Articles and Case Studies

Inadequate History

11 Dec 2012

This case study highlights the consequences of inadequate history-taking.

Case History

A 50 year old executive had noticed blurred vision in recent months. However, as he had been working long hours, he thought he was simply tired. When the patient’s visual problems did not abate, his GP suggested an ophthalmic review.

The ophthalmologist first saw the patient on 16 September 2010. He briefly glanced at the letter of referral and took a history of the patient’s vision becoming increasingly blurry over the past few months. The ophthalmologist noted the patient was wearing glasses and asked if he was still finding them helpful. Although the patient said that his current glasses were partially effective, unlike his previous glasses, he said “they made his eyes do strange things”. On examination, the ophthalmologist noted the patient had moderately advanced cataracts with vision in the right eye being 6/18 and the left eye 6/9 part.

In the circumstances, the ophthalmologist advised the patient that surgery to remove the cataracts and implantation of intraocular lenses would need to be considered to improve his visual acuity. The patient said that he would like to be free of glasses following the cataract surgery, especially since he had always found glasses uncomfortable and difficult to wear.

The ophthalmologist discussed the general principles of cataract surgery with the patient and said that the operation would be performed under local anaesthetic in the local day surgery. He then described how the surgery would be performed and explained post-operative review and eye care to the patient.

Further, the ophthalmologist advised that he would only operate on one eye at a time and that he preferred patients to wait at least 1-2 weeks before operating on the second eye. He informed the patient that if he recovered well from the first operation, he would consider operating on the second eye two weeks later.

The ophthalmologist then discussed the risks associated with cataract surgery, including the risk of loss of vision (from complications such as bleeding into the eye, inadvertent damage to the anterior segment, dropped lens into the vitreous, postoperative infection, etc.). He then spent some time talking to the patient about intraocular lens options to correct his vision. The ophthalmologist explained that a standard monofocal lens would enable him to see clearly for distance without glasses, but that he would need glasses for reading. Monovision could be considered, in which case the dominant eye would be corrected for distance and the non-dominant eye under-corrected to allow him to read at near. The ophthalmologist stressed that even in this situation, reading glasses may be required at certain times.

However, if the patient wanted to be spectacle independent, the ophthalmologist advised he may wish to consider having a ReSTOR lens inserted as most patients do not need glasses post-operatively for near tasks. The ophthalmologist informed the patient that if he elected to have a ReSTOR lens, “touch up” refractive surgery could always be performed if any aspect of the patient’s postoperative vision needed to be “tweaked”. The ophthalmologist then informed the patient that some patients did not cope well with ReSTOR lenses as they were at risk of experiencing glare, blur and decreased contrast sensitivity for distance vision.

As the patient hoped the surgery would render him spectacle independent, he told the ophthalmologist that he wished to have a ReSTOR lens inserted. After the consultation, the patient saw the ophthalmologist’s secretary and booked for surgery.

On 4 October 2010, the patient underwent a left cataract extraction and insertion of a ReSTOR intraocular lens.

The ophthalmologist reviewed the patient the following day (5 October 2010) and noted the vision in the left eye was 6/6 -1. He gave the patient instructions in relation to eye care and the instillation of drops and arranged to review him in one week. The patient returned for review on 12 October 2010 at which time his left eye showed uncorrected vision of 6/6.

In the circumstances, as the ophthalmologist considered the patient’s cataract surgery had been successful, he arranged to perform cataract surgery on the second (right) eye in one week.

On 27 October 2010 the ophthalmologist inserted a ReSTOR lens in the patient’s right eye. The surgery was uncomplicated and proceeded without incident.

When the patient returned for review on 28 October 2010, the ophthalmologist noted that he had a good post-operative visual acuity of 6/6 in each eye, and was healing well. The ophthalmologist gave instructions to the patient in relation to post-operative eye care and the use of eye drops.

On 4 November 2010 the patient returned to see the ophthalmologist for review before leaving on an overseas trip. The patient’s visual acuity was 6/6 and at near he read N6 print clearly.

In February 2011, the ophthalmologist received a letter from the patient’s solicitor, alleging that he had been negligent in inserting the ReSTOR lenses in circumstances where it should have been clear that the patient was unable to tolerate multifocal lenses and that he had failed to warn the patient of the risks associated with multifocal lenses. The letter also alleged that if the patient had known that a ReSTOR lens was a multifocal lens, he would have elected to have monofocal lenses inserted. It concluded by stating that the patient would be making a claim against the ophthalmologist.

The ophthalmologist immediately reviewed the clinical records and noted the patient had said his eyes “did strange things” when he had trialled a new pair of glasses. The ophthalmologist recalled that he had not explored this with the patient. He then reviewed the letter of referral from the patient’s GP, noting that it stated the patient was “unable to tolerate multifocal glasses as he experienced halos and glare when driving at night”. When the ophthalmologist reviewed the remainder of his file, he observed that nowhere did his procedure-specific ReSTOR consent form also refer to it being a “multifocal lens”.

The claim was settled prior to court proceedings being commenced.


The predominant issue in this case was one of inadequate history-taking and the ophthalmologist’s failure to 1. properly read the letter of referral and 2. explore what the patient had meant when he said his eyes had done “strange things” when he had trialled a new pair of glasses.

General Practice, Ophthalmology


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