Download the discipline committee of the college

NOTICE OF PUBLICATION BAN
In the College of Physicians and Surgeons of Ontario and Dr. Roger Cyril Wales, this is
notice that the Discipline Committee ordered that no person shall publish or broadcast the
names and any information that could disclose the identity of patients referred to orally or
in the exhibits filed at the hearing under subsection 45(3) of the Health Professions
Procedural Code (the Code), which is Schedule 2 to the Regulated Health Professions
Act, 1991.
Subsection 93(1) of the Code, which is concerned with failure to comply with these
orders, reads:
Every person who contravenes an order made under … section 45 or 47… is
guilty of an offence and on conviction is liable,
(a) in the case of an individual to a fine of not more than $25,000 for a
first offence and not more than $50,000 for a second or subsequent
offence; or
(b) in the case of a corporation to a fine of not more than $50,000 for a
first offence and not more than $200,000 for a second or subsequent
offence.
Indexed as:
Ontario (College of Physicians and Surgeons of Ontario) v.
Wales, 2015 ONCPSD 1
THE DISCIPLINE COMMITTEE OF THE COLLEGE
OF PHYSICIANS AND SURGEONS OF ONTARIO
IN THE MATTER OF a Hearing directed
by the Inquiries, Complaints and Reports Committee of
the College of Physicians and Surgeons of Ontario
pursuant to Section 26(1) of the Health Professions Procedural Code
being Schedule 2 of the Regulated Health Professions Act, 1991,
S.O. 1991, c. 18, as amended.
B E T W E E N:
THE COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO
- and DR. ROGER CYRIL WALES
PANEL MEMBERS:
DR. C. CLAPPERTON (CHAIR)
D. DOHERTY
DR. J. WATTS
P. GIROUX
DR. C. LEVITT
Hearing Dates:
Decision Date:
Release of Written Reasons:
January 27 to 30, 2014
January 14, 2015
January 14, 2015
PUBLICATION BAN
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DECISION AND REASONS FOR DECISION
The Discipline Committee (the “Committee”) of the College of Physicians and Surgeons
of Ontario heard this matter at Toronto on January 27 to 30, 2014. At the conclusion of
the hearing, the Committee reserved its decision on finding. There was extensive
evidence including patient charts, expert reports, as well as other documentary and
physical evidence. After a thorough consideration of all evidence, including the testimony
of the witnesses, the Committee releases its decision and reasons for decision.
ALLEGATIONS
The Notice of Hearing alleged that Dr. Roger Cyril Wales committed an act of
professional misconduct:
1.
under paragraph 1(1)2 of Ontario Regulation 856/93 made under the Medicine Act,
1991 (“O. Reg. 856/93”), in that he has failed to maintain the standard of practice of
the profession.
The Notice of Hearing also alleged that Dr. Wales is incompetent as defined by
subsection 52(1) of the Health Professions Procedural Code, which is Schedule 2 to the
Regulated Health Professions Act, 1991, (the “Code”), in that his care of patients
displayed a lack of knowledge, skill or judgment of a nature or to an extent that
demonstrates that he is unfit to continue to practise or that his practice should be
restricted.
RESPONSE TO THE ALLEGATIONS
Dr. Wales denied the allegations of professional misconduct and incompetence in the
Notice of Hearing.
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Background
The Issues
The issues to be decided by the Committee in this matter area as follows:
1) Standard of practice – Has the College established that Dr. Wales failed to maintain
the standard of practice of the profession in his clinical care of patients, specifically in
the area of:
i) the use of finger tonometry to measure the intraocular pressure in the eye,
ii) the age of the patients on whom he tested the pressure,
iii) his failure to dilate the pupil to better examine the fundus (posterior eye),
and
iv) his failure to use cycloplegic (paralyzing) drops to better examine
children’s eyes.
2) Has the College established that in the care of patients Dr. Wales displayed a lack of
knowledge, skill or judgment of a nature or to an extent that demonstrates that Dr.
Wales is unfit to practise or that his practice should be restricted?
The Evidence
The Committee heard testimony from two ophthalmologists who were called by the
College and who were accepted by the Discipline Committee as qualified expert
witnesses. Dr. Wales did not call an expert witness, but did testify himself. The exhibits
filed included: a joint book of documents containing 26 patient charts from a s.75
investigation and the record of a complainant reviewed by Dr. Y; charts of 7 patients
observed by Dr. X in a s.75 investigation; a supplementary joint book of documents
containing OHIP information and details about eye examinations from the OHIP
Schedule of Benefits; an expert brief from Dr. X containing his reports on the 7 patients
encounters he observed; an expert brief from Dr. Y containing his reports on Dr. Wales
and after his more detailed review of 7 of the 26 patient charts from the s.75 investigation,
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emails from Dr. Wales; curriculum vitae of the witnesses, photographs of ophthalmic
instruments, guidelines, and journal articles.
Outline of Decision
i)
Applicable legislation, legal principles
ii)
Witnesses’ relevant experience and career history
iii)
Evidence from each of the witnesses relating to the allegations
iv)
Review of the patients
v)
Findings and summary
Applicable Legislation and Legal Principles
i) Burden and Standard of Proof
The College has the burden of proving an allegation of professional misconduct and/or
incompetence against a member. The requisite standard of proof is on a balance of
probabilities and the evidence must be clear, cogent and convincing.
ii) Standard of Practice
A failure to maintain the standard of practice of the profession is an act of professional
misconduct under section 1(1)2 of O. Reg. 856/93, made under the Medicine Act, 1991,
S.O. 1991, c.30.
The standard of practice has been defined as the standard expected of the ordinary,
competent practitioner in the member’s field of practice. It is not necessary to find that
there has been harm in order to find there has been a failure to maintain the standard of
practice.
The Committee understands that the standard of practice may be established on the basis
of the evidence of experts, publications from the College, the teachings of medical
students and residents, the evidence of what Ontario practitioners actually do in their
practice, and guidelines and articles published in particular areas of practice.
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iii) Incompetence
To make a finding of incompetence under s.52(1) of the Code, the Committee must be
satisfied that the member’s professional care of a patient displayed a lack of knowledge,
skill or judgment of a nature or to an extent that demonstrates that the member is unfit to
practise or that his or her practice should be restricted.
Incompetence differs from professional misconduct in that a finding of professional
misconduct will be based on events that occurred in the past. Incompetence is assessed
based on the member’s care of patients in the past, but the Committee must be satisfied
that the member is currently incompetent in order to make a finding of incompetence.
Overview of the Evidence
The Committee examined and weighed the evidence of the witnesses in its determination
of whether Dr. Wales committed an act of professional misconduct and is incompetent.
Both expert witnesses were highly critical of the care provided by Dr. Wales. There were
a number of recurring concerns that were raised by Dr. X and Dr. Y with respect to Dr.
Wales’ care and treatment of 7 patients observed by Dr. X and the 26 charts examined by
Dr. Y. Prior to engaging in an analysis of the individual cases, the Committee sets out, in
general terms, Dr. X’s and Dr. Y’s testimony, and Dr. Wales’ evidence with respect to his
GP refraction practice. Whether, or not, Dr. Wales failed to maintain the standard of
practice of the profession was analyzed in the individual cases, based on the application
of the standard of practice and the particular facts of each case. Whether, or not, the
College established that Dr. Wales committed an act of professional misconduct or is
incompetent is considered on the basis of all the evidence.
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Witnesses
Dr. X
Dr. X is an ophthalmologist who graduated from University of Toronto in Medicine in
1965. After obtaining his specialist’s certification in 1971, Dr. X had hospital affiliations
in various Toronto hospitals up until 2012. He was an assistant professor at the University
of Toronto, where he lectured medical students and taught ophthalmology residents. He
continues to be an honorary consultant in the Department of Ophthalmology at the
Hospital for Sick Children. In the past, he has been a staff surgeon performing cataract
surgery at an eye clinic and until recently he practised at another clinic where his practice
was predominately cataract related with a sub-interest in glaucoma. For the last year, he
has worked one day a week in Barrie, where he sees referrals, the majority of which are
assessments for glaucoma.
The Committee accepted Dr. X as an expert in how to conduct appropriate eye
examinations and in the risks for glaucoma.
