The Importance of Taking an Appropriate History and Correctly Examining Eye Injuries
According to medical reports, a workplace eye injury and subsequent misdiagnosis in a hospital A&E department led to a long-lasting reduction in a patient’s quality of vision.
In this unfortunate case, the worker presented in the accident and emergency department of an NHS hospital with a painful, watering eye and blurred vision. While the employee had been working manually, something had hit the affected eye. An examination confirmed reduced visual acuity and the duty doctor diagnosed corneal abrasion before prescribing antibiotic ointment and discharging the patient.
Within a few days, however, the injured person returned to the same A&E department, unable to see detail and only able to perceive light or darkness through the damaged eye. Further hospital examination revealed corneal laceration with an entrapped iris and a hypopyon, i.e., a layering of white blood cells indicating severe inflammation. Concerned staff duly ordered an x-ray, which showed a splintered metal object in the ocular cavity with accompanying endophthalmitis (purulent inflammation) and a detached retina. Despite several subsequent surgical operations, doctors eventually informed the patient that vision would not improve.
Learning Points
On review, investigators noted that during the original consultation after the workplace incident, the practitioner(s) did not adequately consider the patient’s history, nor the detail of the mechanism which caused the injury.
Secondly, the intraocular foreign body went undetected on the first examination. As a result, there was no appropriate follow up such as a referral to the hospital’s ophthalmology team.
Recommendations
Medical experts arrived at several recommendations to limit the recurrence of such incidents and improve patient safety. Crucially, A&E staff should fully consider the history, circumstances and preceding events in patients presenting with eye injuries.
In this case, if the triage nurse(s) or attending doctor had noted sufficient detail from the worker’s account of events, it would have come to their attention that the injury had occurred while hitting metal on metal without wearing suitable facial protection. Such a background narrative would immediately have suggested the possibility of penetration by a foreign body.
To ensure a correct diagnosis, full examinations of both the front and back areas of injured eyes are essential. If clinicians are unable to examine the posterior part of patients’ eyes satisfactorily, they should refer to an ophthalmologist without delay.
Had the patient received a proper examination, staff would have noted the lacerated cornea and duly requested an x-ray to confirm the presence or absence of a foreign body – even if the latter had not been noticeable on visual inspection. Moreover, an accurate diagnosis during the initial presentation could well have led to an improved outcome with better recovery of vision.
Injuries or incidents that involve possible intraocular foreign bodies ought to receive urgent investigation by CT scan or X-ray, along with an ophthalmologic referral. Proper evaluation and, where necessary, a detailed examination is essential within a maximum of twelve to twenty-four hours of such trauma. Sadly, investigators observed, if the patient had been treated correctly within the first day of attending A&E, the infection would likely not have developed. Consequently, the ensuing eye operations would not have been necessary and the outcome more positive.
Summary
Taking sufficient patient history and carrying out proper examinations in eye injury cases – including imaging – are critical. When the cause of an injury is a high-speed projectile object and there is any suspicion of penetration by a foreign body, further investigation is crucial.