Keeping an Eye on Your Vision: A Review of Retinal Detachment

Our Leeds based Clinical Negligence department recently attended an insightful training session on negligence claims involving eye conditions delivered by the charity, Action Against Medical Accidents.

Of particular interest was the discussions centred around retinal detachment which affects 1 in 10,000 people each year in the UK. The department is instructed to act for patients in retinal detachment cases. In this article we explore what might go wrong and where, symptoms to look out for, treatment, and when treatment may be substandard.

Types of Case:

Many claims centre around delayed diagnosis of retinal detachment leading to reduced vision, or loss of vision. Other cases may involve incorrect diagnosis or substandard management of retinal detachment. Recognition of symptoms and the timing of action tend to be at the heart of these claims. It is a common retinal surgery emergency.

What is Retinal Detachment?

Retinal detachment occurs when the retina becomes loose. It must be treated quickly to prevent loss of vision. As increasing areas of the retina are detached by proliferative vitreoretinopathy scar tissue (PVR), patients suffer sight loss. It is usually suspected and diagnosed by an optometrist if you present with symptoms at an optician.

The BBC newsreader, Lucy Owen, was found to have a retinal detachment after visiting her optometrist for a sight test. For Lucy, it was a routine visit that led to the emergency referral.

Types of Retinal Detachment:

There are two types of retinal detachment, macula-on retinal detachment, and macula-off retinal detachment.

Macula-on retinal detachment occurs when the macula has not become detached. This means that there will not be a change in visual acuity, as subretinal fluid has not affected the central vision. The detachment must be operated on within 1 week.

Macula-off detachment is more severe as the macula has become detached, which is likely to involve central loss of vision. The detachment must be operated on within 24 hours.

Investigation:

An ophthalmologist will diagnose retinal detachment by undertaking the following investigations:

• Visual acuity test

• Visual field tests

• Pupillary reflexes testing (RAPD)

• Intraocular pressures investigations

• Slit lamp biomicroscopy

• Pupillary dilation and fundoscopic examination of the vitreous, optic disc and retina.

What are the causes of a Detached Retina:

A detached retina is usually caused by changes to the vitreous (jelly) inside the eye, which can occur with age. It is more prevalent in individuals who are short sighted, have recently had an eye operation such as cataract surgery, have experienced injury to the eye, or have a family history of retinal detachment. A specialist examining the eye should be alert to this and look for a retinal tear.

What are the symptoms of Retinal Detachment?

Symptoms of retinal detachment will include:

• Floaters

• Flashes

• Loss of visual field which can often be described as a 'grey curtain' that obstructs the vision

• Blurred vision

What is the treatment for Retinal Detachment?

Thee following are examples of treatment for retinal detachment:

• Scleral buckle attaching a small band around your eye

• Vitrectomy (removing and replacing the jelly inside your eye).

Moorfields Eye Hospital NHS Foundation Trust has been awarded 1.2 million by the Medical Research Council (MRC) Development Pathway Funding Scheme (DPFS) to explore a novel treatment for retinal detachment surgery complicated by PVR. This involves the use of a well-established drug to reduce or eliminate retinal scarring from PVR and reduce sight loss. Although not readily available, it is hoped to represent a welcome advance.

What issues do we see most when assessing a retinal detachment claim?

Issues of Delay in Treatment:

Macular-on retinal detachment: The progression from macular-on to macular-off retinal detachment is avoidable, and a failure to operate within the timeframe of 1 week may lead to macular-off retinal detachment and the subsequent loss of sight.

Macular-off retinal detachment: The ophthalmologist must operate within 24 hours of diagnosis to prevent escalation of loss of sight. There will be a breach of duty of care if the surgeon does not operate within this time frame.

If the macula has detached, there is a chance that even with surgery the vision may not return to the pre-detachment visual acuity.

The longer the macular detachment goes untreated, the more difficult it is to operate as scarring will stiffen the retina. If the detachment is not operated on, the patient may go blind.

It is crucial that your symptoms are correctly spotted, and that treatment is quick.

What are the elements of a retinal detachment claim?

In order to bring a successful claim for clinical negligence the Claimant must demonstrate that there has been a breach of duty (negligence) AND that it has caused some damage to their sight when compared to the position that they would be in had the correct treatment been provided in a timely fashion.

In the context of retinal detachment claims, this means that the Claimant must prove that there has been a failure to spot symptoms and refer by an optometrist, or a failure to refer, or spot symptoms, in Accident and Emergency.

An ophthalmologist (a specialist in caring for patients with eye conditions) might fail to diagnose or manage the progression of the condition.

A surgeon might fail to diagnose the retinal detachment/operate within the appropriate timescales.

If the sight returns to the pre-retinal detachment level, the claim is likely to fail. This is because the breach of duty must cause a loss of vision to the Claimant.

If you or your family member has experienced a clinical negligence issue involving retinal detachment, or any other ophthalmology issues that they would like advice on, feel free to contact a member of our Clinical Negligence Team. We have experience in an array of ophthalmology claims and would be delighted to assist you with your case.