Dr. Y
Dr. Y graduated from the University of Toronto Medical School in 1979 and obtained his
specialist certification in ophthalmology in 1984. He has a private practice in Kitchener
and considers himself a general ophthalmologist who sees a wide range of problems, with
the most common problems being glaucoma, macular degeneration, cataracts, and eye
infections. His practice is referral based and he does not do surgery.
Since 2009, Dr. Y has performed approximately 62 peer assessments for the College.
Four of those assessments were of refracting general practitioners, the same category of
practitioner as Dr. Wales, while the others were ophthalmologists. Dr. Y was accepted by
the Committee as an expert in glaucoma and in conducting eye examinations.
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Dr. Wales
Dr. Wales is a 74 year old General Practitioner (GP) refractionist in solo practice in the
Kingston area. Dr. Wales graduated from medical school at the University of London in
1961. After a year of internship, he became a lecturer in physiology and “moonlighted” in
general practice in the evenings. He left the United Kingdom in 1965 to do research at
Johns Hopkins as a post-doctoral fellow. He was also appointed as an assistant
ophthalmologist to the outpatient department at Johns Hopkins. While in the United
States (USA), he passed the Educational Commission for Foreign Medical Graduates
(ECFMG) exams and did not have a clinical practice. He was in the USA from 1965 to
1969. In early 1970, he came to Canada and became a member of the College of
Physicians and Surgeons of Ontario in 1972, when he began clinical work. From 1971 to
1975, Dr. Wales worked at Queen’s University in the Department of Physiology and
Ophthalmology doing work relating to intraocular fluid dynamics. At the time of the
investigation, Dr. Wales had three offices where he has limited his practice to performing
eye examinations – one in Kingston behind the Hakim Optical Store, a second in
Napanee attached to an optician, and a third in Picton adjacent to an optician.
Issue #1 - The use of finger tonometry instead of applanation tonometry to measure
intraocular pressure
Dr. X’s Evidence
Dr. X was appointed on October 19, 2011 as a Medical Inspector by the Inquiries,
Complaints and Reports Committee of the College to investigate the care and treatment
provided to patients by Dr. Wales, including the measurement of intraocular pressure. He
observed Dr. Wales’ care of 7 patients in Kingston at his office in the Hakim Optical
store in November 2011.
During his testimony, Dr. X outlined the essential components of an eye examination,
from his experience, and from the guidelines published in 2006 in the Canadian
Ophthalmological Society (COS) Clinical Practice Guidelines for Adults in Canada, and
these included, in brief:
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i)
History, especially history of ocular and systemic medical history and family
history of eye disease, gender, race (some races have a predisposition to
glaucoma), chief complaint, driving status, current medication, allergies.
ii)
Measure and record vision with and without glasses, near and far, with or
without refraction, including the central vision at the back of the eye and the
peripheral or side vision.
iii)
Physical examination of the eye, including a slit lamp examination, and a
general inspection, muscle balance testing (to check for strabismus or crossed
eyes), checking the pupils and whether or not their reactions are normal.
iv)
Tonometry- the measurement of the pressure of the fluid in the eye.
v)
Dilation of the Pupils- to look at the inside of the eye, especially the back of
the eye at the optic nerve head, the optic disc and the fovea.
Dr. X testified that refraction is the process of determining whether or not there is an
optical error in the eye such that the person is not able to see clearly. Refraction is
performed to see whether the patient is far-sighted or short-sighted, or whether they have
astigmatism, which is a difference in the curvature of the eye. Dr. X testified that there
were many ways to perform refraction, but the standard way is to have the patient sit in
front of a phoropter, a machine to measure vision. Using a retinoscope, which is an
instrument which shines a light into the eye, it can be determined if there is near or farsightedness, or astigmatism.
Tonometry is the measurement of the pressure of fluid inside the eye, according to Dr. X.
He testified that there is a significant relationship between the level of intraocular
pressure and the development of glaucoma, thus, it is important to measure the
intraocular pressure.
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Dr. X testified that glaucoma is a group of conditions derived from two sub-groups, open
and closed angle. Glaucoma is an optic neuropathy in which raised intraocular pressure is
the most important risk factor and can threaten sight. The treatment of glaucoma varies
according to whether it is open or closed angle. Open angle glaucoma is the most
common type and it is asymptomatic until the late stages because people can manage
with significant amounts of reduced peripheral vision. When the central vision is
affected, it becomes symptomatic. Dr. X testified that if it is detected early, before there
is significant visual field and optic nerve damage, it is controllable with drops, although
not reversible.
According to Dr. X, intraocular pressure measurement is absolutely essential for an
assessment of whether the patient is at risk for glaucoma. The test is typically done after
the eye is anesthetized. Other than perhaps a small tingle when the anesthetic drops are
instilled in the eye, the patient feels nothing and the effect of the drops wears off after
about 15 minutes, he said. The test is an easily performed test, if it is done properly, and
provides an accurate numerical measure of the pressure. Thus, it provides a baseline for
follow-up and a number that is easily communicated to another physician. Dr. X testified
that finger tonometry gives only an impression of the pressure in the eye. He is not aware
of any literature supporting finger tonometry as part of a general examination of the eye.
Dr. X testified that in order to check for intraocular pressure, a device called an
applanation tonometer is used, which is a small disc attached to a machine that impresses
the cornea from the front of the eye and measures the pressure indirectly. There are
various types, including some using anaesthetic and some without, and some with a puff
of air, he explained. Dr. X testified that applanation tonometry is inexpensive, easy to
use, and has been the “gold standard” for the last 50 years. Dr. X outlined some of the
factors affecting accuracy and reliability of the procedure. Despite some of those
variables, it is the technique nonetheless that is used in studies and is most reliable.
Dr. X testified that the use of finger palpation to measure intraocular pressure has been
discredited over the last 50 to 100 years and plays no role in regular eye examinations at
10
the relevant times in this case and today. He explained three rare instances where finger
palpation of the eye would be used.
Dr. X stated that some of his patients have glaucoma with low pressure readings. Other
patients have higher pressure readings and no sign of the advancement of glaucoma over
a 30 year period. Some glaucoma patients do not have high intraocular pressure at all.
Therefore, he is not certain what an exact normal pressure reading would be. Dr. X
testified that it was nevertheless important to follow these patients, as they may show
signs of glaucoma later. The earlier they are detected the better, because glaucoma is
controllable if detected early. He stated that it is important to have a baseline
measurement to follow over the years.
Dr. X testified that the determination of intraocular pressure is the key risk factor, the
most important risk factor, in the detection, development, progression and the response to
treatment of glaucoma. 97% of patients are not going to develop glaucoma. He said that
the public demands more than an assessment. When the ability is there to actually
measure the pressure, as it has been for 50 years, patients want to know the number, not
an impression of what the number is. By way of illustration, Dr. X testified that he would
not accept it if someone told him based on his appearance and his pulse, he probably had
normal blood pressure. He would not want someone to “assess” his blood pressure, but
would want his blood pressure measured.
Dr. X in his testimony read from the COS Clinical Practice Guidelines for the
Management of Glaucoma in the Adult Eye. In its recommendations, Dr. X explained
that structural measures of examination would include intraocular tonometry and looking
at the optic nerve and the anterior chamber angle of the eye to see if it is open or closed.
Functional examinations would entail more comprehensive examinations, including
visual field tests, which would not be done in a primary care situation, but would be done
in an ophthalmologist’s office.
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One of the statements in the same document read: “Screening for IOP—intraocular
pressure alone should be avoided since it has low sensitivity, low specificity, and poor
predictive value for the detection of glaucomas.” Dr. X testified that this statement did
not mean that intraocular pressure should not be measured. Instead, it means that
intraocular pressure by itself, without the risk factors and without observing the optic
nerve carefully, would have a low yield.
Dr. Y’s Evidence
The documentary evidence filed showed that in November 2009, Dr. Y, an
ophthalmologist, was asked to review the care of a single complainant as well as 26
patient charts from a s.75 investigation and provide separate reports. He reviewed the 26
charts; one had a photocopy error and no information, resulting in a review of 25 charts.
He wrote his first report before he looked at the chart of the original complainant. Dr. Y
agreed in testimony that he concluded in his initial report that Dr. Wales met the standard
of practice and did not display a lack of knowledge, skill or judgment. However, Dr.
