Queen Victoria Hospital NHS Foundation Trust

7. Mr Y complains about aspects of care and treatment he received from Queen Victoria Hospital NHS Foundation Trust (the Trust) in 2022. He says the surgery that was done in July 2022 was not the right procedure and should not have been done.

8. He also complains that the Trust did not gain his consent to shave his eyelashes off during surgery in October 2022.

9. Mr Y says the incorrect surgery in July meant he had to have further corrective surgery in October and December 2022.

10. He says having to undergo unnecessary surgeries has had a significant impact on his physical and mental health. He says he suffers on a daily basis with pain and discomfort, and his loss of vision impacts on every aspect of his life.

11. He also says the shaving of his eyelashes has had a major knock-on effect as he now does not have this protective barrier to prevent infections and foreign bodies entering his eyes.

12. By bringing this complaint to us, Mr Y would like the Trust to acknowledge the impact its failures have had on him and pay a financial remedy to put things right.

13. Mr Y has a genetic eye disease which was diagnosed after his birth. This is the cause of his ongoing eye problems, and he has had multiple surgeries to try to reduce his pain and discomfort and to help his aesthetic appearance.

14. Mr Y has a number of medical and neurological conditions, which includes a diagnosis of hyperthyroidism, also known as overactive thyroid.

15. Due to Mr Y’s previous corneal (part of the eye) and glaucoma (an eye condition where the main nerve connecting the eye to the brain becomes damaged) procedures, he developed droopy eyelid (ptosis). Mr Y had a ptosis corrective procedure prior to 2022.

16. In April 2022, the Trust explained to Mr Y the hierarchy of treatments. It explained that the first would be to improve his eyelid position and then manage his glaucoma. In turn, it was hoped that this would improve his chances of any corneal grafts being successful.

17. Sadly, Mr Y had developed exposure keratopathy. This is corneal damage caused by incomplete eyelid closure, which leads to dryness, irritation, and vision loss. Treatment for exposure keratopathy focuses on protecting and lubricating the cornea, addressing eyelid closure issues, and preventing complications such as ulceration or infection.

18. In May 2022, the Trust discussed the options available, and it was agreed that a transconjunctival müllerectomy and a left lateral canthopexy would be performed.

19. A transconjunctival müllerectomy is a surgical procedure that involves the removal of the Müller muscle from the conjunctiva of the upper eyelid. The conjunctiva is a thin, transparent membrane that lines the inside of the eyelids and covers the white part of the eye, protecting and lubricating it.

20. A canthopexy is a minor surgical procedure that reinforces and tightens the outer corner of the lower eyelid.

21. In July 2022, the Trust carried out the transconjunctival müllerectomy and left lateral canthopexy on Mr Y. This procedure was performed to correct his upper eyelid drooping, to help straighten his left lower eyelid to match his right side, and to reduce lateral flare and exposure (where the upper eyelid is more elevated at the outer corner).

22. The Trust assessed Mr Y in August 2022. The examination showed he had lost part of the conjunctival sac (a small, fluid-filled space between the eyelid and eyeball for tears and offers protection for the eye). This caused scar tissue to form between Mr Y’s eye and surrounding tissue and limited his eye movement.

23. In October 2022, the Trust carried out surgery to rebuild the lower and outer part of Mr Y’s left conjunctival sac using tissue from inside his mouth. This is known as a buccal membrane graft. It also corrected scarring and inward turning of his eyelids, adjusted his eyelid muscles, placed a small platinum weight in his upper eyelid, and repositioned tissue in his right upper eyelid.

24. In December 2022, the Trust reviewed Mr Y. He complained of constant stinging and pain in the left eye with sticky mucous. On examination, there did not appear to be any sign of infection or inflammation but ingrowing eyelashes. The records indicate the Trust epilated (removed) Mr Y’s eyelashes and replaced the bandage contact lens.

Surgeries in 2022

28. Before we decide if we should conduct a detailed investigation of a complaint, we look at whether there are signs the organisation got something wrong. We do this by comparing what should have happened with what did happen. Having done so, we consider the Trust performed appropriate surgeries in 2022 in line with relevant guidance to reflect good clinical care and treatment.

