• Opinion

    Dilation and Informed Consent

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    Ruth D. Williams, MD

    By Ruth D. Williams, MD, Chief Medical Editor, EyeNet


    It’s too often overcast in the Midwest—especially in the late fall and early spring. When I tell patients that they will be dilated, it’s common here in Illinois for them to respond, “At least it’s a cloudy day.” Experienced patients know that dilation can cause light sensitivity, difficulty driving, and, occasionally, decreased vision.

    Ophthalmologists dilate the pupils of most new patients and many of their existing patients every day. It’s so routine that perhaps we don’t think about it enough.

    Informed consent isn’t needed for certain routine tests and procedures with negligible risks, such as blood tests or x-rays. It’s assumed that the patient understands that these common procedures have few risks, and consent is implied. Ophthalmologists often assume that these considerations apply to dilation, as well. But what are our obligations to our patients? What are our medicolegal risks?

    Anne Menke, RN, PhD, OMIC Patient Safety Manager, explained that the legal doctrine of informed consent is based on what a “reasonable layperson” would like to know before a procedure, not on what the ophthalmologist assumes is common knowledge. “Because dilating drops can cause several hours of photophobia, blurred vision, glare, and decreased contrast threshold, a reasonable person might feel that informed consent is needed.”1 Anne also pointed out that dilation could potentially incite an attack of angle-closure glaucoma, an allergic reaction, dizziness, tachycardia, or arrhythmia; it also can contribute to falls. For these reasons, she suggested, “consider asking patients to sign a consent the first time they are dilated.”

    When asked about the responsibility of the ophthalmol­ogist as it relates to dilation, Ron Pelton, MD, chair of the Academy’s Ethics Committee, quoted the Code of Ethics: “It is the responsibility of an ophthalmologist to act in the best interest of the patient.” But precisely how this plays out in a particular ophthalmologist’s practice is open to interpreta­tion. (See also “Ask the Ethicist.”)

    While no clear recommendation exists, OMIC provides a few suggestions. When possible, advise patients about dilation when the appointment is made so that they can arrange for a ride or allow extra time after dilation for their eyes to adjust before driving themselves home. Remind patients each time about the impact of dilating drops on their vision, and briefly note the discussion in the medical record. Be prepared to offer assistance to patients with mo­bility problems while they are in the office. Consider offering sunglasses as patients leave the office so that glare is less of a problem.

    My glaucoma partner, David Gieser, MD, goes a step further. He is adamant that every dilated patient should have his or her vision rechecked before driving home. David shared several examples of glaucoma patients who drove to an appointment with vision that was legal for driving but that dropped below the legal requirements after dilation. He pointed out that a technician can check the vision of both eyes very quickly. And he added that every few months, he asks a patient to call a family member for a ride or to wait in the office until the drops begin to wear off and vision returns to baseline. “It’s an ethical issue for me,” David said. “My duty is do everything in my power to protect the patient, and I cannot allow a patient to drive home after the dilation has caused the vision to drop below the legal requirement.”

    We all embrace patient safety. Cultivating a culture of patient safety includes reviewing everyday procedures, and this includes a review of how we inform patients about the risks of dilation. It’s worth re­minding ourselves that what seems like common knowledge to us may not be to our patients—even our experienced patients.

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    1 Menke AM. www.omic.com/warn-patients-about-side-effects-of-dilating-drops. Accessed April 12, 2018.

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