Wales recorded intraocular pressure as “nTn”, and Dr. Y recommended that the
intraocular pressure should be recorded as a numeric value for each eye, rather than
simply a “normal” notation for each eye.
When asked about his concerns about the care of the complainant patient, Dr. Y testified
in chief that there were two issues. The first issue was Dr. Wales’ failure to diagnose the
patient’s cataract. Dr. Y testified that the patient’s complaint was not valid in this respect.
It was not a failure to maintain the standard of practice to fail to make this diagnosis in
the circumstances of this patient. He testified in relation to this aspect of the complaint
that Dr. Wales did meet the standard.
The second issue was Dr. Wales’ notation of “nTn” in the patient’s chart. Subsequently
on reviewing the complainant’s chart and related material, Dr. Y testified that he
discovered that Dr. Wales “nTn” notation referred to finger palpation of the eye, and did
not mean that intraocular pressure was measured by an applanation instrument that
provides a numerical value. Dr. Y testified that the idea of doing finger palpation never
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occurred to him, as it just seemed too absurd. He did not think of that possibility. In this
patient, he testified that the failure to use applanation tonometry to measure intraocular
pressure constituted a failure to maintain the standard of practice.
Dr. Y also testified that if Dr. Wales said it was not necessary to perform a measurement
of pressure because intraocular pressure is not determinative of glaucoma since some
people with glaucoma never have high intraocular pressure and some people with high
intraocular pressure do not get glaucoma, he would disagree with the statement. Dr. Y
testified that measurement of intraocular pressure may increase suspicion for glaucoma.
He said that intraocular pressure measurement is often not diagnostic of glaucoma, but it
is an important risk factor, and depending on the pressure, it may influence
recommendations for follow-up and care. Dr. Y did not agree that measurement of
intraocular pressure was invasive.
Dr. Y testified that the use of the finger to measure the pressure in the eye is inaccurate
and inconsistent. A tonometer gives a value rather accurately and consistently and with
repeatability, he said. It is generally always measured by those who do oculo-visual
assessments as part of their practice. In his report of October 10, 2010, Dr. Y said that in
his encounters for consultations or referrals with other ophthalmologists, optometrists and
refracting general physicians, intraocular pressure is measured numerically. In his peer
assessments of general physicians specializing in eye care, he has not encountered a
physician who does not record a numerical value for intraocular pressure. In the same
report, he also commented that the present lesser role of intraocular pressure
measurement in the diagnosis of glaucoma may cause some confusion, but it does not
imply that a lesser level of accuracy is recommended for its measurement.
In his testimony, Dr. Y outlined the components of a primary care eye examination such
as those expected of Dr. Wales. They were similar to those outlined by Dr. X. However,
Dr. Y also confirmed that the OHIP Schedule of Benefits defined the elements as well
and they are similar to those noted above, history, physical examination of the eye, slit
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lamp examination of the anterior segment of the eye, using an ophthalmoscope,
tonometry and refraction, including the provision of a prescription, if required.
Dr. Y also indicated that generally, intraocular pressure should be measured at every
patient visit. He qualified this to say that intraocular pressure should be measured at every
periodic eye examination and that if the patient is seen more frequently than once a year,
intraocular pressure measurement may not be necessary at all visits, depending on the
clinical situation.
Dr. Y indicated that digital tonometry was used very occasionally in settings not in the
realm of primary care, when tonometry would not be possible, or would be greatly
inaccurate. Dr. Y stated that as a minimum for glaucoma risk evaluation in primary care
examinations, he would expect documented measurement (not palpation) of the
intraocular pressure and documented evaluation of the optic discs.
Dr. Y testified that he changed his conclusions regarding Dr. Wales and found that he did
not meet the standard of practice of the profession and that he displayed a lack of
knowledge, skill and judgment. Dr. Y said that Dr. Wales used an inappropriate method
of tonometry, which may reflect a lack of skill. It does reflect a lack of knowledge in the
role of measuring intraocular pressure. Judgment is deficient by his use of an
inappropriate method. Glaucoma may damage the vision and therefore there is a risk of
harm in the potential delay in diagnosis. Patients leave the appointment with a false
reassurance that their eye examination is thorough and complete with no concerns noted.
Dr. Y added a more thorough examination of other aspects of Dr. Wales care as noted
below in subsequent sections of this decision, but he said in testimony that Dr. Wales’
failure to do applanation tonometry was in itself a major deficiency.
Dr. Wales’ Evidence
Dr. Wales testified that he was taught digital (finger) tonometry 54 years ago in 1960
when he was a medical student. It is a surgical procedure, he said. Dr. Wales testified that
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he tests the intraocular pressure at the end of the eye examination. Fifty years of
experience measuring intraocular pressure helps him to interpret the pressure and if he
has any doubts, he measures the pressure using a machine. That intermittent validation
gives him feedback and he is inevitably accurate in his assessment, he said. Dr. Wales
also pointed out that 95% of patients have normal intraocular pressure and he has a lot of
experience feeling what normal is.
He uses the applanation tonometer in instances where his clinical evaluation suggests that
the pressure may be raised or when there are other risk factors present.
Dr. Wales read a portion of the COS Guidelines for Glaucoma:
“Digital (finger) tonometry may be useful to estimate whether IOP [intraocular
pressure] is very high, normal, or very low in certain situations, (such as eyes with
flat anterior chambers, [lens - cornea touch], eyes with keratoprosthesis).”
Ex.9, p 14
Dr. Wales went on to explain that the statement is a physical fact, that is, digital
tonometry can estimate whether the pressure is very high, normal or very low. The
circumstances under which it is used applies to tertiary care. He went on to say that it can
be applied equally well as a statement of physical fact to primary care, that is, his area of
practice. In cross examination, he stated that it is a “time-honoured surgical skill.” Dr.
Wales testified that because it is a technical examination, it is outside the scope of
practice for optometrists to use a surgical skill of finger palpation to measure the
intraocular pressure. Dr. Wales testified that he was “ahead of his time” in his intellectual
understanding of glaucoma and its prevention.
Dr. Wales testified that he thought the numerical value obtained by applanation
tonometry was of limited value. Dr. Wales agreed that he told the College investigators
on one occasion that intraocular pressure is not relevant in definition, risk or diagnosis of
glaucoma. He said in his testimony that intraocular pressure does speak to risk but it does
not speak to diagnosis.
15
Dr. Wales read from another portion of the COS Guidelines stating, in brief, that until
recently glaucoma was diagnosed by elevated intraocular pressure, optic nerve cupping
and visual field damage. Up to 50% of patients have normal intraocular pressure and
some patients with high intraocular pressure never develop glaucoma. Dr. Wales testified
that the significance of the statement is that if you rely entirely on the numerical pressure
to diagnose glaucoma, you will cover up more cases of glaucoma than you will uncover.
The emphasis now is on optic nerve cupping, he said.
In cross examination, Dr. Wales testified that the COS Guidelines recommend against
doing routine applanation tonometry for screening. It was his understanding that it should
not be used. He outlined that when he would use applanation tonometry and that includes
in patients with a family history of glaucoma, who are on glaucoma therapy, are over the
age of 40, of a particular race, or if he suspects that the pressure is within the ranges of
upper normal or above. He only does applanation tonometry on a very small sample of
his patients.
Dr. Wales explained that he does finger palpation to measure pressure as it has zero risk
of harm. He said that applanation tonometry is an invasive mechanical technique. Of
5000 patients in a practice, only 125 of them will have elevated pressure.
Dr. Wales’ views on applanation tonometry were summed up in closing argument by his
counsel:
“Simply put, numerical measurement, when compared to finger tonometry doesn’t
get us to a higher number of people being diagnosed with ocular hypertension.
Finger tonometry when compared to numerical measurement doesn’t get us a
higher number of people being diagnosed with glaucoma. And finally, finger
tonometry, when compared to numerical measurements doesn’t get us to a higher
number of people getting the necessary referral, and that is the crux of his
position.”
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Issue #2 - The age at which intraocular pressure should be measured
Dr. X’s Evidence
Dr. X testified that in the past it was considered that intraocular pressure should be
measured after the age of 40. When they started seeing patients with glaucoma who were
in their 20’s and 30’s, the recommended age for measurement was lowered. Today, the
rule is that intraocular pressure should be measured on anyone on whom you can do it. It
is not done for children who cannot sit still, but it can be performed on older children
who can sit still.