29. In April 2022 Mr Y had exposure keratopathy and upper eyelid drooping, which was causing corneal damage caused by incomplete eyelid closure. Therefore, the Trust carried out a transconjunctival müllerectomy and canthopexy in July 2022.

30. Mr Y says this surgery should not have been done as it was not the right procedure. He says this meant he had to undergo further corrective surgeries in October and December 2022 that could have been avoided.

31. Europe PMC ‘Transconjunctival Müller muscle recession with levator disinsertion for correction of eyelid retraction associated with TRO’ biomedical research study concludes that a transconjunctival müllerectomy is a safe and effective procedure in the correction of mild, moderate, or severe eyelid retraction in TRO patients. The failure rate is less than 10% and can usually be addressed by a second surgery.

32. GMC ‘Good Medical Practice’ guidance says doctors must use their clinical judgement about the likely effectiveness of treatment options they give to their patients.

33. Eyelid retraction is an abnormal positioning of the upper or lower eyelid, causing the eyelid margin to sit higher or lower than normal, often exposing more of the eye than usual. Thyroid-related orbitopathy (TRO) is most common in patients who have hyperthyroidism, like Mr Y.

34. Our adviser explained that the Trust decided to perform a transconjunctival mullerectomy and left lateral canthopexy to rectify the exposure and to correct Mr Y’s upper eyelid drooping and to help match his left with his right side. They said as Mr Y had incomplete eyelid closure due to the position of his eyelid, and hyperthyroidism, this was the appropriate surgery to undertake.

35. Our adviser also says the additional canthopexy that was done during the surgery in July was also appropriate as the clinician believed this additional part of the surgery would benefit Mr Y to improve his eyelid support and function and to improve the appearance of his eye lid position.

36. The clinician used his clinical judgement and felt that this surgery was the best treatment option, and our adviser has agreed that this was appropriate. Therefore, we consider this was in line with the GMC guidance.

37. Therefore, we consider the surgery performed in July 2022 was appropriate based on Mr Y’s symptoms and was in line with the PMC biomedical research study and GMC guidance.

38. Mr Y says that a consultant has since told him that they felt the surgery undertaken in July 2022 was inappropriate.

39. The records indicate the consultant who examined Mr Y in August believed the surgery undertaken in July probably focused more on trying to improve Mr Y’s aesthetic appearance over achieving better closure and protection of the eye and it would not have been their approach.

40. The Trust maintains this was not a ‘wrong’ procedure and it said Mr Y’s medical complexities, along with the involvement of a number of medical professionals, means it is possible that he will receive differing clinical opinions and views.

41. Our adviser confirms that there will always be differing opinions amongst professionals. As above, we consider the surgery performed was appropriate and in line with the Europe PMC biomedical research study and the original surgeon’s clinical judgement. Therefore, we do not consider the consultant’s differing opinion in August means that the original decision to proceed with the surgery in July was wrong.

42. Mr Y says the incorrect surgery in July meant he had to have further corrective surgery in October and December 2022.

43. As outlined in the Europe PMC research studies, failure rate for a transconjunctival müllerectomy is less than 10% but can usually be addressed by a second surgery. Our adviser explained that this is the reason Mr Y required further surgery in 2022, not because the first was incorrect, but because this did not resolve all the issues for Mr Y.

44. On examination in August 2022, it showed Mr Y had lost part of his conjunctival sac (a small, fluid-filled space between the eyelid and eyeball for tears and offers protection for the eye). This caused scar tissue (symblepharon) to form between the eye and surrounding tissue and limited his eye movement.

45. In October 2022, the Trust carried out surgery to rebuild the lower and outer part of Mr Y’s left conjunctival sac using tissue from inside his mouth (buccal membrane graft). It also corrected scarring and inward turning of his eyelids, adjusted his eyelid muscles, placed a small platinum weight in his upper eyelid, and repositioned tissue in his right upper eyelid.

46. Europe PMC ‘Mucous Membrane Graft’ literature explains that symblepharon can limit extra-ocular movements and can also be sight threatening. Studies have shown that buccal mucous membrane grafts prevent the recurrence of symblepharon. Our adviser confirms that this was an acceptable reconstructive option for the damaged tissues.

47. Therefore, we have seen no evidence to suggest that the corrective surgery in October and December was due to the original surgery being incorrect.

