OT poses a monthly scenario from a practitioner. This month, we look at OCT and the responsibility of missed pathology
Anne, AOP member
“I am a newly-qualified optometrist and have just started a new job at an independent practice that has an OCT. While the scans themselves are taken by support staff, I have been given training on how the technology works and have support when it comes to the analysis when I need it. However, I am still nervous about an image later revealing missed pathology. Can you share any advice on where responsibility lies if my work was later questioned?”
Peter Hampson, optometrist and AOP clinical director
Optical coherence tomography (OCT) can be a steep learning curve and many practitioners initially find this difficult as they may find themselves uncertain of what they are seeing. This is often difficult as it is a position that many practitioners will not have been in since the early part of their pre-registration year. However, the more that OCT technology is used and embraced, the easier this becomes, and there are many good resources available, including forums and discussion boards.
When we consider the review of historical images, there are effectively two situations that may arise. The first is where there is clear pathology. If the scans show clear pathology or a clear deviation from the normal appearance and no action has been taken, then you may find yourself at risk of civil or General Optical Council action. The second situation is where there is something on the scan that is either only apparent to an expert, or only becomes apparent as our understanding of the technology advances – you shouldn’t be criticised in this scenario. Although the technology has now been around for a while, OCT in optometric practice is still relatively new and we will continue to see advancements in our understanding. This may mean that with hindsight we start to see signs of disease in historical images that we are currently unaware of.
Returning to the first scenario, a common question is: What can you do to mitigate this risk? The first thing is to ensure that you review all of the images that are taken. It is also important to ensure where multiple slices have been taken, that you scroll through them all and don’t just look at whichever image is initially displayed. As most optometrists are likely aware, there has been a very high-profile case involving images that showed clear pathology, but for one reason or another were not acted upon. Therefore, it is advisable to add a note to your records stating when you have reviewed the OCT images. If the images are clear, say so. And if they are not, make a clear note of what you intend to do.
A wrong decision made with good intentions is nearly always better than no decision at all
Where the OCT scans show a clear deviation from normal, it is important that some action is taken. What is appropriate will depend upon what is visible on the scan. If you are certain about what is being shown on the scan, then you should either manage or refer the patient following the currently accepted management for the condition. Again, it is important to record this plan of action to demonstrate to fellow clinicians, or anyone else who may review the notes, what your thought process was.
If you are unsure what you can see on the OCT scan, then you should err on the side of caution. In cases where you cannot be certain what you are seeing, you should consider the potential differential diagnoses and act based upon the worst case scenario. It is advisable to make this clear in your referral. Although as professionals it is important that we do not over refer and over burden an already strained NHS, it is also important that if there is a potential risk to the patient, you act accordingly.
Nearly all of the cases that the AOP sees with regard to pathology that is visible on images are where the images haven’t been reviewed or haven’t been reviewed thoroughly. In other cases, something abnormal has been noted, but there is no record of what should happen with regard to what has been found. This is particularly difficult to defend, a wrong decision made with good intentions is nearly always better than no decision at all.
It is advisable to add a note to your records stating when you have reviewed the OCT images
In summary you should:
- Review all images carefully and record when this has been done
- Record your actions, eg further tests/monitoring/referral, or state that all is normal
- If there is any doubt, base your decision on the worst case scenario.
Image credit: Getty