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NZ Ophthalmologist forced to apologise after surgical error

The New Zealand Health and Disability Commissioner has ordered an ophthalmologist to apologise for a botched laser eye surgery that left a 52-year-old woman with dry eye and continued impaired vision.

According to a report in the New Zealand Herald, the error occurred when the ophthalmologist failed to confirm that proper flap measurements had been programmed into the laser machine by the assisting nurse.

The doctor has issued a written apology to the woman for the error, and undertaken training on informed consent processes and effective communication on orders from Health and Disability Commissioner Anthony Hill.

The original surgical plan was to correct the woman’s left eye for long-distance vision by creating a thin flap, while a thick flap in the right would have a Kamra inlay placed underneath it improve her near vision. However, the nurse accidentally programmed the settings for the thick flap in the left eye – an error the ophthalmologist only realised after the laser surgery has already started.

After considering his options, the ophthalmologist said he informed the woman of the mistake and her options, and believed she had given consent to proceed with the Kamra inlay in the left eye.

The ophthalmologist argued the patient had equally dominant eyes and the procedure would not cause issues.

However, despite this explanation Hill was critical of the ophthalmologist’s failure to double-check the programmed measurements before conducting the procedure.

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

“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.“

A copy of the commissioner’s report has been provided to the Medical Council of New Zealand, RANZCO and the Nursing Council of New Zealand, while it is also available on the commissioner’s website.


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