In cross examination, Dr. X testified he had no disagreement with the COS Guidelines
2007 stating that “the prevalence of disease in the population under age 40 is low,
suggesting there is limited benefit of a periodic eye examination in the asymptomatic
low-risk patient in this age group. Accordingly, there is little evidence to support periodic
eye examinations in the asymptomatic low risk patient from the time they leave
secondary school to middle age”. This quote was from COS guidelines regarding periodic
eye examinations. Nevertheless, and despite this comment, Dr. X later testified that the
most important risk factor in glaucoma is raised intraocular pressure. It is the only
variable that is treatable. He said that it has been shown to reduce the area of the visual
field loss. Pressure needs to be measured because it can be followed over time.
In his report of January 8, 2010, Dr. Y stated that intraocular pressure should be
measured in everyone over 40. He said that his view at that time was skewed by a
previous case he was involved with. He altered his view later in his report of January 25,
2014, when he realized he had been too lenient in the aforementioned case. Dr. Y
testified that his former statement did not reflect his views accurately, nor the standard of
practice he has observed in others, nor the standard he would expect in primary care. Dr.
Y is of the view that intraocular pressure should be measured starting with cooperative
children from about the age of 10 onwards. He opined that refracting general practitioners
would tend to measure pressure more consistently in older patients rather than younger
ones because glaucoma is not common in younger ages. However, Dr. Y testified that this
17
would be inappropriate. He acknowledged that in the cases he reviewed, Dr. Wales did do
finger tonometry in some patients who were less than 40.
COS Guidelines for routine eye examination reference measurement of intraocular
pressure and do not limit the procedure to those over 40, but state, the test has low
sensitivity and low specificity, the prevalence of the disease in people under 40 is low,
and high quality studies of screening for low vision mostly include populations over 40
years of age.
Dr. Wales’ Evidence
Dr. Wales testified that his practice is to assess intraocular pressure in patients over 40
using digital tonometry. He testified that there were general published risk factors for
intraocular pressure in patients under 30 and that high pressure is accompanied by other
clinical signs like painful eye and reduced vision, in which cases he testified he would
refer the patient for testing.
Issue #3 - Dilation of the pupil in order to better examine the posterior eye
Dr. X’s Evidence
Dr. X testified that in order to have a better look at the back of the eye it is necessary to
dilate the pupils. If there are any cataracts forming, an opacity of the lens of the eye, it
will be missed through an undilated pupil. Dr. X likened the dilation as being akin to the
difference in looking at a room through a key hole and looking at it when the door is
open. Dilating the pupils is opening the door, he explained.
Dr. X did not subscribe to the COS guidelines, which recommended a dilated
examination only if an adequate view of the posterior pole is not obtained. The standard
can also be determined by what doctors actually do. He testified that the standard of
practice of the profession is to dilate the pupil. He added, “No one would look at the
posterior pole of the eye without dilating the pupil.” He went on to say that you can “get
by” by not dilating the pupil if you just want to do an “adequate exam.”
18
Dr. Y’s Evidence
In his report of January 25, 2014, Dr. Y reviewed in more detail 7 of the 26 s.75 patient
charts. He indicated that on further reflection and a more detailed review of patient
charts, he had changed his opinions on some matters. He noted that there was no
indication of pupil dilatation on any of the charts he reviewed. Initially, he overlooked the
issue of pupil dilatation. When the issue was raised in December 2013, he did not turn his
mind to it as he thought it was a separate issue and the breach of the standard of practice
with regard to applanation tonometry was sufficient to not meet professional standards.
Dr. X and Y both were of the view that dilation of the pupil should be done in order to
have a good view of the posterior eye. In his report of January 25, 2014, Dr. Y reviewed
in more detail 7 of the 26 s.75 patient charts. He indicated that on further reflection and a
more detailed review of patient charts, he realized he had overlooked some matters,
including the need for dilatation of the pupils. In some patients with hypertension or
diabetes, he said that a more thorough retina examination needs to be done and the
repeated failure to dilate the pupil on every patient was below the standard of practice.
Dr. Wales’ Evidence
Dr. Wales testified that the examination he routinely did of the back of the eye, using an
ophthalmoscope, without dilating the pupil of the eye, was as effective in his hands as the
standard practice of routinely dilating the pupil, in detecting eye pathology. Dr. Wales
testified that he dilated pupils in his practice when he needed to get a better look at the
posterior part of the eye, for example when the patient had cataracts, a retinal detachment,
a bleed in the eye or blocked artery. Although very often he could see what was wrong
with an undilated pupil, he would be cautious to confirm by dilating the pupil.
Issue #4 - Cycloplegia (paralysis) of the focusing muscle in children
Dr. X’s Evidence
Cycloplegic drops facilitate the examination of the retina in older patients. However, in
children, the use of cycloplegic drops serve a slightly different purpose, Dr. X testified.
Cycloplegia is essential to obtain proper refraction in children, particularly when
strabismus is a problem. In younger patients and children, the lens of the eye focuses to a
19
large degree and may lead to errors in the measurement of vision for glasses. Paralyzing
the muscle of the lens temporarily results in a more consistent result for refraction, Dr. X
testified. It may also disclose some refractive errors that were not previously seen.
Dr. X testified that it is necessary to do a full and accurate assessment of the refractive
error. The child does not get a prescription for the refraction obtained under cycloplegia,
unless the child has severe far-sightedness and strabismus. The drops need to wear off or
the child needs to return for manifest refraction. Otherwise, the child may receive an
over-corrected prescription and not be able to see properly. To do a refraction in a child
without cycloplegia would be unheard of, according to Dr. X.
Dr. Y’s Evidence
In his report of January 25, 2014, Dr. Y comments that he overlooked the issue of
cycloplegia in the examination of children. Cycloplegia assists in obtaining a more
consistent result for refraction and may disclose some refractive errors that were not
previously seen.
Dr. Wales’ Evidence
Dr. Wales testified that cyclopegic drops were not a routine in his practice with children.
He said that the children he works with can give him a sufficient feedback that he can do
a manifest refraction on them and get a good result. In a situation where a very young
child was cross-eyed, that sort of thing, he referred the patient to a paediatric
ophthalmologist.
Findings
The findings of the Committee on each of the four issues are outlined below. Although
the patients were assessed as part of the analysis of each issue, the summary of the
patients’ charts follows the findings for ease of reading.
20
Issue #1 - Did Dr. Wales fail to maintain the standard of practice with regard to
measuring the intraocular pressure by using finger tonometry instead of applanation
tonometry?
The Committee accepted the opinion of the expert witnesses that the standard of practice
for a comprehensive eye examination by a GP refractionist includes measurement of
intraocular pressure using an applanation tonometer, where the pressure is measured
numerically. The Committee finds that Dr. Wales’ failure to perform applanation
tonometry, in all of the adult patients who qualified for it, constituted a failure to maintain
the standard of practice of the profession. Also, Dr. Wales shows a deficiency in
knowledge, skill or judgment regarding applanation tonometry.
Although counsel for Dr. Wales submitted Dr. X was not well placed to comment on a
general practitioner doing primary eye care, the Committee disagreed. He had many years
of experience in many settings and had dealt with referrals for years from a primary care
eye specialist. He taught residents as part of his connection with a medical school. The
Committee accepted his opinion as an expert on all aspects of Dr. Wales’ care of his
patients in relation to how to conduct appropriate eye examinations and the risk of
glaucoma. Although he did make errors in his comments on the 7 patient examinations he
observed, they did not detract from his evidence in this hearing. Dr. X was cognizant of
the differences in the scope of practice of an ophthalmologist in comparison to a general
practitioner doing primary care and clear about what should be expected as the standard
of practice for a GP refractionist.
Counsel for Dr. Wales argued that Dr. Y was not thorough in his initial reviews of Dr.
Wales’ patient charts. Dr. Y explained why he thought Dr. Wales met the standard of care
in his first assessment of his care of 25 patients. It was because he did not realize that Dr.
Wales was using finger tonometry to assess for intraocular pressure. He also did not turn
his mind to issues of cycloplegia and dilatation of the pupils. Subsequently, he changed
his opinion about the age that tonometry should be done. The Committee was satisfied
with his explanation. Dr. Y later looked at the issues of cycloplegia and pupil dilatation
21
that he had neglected to address in earlier reports, and he opined that Dr. Wales was not
dilating the pupil or using cycloplegia in children and this did not meet the standard of
practice of the profession and revealed a lack of knowledge, skill and judgment. The
Committee accepted that Dr. Y needed to change his opinions as other issues came up for
evaluation.
