Medical Malpractice Insights: Corneal abrasion or perforated globe?

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Chuck Pilcher, MD, FACEP

Editor, Medical Malpractice Insights

Editor, Med Mal Insights

Corneal abrasion or perforated globe?

There’s a difference.

Facts: While at a hardware store buying wood for a home project, an adult male with no prior eye problems pulls a piece of lumber off the rack. As he does, he feels something sharp strike his R eye and experiences severe pain and tearing. The store manager helps him wash his eye. No foreign object is seen in the eye, but when pain and tearing persist, EMS is called, and he is taken to the ED. There he asks to see an eye doctor but is sent to fast-track and seen by a PA. Visual acuity is L 20/50, R 20/100. After a limited history and exam (no tonometry or slit lamp exam), he is diagnosed with a corneal abrasion and referred to an ophthalmologist for follow up. He experiences persistent pain, tearing and decreased vision until seen by the ophthalmologist 2 days later. The ophthalmologist quickly finds a perforated, misshapen globe with loss of aqueous (and possibly vitreous) fluid. Immediate surgery is performed, but he is left with no useful vision in that eye. An attorney is contacted and a lawsuit filed.

Plaintiff: My injury was severe enough that an ambulance was called. I knew this was serious and asked to see an eye doctor when I arrived. You didn’t document details about what happened. My pain and tearing were excessive. You didn’t check the pressure in my eye. You didn’t use a slit lamp, and when my attorney deposed you, you couldn’t even explain how one works – or define the word “ptosis.” You just treated me as a routine corneal abrasion and never considered that my globe might be punctured. And you teach differential diagnosis to other PA students? Now my right eye is useless.

Defense: Your history and exam were typical of a corneal abrasion. Yes, you were tearing a lot, but corneal abrasions cause tearing. Yes, aqueous fluid may be a bit thicker than tears, but I thought your leakage was only tears. When I checked your eye with a Woods lamp, I could see an abrasion over your medial iris. And if you had asked me to call an ophthalmologist, I would have. I always do that.

Result: Pre-trial settlement against the hospital and its employed PA for undisclosed amount. Hardware store also paid a small amount (for unknown reasons).

Takeaways:

• Always take a history that differentiates between a simple abrasion and a more forceful strike to the eye.
• Consider perforation in the differential of any corneal abrasion. A good history and exam of the “tears” can usually eliminate it from the differential.
• Perform a full examination of the eye. Always obtain visual acuities, and use a slit lamp on all injuries to the eye.
• Do a Seidel Test (see video). while looking for a foreign body or corneal abrasion. https://www.youtube.com/watch?v=GlFcAv0DR4c

Reference:

• Corneal Laceration. Adesina A, Medscape eMedicine, September 20, 2018. https://emedicine.medscape.com/article/798005-overview
• See also: Conjunctivitis or endophthalmitis?. Med Mal Insights, September, 2016. https://madmimi.com/s/7d832c