should not be expected to know everything, he reassured, but warned that practitioners need to be careful not to expose themselves to allegations of malpractice.

Sharma said: “Nowadays we’re seeing more patients seeing optometrists for first-line emergency consultations. Your duty of care now is to pick up any red flags and refer them on if you need to or at least start treatment specifically within your area of expertise.”

There are several aspects to the making of a clinical negligence case, Sharma outlined: there must be a duty of care, this care must have fallen below the standard expected from a responsible body of clinicians, and damage to the claimant’s health must have occurred as a result of the breach of care.

Ask: What are the red flags?

The first of the three cases presented by Sharma was of a young male contact lens wearer who complained of a something in his eye and a watering sensation. The patient was also a high myope.

Delegates looked at additional information around this case presentation and what tests were carried out.

Sharma explained that, in this case, the pre-registration optometrist providing the examination likely made assumptions that the blurry vision was caused by the watering eyes, and that differentiation of temporary, intermittent or permanent blur was not explored.

In a discussion on the case, Sharma pointed out that while the complaint was of a foreign body, this was not necessarily what the patient was describing: “It’s very subtle to pick out – is the patient describing a floater or do they actually feel the sensation of a foreign body?”

“Don’t be blinkered by the patient telling you: ‘I’ve got something in my eye,’” Sharma said, calling this a “pitfall.”

He emphasised: “Always consider all the other options for this patient.”

In this case, listening closely to the patient and questioning them directly on their exact concerns would have alerted clinicians to the red flag symptom of a fresh floater, he suggested.

Sharma drew attention to the importance of record keeping as in this case, no visual acuity was performed, the exam was limited to anterior slit lamp of the right eye only, and there was no evidence that a supervisor had reviewed the OCT or provided input into the management.

Taking an overview of the case and the level of examination required, Sharma encouraged delegates: “Do consider what the red flags are here: a high myope, with a floater in his eye.”

OCT scans “quite clearly” showed the retina detaching involving the macula, he said, making an urgent referral to the eye hospital necessary.

Retinal detachment occurs in one in 10,000 in the population. Most are caused by middle-aged changes where the vitreous pulls on the retina, Sharma said.

Risk factors in this particular case were the high level of myopia in the patient and his symptom of floaters.

Sharma explained that if a patient has had lens surgery and is therefore no longer myopic, this presents an even-greater risk factor because “having had surgery predisposes a vitreous to detachment at an earlier stage.”

Considering the referral and treatment for these cases, Sharma said that if the macula has become involved, the urgency is within four to five days.

If the macula is on and vision is normal, Sharma emphasised: “Get them seen on the same day or within 24 hours to make sure you protect the macula because the risk of losing sight is very high.”

Ask: How long was the vision blurred for?

The second case saw a patient who presented to a practice for the first time for a sight test. The patient was last examined three years previously where a reduction in vision had already been documented but with no pain, redness or trauma.

The patient had previously had cataract surgery seven years earlier and soon afterwards experienced a stroke but fully recovered.

In this case, the OCT was the key “giveaway” showing a full-thickness macular hole.

Though this may have gone back several years, Sharma said it is “still opportune to try and get the hole closed.”

“The success rate and the final visual outcome is not going to be as good as if she was operated on within a matter of months, but it actually gives them a little bit more stereovision if you manage to close the hole and avoid that blank scotoma in the central field,” he said.

It would have been in the best interest of the patient to make a “speedy referral,” Sharma said, adding: “We prioritise macular holes.”

If an optometrist sees a patient with an unknown cause for visual loss, Sharma recommended going ‘back to basics’ and following an algorithm to determine what steps to take.

The first step is to determine if it is monocular or binocular vision loss, and then to assess whether there is any pain.

The third step would be to take a targeted history, asking further details about onset, ocular and systemic symptoms, and medical history.

Practitioners should then perform a focused examination and identify red flags, before taking action by referring or starting initial management.

Macular hole classification shows that the early stages have a very good outcome in surgical treatment, Sharma explained, with prognosis depending on presenting vision, the size of the hole, and how quickly the patient can receive surgery.

Sharma said: “The incidence is not huge, but they are there. They are more common in females and 60-70 is the age range for picking up these patients with macular holes.”

If a patient chooses to decline the referral or not to go ahead with surgery, they should always be warned that there is a 10% risk to the fellow eye and that they should be alert to any signs of distortion or scotoma in the fellow eye.

Ask: Am I able to see what I need to see?

The third case focused on a 60-year-old woman complaining of worsening vision in distance and near over a period of a few weeks to months, and particular difficulty in driving at night.

The patient was last seen two-and-a-half years ago, has a family history of glaucoma and has hormone replacement therapy.

Sharma highlighted that the key aspects to focus on in this case were the fundus findings and reminded practitioners to consider: “Am I able to see as much as I need to see?”

This was a case of birdshot chorioretinopathy and while Sharma acknowledged this was a rare and “esoteric” example, he suggested this encapsulated his key messages: “Am I listening to the symptoms of the patient? Am I putting them into context? Am I doing the remit that I’m supposed to do, which involves the back of the eye and vision check?”

In this case, abnormal retinal signs were not spotted and acted upon, and record keeping did not reflect the clinical imaging.

Findings in this case indicated irregular subretinal pale lesions as well as irregular vessels and vascular leakage.

Sharma told delegates: “Be wary that these are rare signs in patients with posterior uveitis who then need onward specialist referral.”

Night vision problems are a “classic” feature of posterior uveitis, Sharma said, but pointed out: “You may not get anything in the anterior chamber, in the pupil or the white of the eye. You will only see a subtle collection of vitreous cells and subtle areas in the choroid.”

“At presentation, these signs may not be there. You may get the story of night vision problems, or floaters, but the examination may be negative the very first time they present,” he flagged.

Wrapping up the session, Sharma told delegates: “If you’ve done all those checks on vision. If you’ve examined and recorded what the optic nerve and macula look like. If you’ve consulted with your supervisor and you’ve ruled out all the red flags – generally you will be absolutely fine.”

“You do not get sued for an error of judgement if you took the time and patience to examine the patient,” he said.