The Committee accepted the evidence of both experts that physicians doing primary eye
care should use applanation tonometry as part of the examination and that it has been the
standard for about 50 years. The fact that Dr. Y was surprised to learn that Dr. Wales
used finger tonometry underscored the fact that the technique has been discredited for use
for about 50 years, except for three rare exceptions.
The COS Guidelines supported intraocular pressure determination, meaning applanation
tonometry, according to the experts.
The Committee acknowledges the arguments regarding the OHIP Schedule of Benefits
listing tonometry as part of an oculo-visual assessment and finds that this material, while
consistent with the COS guidelines, is not determinative of the standard of practice.
The OHIP Schedule of Benefits sets out the billing requirements for an intraocular eye
examination and applies a certain fee code for GPs who do refractions or a periodic
ocular visual assessment. Counsel for the College in her closing statement argued it did
not define the standard of care and the standard of care did not define it, but it mirrors the
standard of care and was consistent with the evidence of both experts. The word
“tonometry” is in the OHIP Schedule and does not mean finger tonometry. She stated that
Dr. Wales regularly bills for oculo-visual examinations using a fee code which included
tonometry. She argued that this was further evidence that Dr. Wales was not performing
an essential element of the eye examination. Counsel for Dr. Wales argued that OHIP
does not issue clinical guidelines, it is a payment agency and there has been considerable
debate in recent years between the billing requirements in particular codes versus clinical
necessity. Counsel for Dr. Wales cautioned that a finding as to whether Dr. Wales meets
22
the standard of care or is incompetent based on billing codes would have a very poor
foundation.
The Committee does not accept that the OHIP Schedule of Benefits is evidence of the
standards for tonometry measurement. The Committee agrees that OHIP is a payment
agency only, does not issue clinical guidelines, does not establish the standard of care and
therefore is not relevant in determining whether Dr. Wales failed to maintain the standard
of practice of the profession.
Both experts acknowledged that although elevated intraocular pressure was no longer
associated with the diagnosis of glaucoma, it was associated with risk and it was the one
risk factor that was measurable for a baseline and follow-up. It was the one variable that
was modifiable with treatment. Finger tonometry simply gave an impression and did not
allow for an accurate numerical measurement for these purposes.
Dr. Wales’ justification for using the finger tonometry technique was not persuasive. He
stated that if applanation tonometry was used entirely for diagnosis of glaucoma, it would
cover up more cases of glaucoma than it would uncover. Dr. Wales’ apparent failure to
understand what the experts said in their testimony did not enhance his arguments. His
interpretation would mean that you do not just rely on intraocular pressure alone, but you
do not rely on it at all. Consequently, rather than assess it along with other factors, he
just did not measure it. Neither expert gave an opinion that applanation tonometry alone
be used to diagnose glaucoma. Both testified that applanation tonometry should be used
to get an initial measurement that can be followed over time.
When Dr. Wales was asked in examination in chief about the risk factors for glaucoma,
he omitted the major factor of intraocular pressure, and mentioned age and race. This was
consistent with his comment in a letter to the College investigator that intraocular
pressure measurement is no longer relevant in the definition, risk or diagnosis of
glaucoma. However, he attempted to take back that comment in his testimony during
23
cross examination, when he said that intraocular pressure measurement does speak to risk
although it does not speak to diagnosis.
Dr. Wales testified that the finger palpation that he used was a “time honoured surgical
skill” and that he was “ahead of his time”. Dr. Wales testified that digital tonometry is a
surgical procedure that he had learned in medical school in 1959 and practised for more
than 50 years. He testified it was sufficiently accurate in his hands to screen for abnormal
intraocular pressure. He said that this technique allowed him to determine with his fingers
if the intraocular pressure was extremely low, low, normal, above normal or high. If he
detected a problem using digital tonometry, he followed up with applanation tonometry.
Dr. Wales acknowledged that while applanation tonometry is commonly used by
practitioners, digital tonometry was outside the scope of practice of optometrists, that it is
a surgical technique and that optometrists have not done a rotation in surgery. He testified
he had used it in his practice with more than 75,000 patients. He stated that using
applanation tonometry was what patients would regard as invasive. Of 5,000 patients
tested in his practice, only 125 would have elevated pressure. The Committee fully
recognizes that the onus is on the College to establish the allegations in the Notice of
Hearing, but notes that Dr. Wales had an opportunity to present independent expert
evidence to support his practice of digital tonometry and he did not. His claims of being
ahead of his time were grandiose in light of the evidence to the contrary.
The Committee is persuaded on the expert evidence that finger tonometry is not the
standard of practice for GP refractionists.
The Committee is not persuaded by the testimony of Dr. Wales that his digital tonometry
technique resulted in a similar pick-up of intraocular hypertension as applanation
tonometry. The Committee accepts the evidence of the expert witnesses that Dr. Wales
failed to maintain the standard of the profession when he used digital or finger to measure
intraocular pressure.
24
Dr. Wales testified that there was zero risk in his approach. He testified that he would not
miss a case of glaucoma. The Committee finds that his view reveals an extraordinary lack
of insight. Dr. Wales missed the point of why the applanation technique was useful.
With respect to skill, Dr. X testified that he had observed Dr. Wales perform applanation
tonometry on one patient, and Dr. Wales had deficits that were dangerous. Dr. Wales
repeatedly performed the procedure risking corneal abrasion with each try, and that it
took much longer than was needed. Dr. X was also concerned about the sterility of the
procedure. Dr. Wales testified that he learned to use the Goldmann Tonometer more than
50 years ago and is familiar with it, but was extremely nervous during the observation.
Dr. Wales said he used multiple applications in each eye routinely to get a more accurate
and stable measurement. The review of patient charts indicated that Dr. Wales did
applanation tonometry on this one patient only. The Committee finds it highly unlikely
that Dr. Wales used applanation tonometry with any regularity. He demonstrated that his
skills are lacking in performing the measurement. The Committee is persuaded by the
evidence that Dr. Wales lacked the skill to perform applanation tonometry on the basis of
his preference for digital tonometry, his performance in the one patient observed and his
failure to use it in the charts reviewed.
In testimony, Dr. Wales stated that until recently, glaucoma was diagnosed by elevated
intraocular pressure, optic nerve testing and visual field testing. According to this
statement, at a time when intraocular pressure was thought to be diagnostic of glaucoma,
Dr. Wales was using finger tonometry. Applanation tonometry has never been routine for
him. This fact does not lend credence to his argument that it is not useful. He was not
performing applanation tonometry in the days when raised intraocular pressure was
thought to be even more important for diagnosis. This fact raises the question of his
skewed thinking and the implications for his judgment, and ultimately his clinical care.
Dr. Wales presented as adamant in his opinions and resistant to any view that was
different than his own. When that was considered along with his lifelong practice of
finger tonometry and his statements that he was “ahead of his time”, the Committee has
concerns about his rigidity of thought.
25
The Committee accepts the evidence of the expert witnesses that Dr. Wales’ failure to
perform applanation tonometry presented a risk of harm to his patients. High intraocular
pressure could be missed. Patients were falsely reassured that all the elements of the eye
examination had been performed. Routinely measuring normal or elevated intraocular
pressure, an important risk factor for glaucoma, was a necessary component of a
comprehensive eye examination.
The Committee finds that Dr. Wales failed to maintain the standard of practice in using
finger tonometry and failing to use applanation tonometry in the measurement of
intraocular pressure. He showed a lack of knowledge skill and judgment that persists
currently.
Issue #2 - Did Dr. Wales failure to measure intraocular pressure in certain age groups
fail to maintain the standard of practice?
The Committee accepted the evidence of the experts that measuring intraocular pressure
in all patients on whom it is possible is the standard of practice of the profession.
Although it is not necessary to do in young children, the measurement can be completed
as soon as the child is able to sit still. Dr. X testified that glaucoma is now evident in 20
and 30 year olds and thus the reason for doing it early is more compelling. Dr. Y testified
that testing intraocular pressure in those under 40 is his practice. Both experts have
experience that this is the standard from many referring physicians, other specialists, as
well as some GP refractionists.
