A 52-year-old woman says she was left with dry eye and continued poor vision after an error was made in her laser eye treatment.

Health and Disability Commissioner Anthony Hill found the ophthalmologist failed to ensure that the correct flap measurements were programmed into the laser machine, a report released today says.

The woman was given a written apology by the ophthalmologist admitting to his wrongdoing.

After a consultation with the ophthalmologist, the woman provided written consent for the surgical treatment plan recommended to her.

The plan was to correct the left eye for long-distance vision by creating a thin flap, and to create a thick flap in her right eye and place a Kamra inlay underneath the thick flap to improve her near vision.

Instead, the nurse accidentally programmed the thick flap in the woman’s left eye.

The ophthalmologist realised the error only after surgery had begun. He stopped the surgery and took some time to consider what to do.

The ophthalmologist told Hill that he then informed the woman of the options available to her and believed he obtained her consent to proceed with the Kamra inlay in her left eye.

Hill said he was critical of the ophthalmologist for failing to ensure that the correct flap measurements were programmed into the laser machine, and for not detecting this error prior to commencing the procedure.

“The ophthalmologist discussed the change in procedure with the woman during the surgery, while she was sedated.

“The woman was not able to give adequate consideration to whether she wanted to have the Kamra inlay inserted in her left eye, and was not in a position to give her consent to the change in procedure freely.”

The ophthalmologist said Kamra inlay, which is a clear ring-shaped device intended for short vision, is placed in the non-dominant eye.

“The dominant eye is the most sensitive to distance vision blur and that the Kamra inlay does normally cause some distance vision blur.”

But the ophthalmologist argued the woman had equally dominant eyes and it wouldn’t cause any issues.

The ophthalmologist has undertaken further training on informed consent processes and effective communication, as well as the letter of apology to the woman, as recommended by Hill.

A copy of the report will be given to the Medical Council of New Zealand, the Nursing Council of New Zealand and the Royal Australian and New Zealand College of Ophthalmologists. It will also be placed on the Health and Disability Commissioner website for educational purposes.

Source: NZ Herald

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