A Case Example
The patient, in this case, attended A&E with a painful, watery eye with blurred vision having felt something hit their eye at work. The patient’s visual acuity was reduced in the painful eye and they were diagnosed with corneal abrasion and discharged with antibiotic ointment.
A few days later, the patient reattended A&E with only light perception in the eye. Upon examination the patient was found to have corneal laceration with iris entrapment and a hypopyon. An x-ray was undertaken which showed an intraocular foreign body and a formal ophthalmic examination revealed endophthalmitis and retinal detachment. Following multiple operations, the patient was informed that their vision would not improve.
The main learning points from this review stem from the following events:
- The original consultation did not take into account the full history and mechanism of the injury.
- The original examination did not reveal the intraocular foreign body and the appropriate investigations were not carried out.
- The original examination did not result in a referral to the ophthalmology team.
Recommendations to Prevent Incident Recurrence and Improve Patient Safety
TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:
It’s important that all A&E clinicians take full consideration of history and events leading up to eye injuries. In this case, an appropriate history would have revealed that the patient was hitting metal on metal without any protective eywear when he felt something hit his eye.This history alone should have suggested to the clinician the possibility of an intraocular foreign body
Full examination of the front and back of the eye should be taken in order to ensure a correct diagnosis. This includes a full dilated examination and an X-ray and/or CT scan. If clinicians feel unable to examine the posterior segment sufficiently, they should be referred to an ophthalmologist. In this case, had a full examination been undertaken it would have identified a corneal laceration. An X-ray would have been taken which would have identified the intraocular foreign body even if this hadn’t been seen on examination. Had the patient been diagnosed and treated appropriately on initial presentation, their visual outcome would have improved.
- Any definite or suspected intraocular foreign bodies should be urgently investigated with Xray/CT scan and referred to ophthalmology and on balance are treated within 12-24 hours.. In this case, had the patient had been treated appropriately within 24 hours of the first A&E attendance, the patient would have not developed infection, would have required feewer operations and would have had a better visual outcome.
TMLEP would like to highlight the importance of taking a full, relevant history and carrying out full examinations of eye injuries including appropriate imaging when a history suggests impact with high speed or high impact projectiles.
If there is any suspicion of penetrating injury or intraocular foreign body, further examination and investigation by an ophthalmologist should be considered.