The Committee accepts that the experts’ practice and their experience with ordinary,
competent practitioners are reflective of the standard of practice.
Dr. Wales did use his outmoded technique to measure intraocular pressure in some
patients under 40, but it was clearly not his routine to do so. Thus, the Committee finds
that he is not consistent in his approach and failed to maintain the standard of practice in
this regard. He demonstrates a lack of knowledge, skill and judgment.
26
Issue #3 - Did Dr. Wales fail to maintain the standard of practice in not dilating the
pupil to look at the fundus or back of the eye?
The Committee accepted the evidence of the two experts on this issue. The pupil needs to
be dilated to view adequately the back of the eye. Pupil dilation is performed for a more
detailed and thorough examination of the retina. Although Dr. Wales testified that he
could get a good view with his ophthalmoscope, the evidence of Dr. X was more
compelling. Why look through a key hole when you can open the door? In the patients
reviewed by both experts, Dr. Wales never dilated the pupils, even when there were good
reasons for doing so, such as when the patient had diabetes or hypertension. This
deficiency suggests that his examinations were cursory.
The Committee accepted the evidence that the COS guidelines were simply that,
guidelines, and what practitioners actually did was the standard. Both experts testified
that having a good look through a dilated pupil was the standard of practice of the
profession. It is important to rule out abnormalities.
The Committee finds that Dr. Wales failed to maintain the standard of practice in not
dilating the pupil to look at the fundus of the eye in any of the charts reviewed and
patients observed. In not doing so, he demonstrates a lack of knowledge, skill and
judgment when he performs an examination of the posterior of the eye.
Issue #4 - Did Dr. Wales fail to maintain the standard of practice when he failed to use
cycloplegia in children?
The reasons provided in evidence for using cycloplegia in children were persuasive. Both
experts spoke to the need for cycloplegia in order to obtain a proper refraction and so the
child will not be overcorrected. Cycloplegic drops paralyze the ciliary muscles of the eye
to prevent accommodation (focusing) by the eye so that refraction can be accurately
measured. The drops also paralyze another muscle of the eye resulting in dilation of the
pupil to enable a more thorough visualization of the retina. The Committee believes Dr.
27
Wales’ testimony that he listens to the feedback of children during refraction in order to
assess whether the vision is corrected because they may not be able to discern an
overcorrection or express their feedback. However, the Committee is not persuaded that
the children’s feedback was sufficient.
The Committee is persuaded on the evidence that Dr. Wales failed to maintain the
standard of the profession (the standard of practice for the ordinary, competent
practitioner in Dr. Wale’s field of practice) in that he failed to routinely administer
cyclopegic drops to children as an essential procedure to obtain proper refraction in
children especially where strabismus is a problem.
Dr. Wales failed to maintain the standard of practice in not using cycloplegia in children
and he demonstrates a lack of knowledge, skill and judgment, when he did not use
cycloplegic drops in the children.
Dr. X’s Evidence regarding his Observation of Seven Patients
The Committee made findings on the treatment and care by Dr. Wales on four specific
issues: the use of finger tonometry, the age of the patients who should be examined with
tonometry, the failure to use cycloplegia in children and the failure to dilate the pupils to
look at the posterior eye. In some cases, Dr. X who had observed Dr. Wales examine 7
patients, was critical of other aspects of Dr. Wales’ care, for example, the way he did
refraction or his failure to use a slit lamp. That evidence did not reach the level of
sufficiency to support findings that he failed to maintain the standard of practice of the
profession with regard to other aspects of Dr. Wales’ care. The Committee was not asked
to make those findings. Thus, the Committee focused on the four issues in question in
relation to the following patients:
Patient A (age 20)
Dr. X testified that Dr. Wales’ care did not meet the standard of practice of the profession
and that his care displayed a lack of knowledge, skill and judgment because he did
manifest refraction, not cyclopegic refraction, and did not do tonometry. Applanation
28
tonometry should have been done as well. Dr. Wales did not use cyclopegic drops in this
young patient to dilate the pupils to ensure he was not overcorrecting.
Dr. Wales testified about how he refracted this patient and the Committee was not
convinced that his technique obviated the need for cycloplegic drops in order to do a
comprehensive examination. As indicated earlier in these reasons, the Committee found
that the standard of practice for eye examinations by GP refractionists requires dilation of
the pupils to see the fundus properly and rule out pathology. The Committee finds that
Dr. Wales failed to maintain the standard of care when he failed to dilate the pupils in this
patient, or use cycloplegic drops and do applanation tonometry.
Patient B (age 42)
Dr. X testified that Dr. Wales’ care did not meet the standard of practice of the profession
and that his care displayed a lack of knowledge, skill or judgment and had a number of
shortcomings. Dr. Wales spoke to some of the concerns of Dr. X particularly regarding
the refraction. Failing to do applanation tonometry or dilate the pupils convinced the
Committee that Dr. Wales failed to maintain the standard of practice and that his care
displayed a lack of knowledge, skill and judgment.
Patient C (age 38)
Dr. X testified that Dr. Wales’ care did not meet the standard of practice of the profession
and displayed a lack of knowledge, skill and judgment in that he did not use applanation
tonometry to measure intraocular pressure and that he did not use dilating drops.
The Committee finds that Dr. Wales failed to maintain the standard of practice of the
profession in that he was deficient in these examinations.
Patient D (age 9)
Dr. X testified that Dr. Wales’ care did not maintain the standard of practice for the
profession and displayed a lack of knowledge, skill or judgment because he should have
used cyclopegic drops for this 9 year old patient. He would not have faulted Dr. Wales
29
for not measuring intraocular pressure because of her age; she might have been too young
to be able to cooperate.
Dr. X had other concerns about Dr. Wales’ examination of this child and Dr. Wales
testified about his examination. Those concerns of the expert were not persuasive, as the
evidence was not clear, cogent and convincing. As indicated earlier in these reasons, the
Committee found that the standard of care for a GP refractionist performing an eye
examination in children requires the use of cycloplegic drops.
The Committee is persuaded by the expert evidence and finds that Dr. Wales failed to
maintain the standard of the profession in that he failed to administer cyclopegic drops to
this 9 year old patient. His deficits reveal a lack of knowledge, skill and judgment.
Patient E (age 10)
Dr. X testified that Dr. Wales’ care did not maintain the standard of practice of the
profession and he displayed a lack of knowledge, skill or judgment in that he should have
used cyclopegic drops in this 10 year old patient. He would not have faulted Dr. Wales
for not measuring the patient’s intraocular pressure because of her age.
The Committee found that the standard of care for a GP refractionist eye examination in
children requires the use of cycloplegic drops. The Committee finds that Dr. Wales failed
to maintain the standard of practice of the profession in that he failed to administer
cycloplegic drops to this patient.
Patient F (age 29)
Dr. X testified that Dr. Wales’ care did not maintain the standard of practice of the
profession and displayed a lack of knowledge, skill and judgment in that he did not use
dilating drops or do applanation tonometry to test for intraocular pressure.
Dr. Wales testified that he performed a fundus examination which was normal and did
not check her intraocular pressure because there seemed to be no risk factors involved.
30
For the reasons given earlier in relation to the standard of care regarding the use of
dilating drops and tonometry, the Committee accepts the expert evidence and finds that
Dr. Wales failed to maintain the standard of practice of the profession in that he did not
dilate the pupils in this patient. His care demonstrates a lack of knowledge, skill and
judgment.
Patient G (age 52)
Dr. X had several concerns about Dr. Wales’ examination of this patient including the
lack of a retinoscopic examination to check for astigmatism, the lack of a slit lamp
examination, and the technique of applanation tonometry that he performed. This was the
only observation of Dr. Wales’ technique of doing applanation tonometry. While the
Committee makes no finding on the first two concerns, it does make a finding with regard
to the technique of the applanation tonometry.
Dr. X testified that he watched from across the room while Dr. Wales did applanation
tonometry on this patient. Dr. X said that normally, a bottle of anesthetic drops is close by
and as the patient looks up, a drop is instilled in each eye and the patient is given a
Kleenex. Then a drop of anesthetic is put on a sterile strip of dye to wet it. That strip is
then touched to each eye. The head of the tonometer is wiped with an alcohol wipe to
sterilize it and dried. The tonometer head is touched to each eye once and the
measurement taken. Dr. X testified that this process takes about a minute in total for the
measurement of both eyes.
