Refractive Error in Childhood: When Does It Become Negligence?

Refractive error in a child

Refractive error in childhood is common, correctable, and often harmless when identified early. Yet it is also a significant source of paediatric ophthalmology litigation. When children are assessed without adequate cycloplegia, misdiagnosed due to inexperience, or reviewed at inappropriate intervals, refractive error can directly lead to amblyopia, developmental delay, and long-term functional consequences.

For solicitors, understanding when a missed or mismanaged refractive error becomes a breach of duty is essential. This blog outlines the key medico-legal principles, common pitfalls, and the standards expected of clinicians assessing children’s vision.

1. Why Refractive Error Matters Medico-legally

Children rely on accurate optical clarity to drive normal visual brain development. When refractive error is unrecognised or inadequately corrected:

• amblyopia may develop

• visual development may stall

• binocular vision may be impaired

• educational performance may be affected

• long-term visual disability may occur

In adults, uncorrected refractive error is inconvenient.

In children, it can be permanently damaging.

This difference sits at the heart of medicolegal assessment.

2. Cycloplegic Refraction: The Standard of Care

Cycloplegia is the gold standard for measuring paediatric refractive error. Without cycloplegia:

• latent hypermetropia is missed

• accommodative spasm may appear as myopia

• anisometropia can be underestimated

• optical correction may be inaccurate

Clinically, the expectation is clear:

• all young children with reduced acuity

• all children with esotropia

• all cases where refractive error is relevant

  must undergo cycloplegic refraction performed correctly and interpreted accurately.

Failure to carry out cycloplegic refraction when indicated is one of the most frequent breaches of duty in paediatric ophthalmology claims.

3. Missed Hypermetropia and Anisometropia: High-Risk Scenarios

Some refractive patterns present a particularly high risk of amblyopia:

A. Moderate to high hypermetropia

If left uncorrected, children may develop accommodative esotropia or bilateral amblyopia.

B. Anisometropia

Even a small difference between the two eyes can suppress input from the weaker eye, causing unilateral amblyopia.

C. High astigmatism

If symmetric and uncorrected, bilateral amblyopia may result.

If asymmetric, unilateral amblyopia is likely.

A reasonably competent clinician is expected to recognise these patterns promptly, prescribe correction, and ensure appropriate follow up.

4. When Delay Becomes Negligence

Negligence arises when a clinician:

• fails to perform cycloplegic refraction at the appropriate time

• misinterprets results

• provides an inadequate prescription

• delays referral to paediatric ophthalmology

• sets overly long review intervals

• fails to escalate management when acuity does not improve

Because visual development is time sensitive, even short delays may be causative.

Solicitors should examine the timeline carefully:

• the child’s age

• when the refractive error should have been identified

• the expected improvement with timely correction

• the consequences of the actual delay

The expert’s task is to quantify not only what happened, but what should have happened.

5. Documentation: A Critical Medico-legal Factor

In paediatric refractive error claims, documentation often reveals the breach.

Red flags include:

• no record of cycloplegia

• no prescription details

• no acuity measurements by age norm

• no documentation of parental communication

• no follow up plan

• no clinical reasoning for review intervals

Where documentation is sparse, courts often infer that the examination was incomplete or substandard.

6. Causation in Refractive Error Claims

The central causation questions are:

• Would timely cycloplegic refraction have identified the refractive error?

• Would earlier optical correction have prevented amblyopia?

• Did delayed or incorrect prescription allow amblyopia to become permanent?

• Were the child’s outcomes modifiable at the time the breach occurred?

Unlike many ophthalmic conditions, causation in refractive error cases is usually straightforward once the timeline is clear.

7. Long-Term Impact and Prognosis

Poorly managed refractive error may lead to:

• permanent unilateral or bilateral amblyopia

• impaired depth perception

• reduced reading speed and educational progress

• limitations in future career choices

• psychosocial impact from visual impairment

• dependency on additional educational support

The expert must present a medically grounded prognosis that reflects the child’s developmental trajectory.

8. Practical Advice for Solicitors

When preparing a refractive error case, solicitors should:

• obtain all optometry, orthoptic, GP, and school vision screening records

• confirm whether cycloplegic refraction was performed

• review acuity measurements over time

• identify gaps in follow up

• seek early medico-legal input to establish whether breach is arguable

• assess whether the child’s age made harm avoidable at the time

Early ophthalmic review is often decisive.

Conclusion

Refractive error in childhood is common, treatable, and time sensitive. When clinicians fail to follow established paediatric standards, the consequences can be permanent. For solicitors, understanding when mismanagement constitutes negligence is crucial to building a strong case.

Correct cycloplegic assessment, timely prescribing, clear documentation, and structured follow up form the foundation of safe practice. When these foundations fail, refractive error becomes a frequent and significant source of medicolegal claim.