A Kiwi ophthalmologist has been ordered to apologise after botching a customer's $7000 laser eye surgery so badly she was left with severe headaches, migraines, and blurry and double-vision.
An investigation by the Health and Disability Commissioner (HDC) found that both the specialist and the clinic they worked for were at fault for the blunder, although both identities remain a secret.
The incident occurred in October 2017, when a woman in her 50s went into the clinic for LASIK surgery to treat her long-sightedness, an HDC report released on Monday said.
She was asked to pay the $7000, given sedatives, and then sat in a waiting area, where she signed a consent form.
When it came time to carry out the surgery, the investigation found that the ophthalmologist had selected the wrong-sized treatment pack. This meant the laser failed to slice completely through the woman's cornea, the outer layer of the eyeball that refracts light.
"At the end of the procedure, it was discovered that a small-sized treatment pack had been used instead of the medium size that was required for flap formation in the surgery," the HDC noted.
"As a result, the flap size was smaller than expected, and the laser could not complete the side cut of the flap."
The woman says since the botched surgery, she has suffered from severe headaches, double and blurry vision, and migraines. However after going to another clinic and getting approval for ACC cover, she was provided with retreatment surgery.
The HDC's investigation found that while the woman signed a consent form, the form was "rudimentary and non-specific" and didn't adequately state the risks and complications of the procedure.
It also found the ophthalmologist breached Right 4(1) of the Code of Health and Disability Services Consumers' Rights by failing to ensure the correct treatment pack was given to him before commencing the surgery, and for using the pack when it was the wrong size.
Former HDC Anthony Hill was critical that the ophthalmologist didn't abandon the procedure and allow the cornea to heal before performing the treatment later.
"[He] had overall responsibility, as the supervising ophthalmologist performing the surgical procedure, to ensure that the correct treatment pack size had been selected prior to commencing the surgery," Hill said.
The HDC was also critical that the clinic did not have any policies or procedures in place to prevent mixing up of the different size packs, or a checking process to ensure that the correct size was used for the procedure.
While the clinic is no longer operating, so doesn't feature in the HDC's recommendations, Hill recommends the ophthalmologist undertake further training on documentation and an audit of his informed consent process over the last six months.
He also urges the ophthalmologist to apologise to the woman.
The Medical Council of New Zealand and Royal Australian and New Zealand College of Ophthalmologists have been notified of the decision, and both have been told the identity of the ophthalmologist.