In the examination Dr. X observed, Dr. Wales left the room. After one to two minutes, he
returned with a bottle that looked like topical anesthetic and he put a drop in each eye and
dabbed the patient’s eye himself and gave the tissue to the patient. Dr. Wales then left the
room again to retrieve a container of what he presumed to be fluorescein dye. He poured
some dye onto a piece of gauze and touched the conjuctiva of each eye. Dr. X testified
that the dye should be in a sterile container or put on a strip that is sterile, as something
dry should never be put on the conjunctival surface. Dr. Wales then attempted to measure
the pressure in each eye ten times. He came to the eye and poked the eye, which is the
31
appropriate way, but then he returned and repeated it again ten times with each eye. Dr. X
was concerned with Dr. Wales’ technique, because it increases by a factor of ten the
likelihood of getting a corneal abrasion. Dr. X also testified that with ten attempts to
measure, he had concerns about the accuracy of the reading. Dr. X testified that from
observing the technique of Dr. Wales, he concluded that this was not a procedure that he
did very often.
Dr. X was of the view that Dr. Wales’ applanation tonometry technique was highly
suspect in terms of accuracy and sterility and suggestive of the fact that he did it rarely.
He would not trust the numbers Dr. Wales obtained. Dr. X viewed Dr. Wales’ skill as
lacking. Dr. X considered Dr. Wales failed to meet the standard of practice by not
dilating the pupils to examine the fundus of the eye more thoroughly, especially since this
patient was obese and may have had pathology at the back of the eye related to health
problems related to obesity.
Dr. X had concerns about Dr. Wales’ judgment, because in the letters Dr. Wales sent him
he said he was very interested in glaucoma. Despite his professed interest, Dr. Wales
nonetheless does not use applanation tonometry routinely. Dr. X testified that Dr. Wales
should have learned to use this properly and use it on every patient that he could.
Dr. Wales testified that there were physical difficulties with this obese patient and with
the adjustability of the slit lamp in the office. He testified it was virtually impossible to do
a slit lamp examination. Dr. Wales thought this patient’s intraocular pressure may be
raised. To be cautious, Dr. Wales measured his intraocular pressure using the applanation
tonometer and found the results that he interpreted to be within normal limits. Dr. Wales
explained his technique in detail and made multiple measurements because in his view a
number of factors may introduce error into the measurement. When he got three readings,
each giving him the same number, he stopped. He stated that Dr. X’s recollection of ten
attempts was probably an exaggeration and that the procedure was performed under
pressure, as he was being observed.
32
The Committee is persuaded on the evidence of the expert that Dr. Wales failed to
maintain the standard of practice of the profession in his poor technique using
applanation tonometry and failure to dilate the pupils in order to observe the posterior
eye. He showed a lack of knowledge, skill and judgment. The Committee considers it
likely that Dr. X was able to see enough of Dr. Wales’ technique, even from across the
room, to provide a reliable opinion, which the Committee accepts. He would have been
able to see him touch the eye each time and he was very descriptive of what he was
witnessing, no doubt because the technique was so unusual. Whether or not it was a
sterile procedure is less certain but the Committee makes no finding in this regard. As
with other criticisms of Dr. Wales’ care of this patient, the Committee makes no finding.
In summary, Dr. Wales failed to maintain the standard of care by not performing
applanation tonometry in Patients A, B, C and F. His performance of applanation
tonometry in Patient G failed to maintain the standard of the profession. He did not meet
the standard of practice by not dilating the pupils for an optimum look at the posterior eye
in Patients A, B, C, F, and G. Cycloplegic drops should have been used in Patients A, D,
and E, and Dr. Wales failed to maintain the standard of practice of the profession by not
using cycloplegic drops in those cases.
Dr. Y’s Evidence regarding 25 Patient Charts
Dr. Y reviewed 26 charts, plus one complainant chart. One chart was incomplete and
excluded, thus, he had 25 charts. Dr. Y did not observe Dr. Wales in his practice but was
assessing the care based on clinical notes that were fairly neat and legible.
Dr. Y’s report and testimony changed and was augmented by subsequent reviews of the
charts. The Committee reviewed these changes. In essence, with regard to Dr. Y’s
reports:
i) He changed his view from his initial report where he found the care of Dr. Wales
met the standard, when he realized later that the record of normal tonometry
“readings” was actually finger tonometry, a technique that he testified was so
absurd, he had not even considered it.
33
ii) In an earlier report he testified that he had been “lenient” and stated that
applanation tonometry needed to be done for all patients over 40. Subsequently,
he changed that view to what he actually did, and what others did, including the
GP refractionists he has assessed. The Committee accepted his change in opinion
as reasonable and reliable.
iii) When he was later asked to turn his mind to the issue of dilation and cycloplegia
of the pupils, he realized he had overlooked these issues. He stated that at the time
he was of the view that not doing applanation tonometry was the deficiency. Dr. Y
acknowledged that he ought to have been more critical and rigorous in evaluating
Dr. Wales from the beginning. This ultimately did not detract from the acceptance
by the Committee of his opinions. Dr. Y’s opinions did not change, except for the
age of tonometry issue; he simply was not thorough and rigorous enough in
evaluating Dr. Wales practice in the first place.
With the changes in Dr. Y’s opinions and augmented reports in mind, the Committee
reviewed the patient charts that he assessed. The charts that were assessed by Dr. Y in his
report of January 25, 2014 are marked with an asterisk.
Dr. Y noted in his reports of December 27, 2009 and January 12, 2010 that he reviewed
the patient charts within the context of his expectations of eye care done by a provider of
primary eye care, a refracting general physician, rather than expectations of eye care by
an ophthalmologist.
The Committee’s findings with regard to various patients are summarized below
following the chart review.
Patient 1: --age 15-- Dr. Wales testified he had manifest refraction but no pupil dilation
or cycloplegia.
34
Patient 2: --age 88-- Dr. Wales testified he had manifest refraction but no dilating drops.
He used finger tonometry.
Patient 3: --age 63-- Dr. Wales testified he did manifest refraction. He did not dilate the
pupils but did do digital tonometry and evaluated the optic nerve head carefully.
Patient 4: --age 13-- Dr. Wales testified he performed a manifest refraction. He did not
use cycloplegic drops.
Patient 5: --age 7 at last visit, age 5 at previous visit-- Dr. Wales testified he performed
manifest refraction but did not use cycloplegic drops.
Patient 6: --age 65-- Dr. Wales testified he performed manifest refraction and finger
tonometry and did not use dilating drops.
Patient 7: --age 81 on last visit-- Dr. Wales testified he performed manifest refraction,
but did not use dilating drops. He used finger tonometry.
Patient 8*: --age 41 at time of last visit and age 39 at previous visit-- This patient’s chart
was re-reviewed by Dr. Y in his report of January 2014. Dr. Y indicated in his January
2014 report that intraocular pressure should have been measured at both visits. Pupil
dilation or cyclopegia was not done at either visit and should have been done on at least
one of the visits. Dr. Wales testified the patient had manifest refraction and he assessed
intraocular pressure using digital tonometry not at the first visit in April 2006, but at the
second visit in December 2008. Dr. Wales testified that in 2006, the patient had not yet
reached her 40th birthday, but had by 2008. Dr. Wales also paid attention to the discs and
disc/cup ratio. He did not provide cyclopegic drops as he had a good look at the fundus.
Patient 9: --age 66-- Dr. Wales testified he performed finger tonometry but used no
drops of any kind.
35
Patient 10: --age 70 at time of last visit, age 68 at time of previous visit-- Dr. Wales
testified he performed finger tonometry on both visits. Dr. Wales testified that he checked
the discs (optic nerve head) and they were normal which eliminated it as a risk factor.
Patient 11*: --age 72 at the time of the last visit and age 71 when seen the year before-This patient had diabetes. Dr. Y indicated in his report of January 2014 that intraocular
pressure was not measured on either visit even though the patient was under a specialist’s
care. Dr. Y was of the opinion that the intraocular pressure should have been measured
even though she was being seen by a specialist. Because the specialist would have dilated
her pupil, that examination could be omitted for these visits. Cycloplegia for refraction is
not required at this age, Dr. Y reported.