48. We recognise how difficult it has been for Mr Y having many different medical professionals involved in his care and treatment over the years. We also understand how frustrating and confusing it has been for him given the differing clinical opinions he has received.

49. We recognise the profound impact Mr Y’s condition has on his daily life. We understand this impacts both his physical and mental health. Therefore, we appreciate the further upset and distress it has caused when the surgeries have not been as successful as he had hoped for.

50. Having taken everything into account, we consider the Trust performed appropriate surgeries in 2022 in line with GMC guidance and best practice as outlined in medical literature and research studies. We hope this provides Mr Y with the reassurance and closure he needs regarding these surgeries.

Eyelash removal

51. There are times when further investigation of a complaint is impractical and unlikely to reach a satisfactory conclusion for a complainant. We consider this part of Mr Y’s complaint falls into this category.

52. Mr Y says the Trust did not gain his consent to shave his eyelashes off during surgery in October 2022. He says this has had a major knock-on effect as he now does not have these as a protective barrier to prevent infections and foreign bodies entering his eyes.

53. There is documented evidence that Mr Y suffered with issues with his eyelashes earlier than October 2022. In Mr Y’s letter of complaint to the Trust dated 25 January 2021 he complained about ingrown embedded eyelashes that required removal due to the pain and discomfort they were continuing to cause him.

54. The records between 2020 and 2022 also indicate Mr Y had repeatedly raised the issue of ingrowing eyelashes and that he was happy to attend an optician more locally to have them removed rather than having an expensive trip to the Trust to have it done.

55. The Trust says at the time of Mr Y’s eyelid surgery in October 2022, he was found to have a diseased eyelid margin with multiple layers of inturning and aberrant lashes. The Trust explained that it could not give Mr Y reassurance that his inturning lashes were not going to recur had they not been removed. Its records suggest that verbal consent was gained for this.

56. The records from clinic in November 2022 states that there was one eyelash that was long and growing upwards that was removed at Mr Y’s request.

57. The Trust reviewed Mr Y in clinic in December 2022. The records suggest Mr Y was complaining of constant stinging and pain in his left eye with sticky mucous. On examination, the records indicate, there was no sign of infection or inflammation but there were ingrowing eyelashes. The records state the Trust epilated Mr Y’s eyelashes and replaced the bandage contact lens.

58. Having taken everything into account, it appears the Trust had removed Mr Y’s eyelashes on a number of occasions. It also appears that Mr Y’s eyelashes have caused him pain and discomfort over the years.

59. That said, we have two conflicting accounts on whether Mr Y consented to the removal of his eyelashes at the time of the surgery on 4 October 2022. The records imply verbal consent was received for the removal of his eyelashes at each juncture due to the issues they were causing him. However, Mr Y denies that consent was given for them to be removed at this time.

60. It is our view that further consideration of this part of Mr Y’s complaint would not lead to a satisfactory outcome. We understand this will be disappointing to Mr Y. There is no further evidence we can obtain to allow us to come to a decision, even on the balance of probabilities, on whether consent was appropriately gained for his eyelashes to be removed during surgery in October 2022. Therefore, we will not consider this issue any further.

61. We are sorry that Mr Y appears to be at an increased risk of infection because he no longer has his eyelashes to protect his eyes. Sadly, due to the pain and discomfort his eyelashes have caused him over the years, it appears removal could not have been avoided.

1. We have carefully considered Mr Y’s complaint about Queen Victoria Hospital NHS Foundation Trust (the Trust). We are very sorry to hear about Mr Y’s concerns. We understand he has been through many eye operations over the years and how difficult this must have been for him both physically and emotionally.

2. We also appreciate how upsetting and exhausting it has been for him to face further surgeries that he believes were unnecessary. We also understand that he considers these operations caused more harm than good, so we recognise how important this complaint is to him.

3. We have considered all information Mr Y has provided us along with the Trust’s complaint responses. We have also considered Mr Y’s medical records.

4. Having considered all relevant information, we are of the view the Trust carried out appropriate surgeries in 2022.

5. Unfortunately, we do not have enough evidence to reach a decision, even on balance, on whether the Trust gained appropriate consent to remove Mr Y’s eyelashes during surgery in October 2022.

6. Therefore, we will not consider this complaint any further. We have explained the reason for our decision in more detail below.