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- Dec 17, 2007
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I have a 10 yo bilateral (meridional?) amblyopic patient. I'm debating whether this is a case of neglect on the part of her parents and could use some outside opinions.
The patient was first seen a little less than two years ago (by another intern). At the time, her BCVAs were 20/40 OD & OS. Being 8 yo at the time, she was referred to our pediatrics clinic to finalize her refraction and begin amblyopia treatment. Her parents did not take her to her appointment. I do not know to what degree the intern who saw her stressed the importance of the appointment, but chart notes do state the parent present was told the patient needed glasses.
Fast forward about two years and the patient is now in my chair. On the intake form, the patient's mother made a note that the patient has a mental deficit (can't remember her exact wording); more on that later. The patient's chief concern was difficulty reading; she reported having to hold materials closer to read. She reported distance vision was fine. POHx, PMHx, FOHx, and FMHx were all reported as unremarkable.
Unaided VAs were:
OD: 20/400 at distance, >20/200 at near; no improvement with pinhole
OS: >20/400 at distance, >20/200 at near; no improvement with pinhole
Entrance testing was unremarkable, though I was unable to perform confrontational fields.
Her refraction showed low to moderate hyperopia and WTR astigmatism of -5.00 OD and -7.50 OS. Ks match these findings. Her BCVAs were 20/200- OD and 20/400 OS. Ant seg health was unremarkable.
At this point, I left the room to confer with my attending before taking IOP and dilating the patient. When I returned, the mother and the patient's two siblings had left. The mother made no attempt to inform me that she was leaving. Later, I found out that she had gone to take her other two kids to school. She returned about an hour and a half later.
In the mean time, the patient became very uncooperative. I was able to instill 1% cyclopentolate and 2.5% phenylephrine, but neither I nor my attending could get her to cooperate enough to evaluate the post seg.
Once the mother returned 90 minutes later, I had the front desk schedule her for another exam in one week with the absolute condition that the mother must be present for the entire exam. We made the appointment for later in the morning so the mother could drop her other kids off at school before the exam.
Next week, the mother arrives with only one extra kid. After a quick dry refraction, I gave her 1% cyclopentolate and 2.5% phenylephrine. The mother then told me she was going to leave to take her other kid to school. I explained to her the exam would not continue until she returned. It only took her 30 minutes to return. Wet refraction roughly matched her dry refraction. I was able to examine the patient's post seg. Post seg was unremarkable and I was able to achieve a clear image of her retina.
After consulting with my attending, we prescribed her best dry refraction. We explained to her mother that her child could not see, that the patient would likely notice little difference when wearing her glasses even though the glasses were helping, and needed to be seen regularly to monitor the patient's progress. The mother was told that the patient needed to be seen one month after getting the glasses.
It's been two weeks since she picked up her glasses and the patient has no appointment on the books. Tomorrow, I plan to do my own followup and try to get the patient an appointment.
If you're still reading this, thank you!
While my case for neglect is in no way complete enough for me to make a judgement, here are my points of contention:
1. The parent disregarded instructions to care for her child's vision.
2. This led to her child's BCVAs dropping from 20/40 to 20/400.
3. The parent left the child in my care without informing me.
4. The parent appears to be disregarding present instructions to care for her child's vision.
My other concern goes back to the mother's report that the patient has a mental deficit. I had the privilege of spending 90 minutes working with just the patient. She is quick witted, choses her words carefully, and is very knowledgeable as to how to manipulate others. In my own opinion, she is at least of average intelligence and likely has potential beyond that. She just can't see. I am concerned that her parents are simply categorizing her as such because of her poor performance in school.
Does this look like a case where I should suspect neglect? If what I suspect is true, does that even qualify as neglect?
Once again, thank you for making it this far down my lengthy post.
The patient was first seen a little less than two years ago (by another intern). At the time, her BCVAs were 20/40 OD & OS. Being 8 yo at the time, she was referred to our pediatrics clinic to finalize her refraction and begin amblyopia treatment. Her parents did not take her to her appointment. I do not know to what degree the intern who saw her stressed the importance of the appointment, but chart notes do state the parent present was told the patient needed glasses.
Fast forward about two years and the patient is now in my chair. On the intake form, the patient's mother made a note that the patient has a mental deficit (can't remember her exact wording); more on that later. The patient's chief concern was difficulty reading; she reported having to hold materials closer to read. She reported distance vision was fine. POHx, PMHx, FOHx, and FMHx were all reported as unremarkable.
Unaided VAs were:
OD: 20/400 at distance, >20/200 at near; no improvement with pinhole
OS: >20/400 at distance, >20/200 at near; no improvement with pinhole
Entrance testing was unremarkable, though I was unable to perform confrontational fields.
Her refraction showed low to moderate hyperopia and WTR astigmatism of -5.00 OD and -7.50 OS. Ks match these findings. Her BCVAs were 20/200- OD and 20/400 OS. Ant seg health was unremarkable.
At this point, I left the room to confer with my attending before taking IOP and dilating the patient. When I returned, the mother and the patient's two siblings had left. The mother made no attempt to inform me that she was leaving. Later, I found out that she had gone to take her other two kids to school. She returned about an hour and a half later.
In the mean time, the patient became very uncooperative. I was able to instill 1% cyclopentolate and 2.5% phenylephrine, but neither I nor my attending could get her to cooperate enough to evaluate the post seg.
Once the mother returned 90 minutes later, I had the front desk schedule her for another exam in one week with the absolute condition that the mother must be present for the entire exam. We made the appointment for later in the morning so the mother could drop her other kids off at school before the exam.
Next week, the mother arrives with only one extra kid. After a quick dry refraction, I gave her 1% cyclopentolate and 2.5% phenylephrine. The mother then told me she was going to leave to take her other kid to school. I explained to her the exam would not continue until she returned. It only took her 30 minutes to return. Wet refraction roughly matched her dry refraction. I was able to examine the patient's post seg. Post seg was unremarkable and I was able to achieve a clear image of her retina.
After consulting with my attending, we prescribed her best dry refraction. We explained to her mother that her child could not see, that the patient would likely notice little difference when wearing her glasses even though the glasses were helping, and needed to be seen regularly to monitor the patient's progress. The mother was told that the patient needed to be seen one month after getting the glasses.
It's been two weeks since she picked up her glasses and the patient has no appointment on the books. Tomorrow, I plan to do my own followup and try to get the patient an appointment.
If you're still reading this, thank you!
While my case for neglect is in no way complete enough for me to make a judgement, here are my points of contention:
1. The parent disregarded instructions to care for her child's vision.
2. This led to her child's BCVAs dropping from 20/40 to 20/400.
3. The parent left the child in my care without informing me.
4. The parent appears to be disregarding present instructions to care for her child's vision.
My other concern goes back to the mother's report that the patient has a mental deficit. I had the privilege of spending 90 minutes working with just the patient. She is quick witted, choses her words carefully, and is very knowledgeable as to how to manipulate others. In my own opinion, she is at least of average intelligence and likely has potential beyond that. She just can't see. I am concerned that her parents are simply categorizing her as such because of her poor performance in school.
Does this look like a case where I should suspect neglect? If what I suspect is true, does that even qualify as neglect?
Once again, thank you for making it this far down my lengthy post.