Dr. Wales testified that the patient came to see him for glasses. He did not measure
intraocular pressure or dilate the pupil because the patient had recently been seen in
tertiary care and was being followed by an ophthalmologist. Although Dr. Y thought that
the intraocular pressure should have been measured in this patient, the Committee was
not convinced. She had seen her specialist days before each of her visits with Dr. Wales
and the Committee considers that his examination would suffice.
Patient 12*: --age 76 at last visit and 73 at the first-- Dr. Y in his report of January 25,
2014, indicated that intraocular pressure should have been measured at all four visits
between 2006 and 2009. The patient had cataract surgery which can affect intraocular
pressure and it should have been checked. Pupil dilation was not performed on any visit.
Dr. Y reported that because the patient had diabetes, he should have had his pupils dilated
in 2007 and at least once in the two 2009 visits.
Dr. Wales testified that he performed manifest refraction, with no drops. He returned in
August 2007 and had manifest refraction. He performed digital palpation but did not do
tonometry or give drops. He assessed him as having low-normal pressure. This patient
returned in January 2009 and he performed manifest refraction, no drops, no palpation,
but he examined the optic nerve head. He testified he did not have an intraocular
tonometry measurement (numbers) on file for this patient from 2006 to 2009.
36
Patient 14 (DM)*: --ages 35 at the last visit and 31 at the first-- This patient had myopia
and angina. Dr. Y reported on January 25, 2014, that intraocular pressure measurement
and pupil dilation should have been performed at both visits. He thought that since this
patient had vascular disease, pupillary dilatation was required for proper retinal
examination given her history.
Dr. Wales testified he did a manifest refraction, checked for intraocular pressure using
finger tonometry in 2009, and even though she had vascular disease he had a good view
of the discs, therefore, cyclopegic drops were not necessary. When she was seen in 2004,
he did not use drops or finger tonometry.
Patient 15: --age 11 at last visit and age 8 and 10 at the previous visits -- This child was
not given cycloplegic drops on any visit.
Patient 16: --age 10-- Dr. Wales testified that he performed manifest refraction with no
drops. He stated that he also checked his apparent refraction with the retinoscope, and
that was within the expected limits for his manifest refraction. Also, he checked his extra
ocular movement related to the hyperopia.
Patient 17: --age 39-- Dr. Wales testified he performed manifest refraction and finger
tonometry in this patient.
Patient 18: -- age 71-- Dr. Wales testified he performed manifest refraction. He did
finger tonometry and did not use drops.
Patient 19*: -- age 33 years-- Dr. Y commented on January 25, 2014, that neither
intraocular pressure measures nor pupil dilation were performed. Dr. Wales testified he
did not measure the intraocular pressure because the patient was below 40.
Patient 20*: --age 67 at the last visit in 2009 and 61 at the first visit in 2003-- Dr. Y
commented on January 25, 2014, that finger tonometry was performed on the visit in
2003 only. He reported that she should have had tonometry measured at both visits along
37
with pupil dilatation or cycloplegia. Her history of hypertension was a particular reason
for the pupil dilatation.
Dr. Wales testified he measured the intraocular pressure using digital tonometry in 2003
and observed the discs to be normal. In October 2003, he performed manifest refraction,
no tonometry and no pupil dilation. In 2009, she had been seen by a specialist at a local
hospital. Dr. Wales assumed that she had been fully assessed there, so he did not measure
her intraocular pressure. In addition, because he did not get a copy of the consultant’s
report, he thought that absolved him of any responsibility in following up. He did notice
she was developing cataracts, so he did a full slit lamp examination with magnification.
Even without pupil dilation, he testified he could see enough of the edge of the lens to
notice there were some cortical cataracts developing. He testified he did not need to dilate
her eyes, because she was on blood pressure medications, and if her pressure was
controlled, there was no concern about changes in the fundus and dilation was not
indicated.
Patient 21: --age 10-- Dr. Wales testified he did manifest refraction without cycloplegic
drops.
Patient 23: --age 55 on the last visit and 53 on the first visit-- Dr. Wales testified he
performed manifest refraction, used no drops but performed finger tonometry on the visit
in 2007. He saw her again in 2009, and did manifest refraction, performed finger
tonometery, but did not use drops or applanation tonometry.
Patient 24: --age 5-- Dr. Wales testified that he did a manifest refraction with no drops.
He did finger tonometry and evaluated the discs.
Patient 25: --age 42 at last visit and age 38 at first visit-- Dr. Wales testified that he
performed a manifest refraction with no drops given or use of applanation tonometry on
both visits. He did do finger tonometry on both visits.
38
Patient 26: --age 58 at the first visit, and age 60 at the last visit-- Dr. Wales testified that
at the 2007 visit, he did manifest refraction, and finger tonometry but he used no drops,
and did no applanation tonometry. She complained of double vision and Dr. Wales
testified he used a small device to measure the protrusion of her eyes and followed this at
her next visit in November 2008, where he did not dilate her pupils or measure her
intraocular pressure. Dr. Wales testified that he likely did do tonometry which was not
recorded. He saw her again January 2009 and did not use a tonometer because it was a
follow up. Dr. Wales saw her again September 2009 and did a manifest refraction where
he recorded “over” refraction. He used no drops and did not measure her pressure using a
tonometer.
In the Committee’s view, of the patients reviewed by Dr. Y, Dr. Wales failed to maintain
the standard of practice of the profession and demonstrated a lack of knowledge, skill and
judgment in the following patients with regard to:
i)
Failing to do applanation tonometry in patients on whom it could be done (older
children and adults):
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Patient # 1
Patient # 2
Patient # 3
Patient # 4
Patient # 6
Patient # 7
Patient # 8
Patient # 9
Patient # 10
Patient # 11
Patient # 12
Patient # 14
Patient # 17
Patient # 18
Patient # 19
Patient # 20
Patient # 23
Patient # 24
Patient # 25
39
•
•
ii)
Failing to dilate the pupils to better examine the posterior eye:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
iii)
Patient # 26
the Complainant Patient
Patient # 2
Patient # 3
Patient # 6
Patient # 7
Patient # 8
Patient # 9
Patient # 10
Patient # 12
Patient # 14
Patient # 17
Patient # 18
Patient # 19
Patient # 20
Patient # 23
Patient # 24
Patient # 25
Patient # 26
the Complainant Patient
Failed to use cycloplegic drops for refraction in children:
•
•
•
•
•
•
Patient # 1
Patient # 4
Patient # 5
Patient # 15
Patient # 16
Patient # 21
The Committee did not make findings of failure to maintain the standard in respect to the
following patients:
Patient #11: Both visits with Dr. Wales were within days of seeing an ophthalmologist
where she would have had a complete examination. The Committee did not find the
evidence clear, cogent and convincing enough to support a finding that Dr. Wales should
have done applanation tonometry or dilated her pupils.
40
Patient #13: No finding was sought or made.
Patient #22: The chart was incomplete for this patient. No finding was sought or made.
SUMMARY
Counsel for Dr. Wales submitted in closing argument that Dr. Wales believed firmly with
all of his heart in an evidence-based approach to medicine that seeks to combine clinical
skill with clinical judgment and the best available evidence. However, Dr. Wales’ actions
belie his beliefs. As a primary care refractionist, Dr. Wales did not use examination
techniques that his primary eye care colleagues in Ontario routinely perform. He used his
finger to assess the pressure in the eye. Dr. Wales has never used applanation tonometry
regularly, nor has he used cycloplegia when doing refractions in children or dilatation of
the pupils to improve the quality of eye examination. He was not skillful using an
applanation tonometer when he was being observed. If he had been doing applanation
tonometry as regularly as he testified he did for the last 40 years, Dr. Wales would have
been more skilled in its use.
The Committee finds that the College has satisfied the burden of proof on the balance of
probabilities that Dr. Wales has failed to maintain the standard of practice of the
profession in his care of the patients noted above.
The Committee also finds that the College has satisfied the burden of proof that Dr.
Wales’ care of these patients demonstrates a lack of knowledge, skill and judgment of
such a nature and to an extent that he is unfit to continue to practise or that his practice
should be restricted. The deficiencies he displays are current. Accordingly, the
Committee finds Dr. Wales incompetent.
The Committee instructs the Hearings Office to schedule a penalty hearing at the earliest
possible date.