A checklist for ophthalmology?: a practical case

Ocular pain and glaucoma are associated in doctor,s mind … but this could be an oversimplification prone to error

CLINICAL CASE: A 56 year old man started with a vision problem, like “fog” around electrical lights, without pain. Six months before he had an ophthalmological examination and he had a diagnosis of “exfoliation syndrome” on his right eye.  An ophtalmologist saw him at the Emergency Department and the final diagnosis was a posterior vitreous detachment (PVD).

CLINICAL EVOLUTION: Some days after the patient  noticed  symptoms  like “a spider net moving” or black dot changing the position following the movements of the eyes and a disturbing feeling looking to the computer screen. He went to another ophtalmologist and the retinal examination was normal. He was a health worker and he was trying to recover information about his  intraocular pressure but there was no written information and he didn,t remember if he had  a measure of it  across the diagnostic process. He went back for a third examination asking for a measure of the intraocular pressure. The pressure inside the right eye was over 30. A second diagnosis of glaucoma related with the exfoliation syndrome was established.

ANALYSIS: 

CLASSIFICATION OF THE PROBLEM: Diagnostic Delay

A) COGNITIVE ASPECTS

CLINICAL JUDGMENT:

PVD is a prevalent situation and can be responsible of symptoms like “spider net”, dark points, etc. But in this case the “satisfaction of finding” was a bias because there was another problem , the exfoliation syndrome , that could explained the “fog lights” related to corneal edema after an increase in intraocular pressure.

B) SYSTEM FACTORS:

An important step in an ophtalmological examination is to be sure about intraocular pressure measurement. This key piece of information must be saved at the moment of the examination.  The development of a checklist could be an important improvement and an important safety measure in ophthalmology. Nowdays, ophthalmology is a teamwork, with different doctors with different expertise, separated under anatomical division.

COMMENTS: This common cause of glaucoma is found  In about 10% of the population over age 50, a whitish material, which looks on slit-lamp examination somewhat like tiny flakes of dandruff, builds up on the lens of the eye. This exfoliation material is rubbed off the lens by movement of the iris and at the same time, pigment is rubbed off the iris. Both pigment and exfoliation material clog the trabecular meshwork, leading to IOP elevation, sometimes to very high levels.

Exfoliation syndrome can lead to both open-angle glaucoma and angle-closure glaucoma, often producing both kinds of glaucoma in the same individual. Not all persons with exfoliation syndrome develop glaucoma. However, if you have exfoliation syndrome, your chances of developing glaucoma are about six times as high as if you don´t. It often appears in one eye long before the other, for unknown reasons. If you have glaucoma in one eye only, this is the most likely cause. It can be detected before the glaucoma develops, so that you can be more carefully observed and minimize your chances of vision loss