2 Heuristic Errors in Medicine: The Patient with a Red Eye Richard K. Reed, M.D., F.A.C.P.
3 History CC: Problem with right eye PI: RJ is a 40 yo female with Downs Syndrome with itching of the right eye for 3 days. She had associated pain in the eye. Her caregiver could not restrain her from rubbing the eye. There was no known history of trauma to the eye. She had no recent URI symptoms.
4 PMH Downs Syndrome – functions as 3 yo Leukemia as a child Stroke as result of complication of chemotherapy for leukemiaObesityHypertensionHyperlipidemiaPrimary hypothyroidismSleep apnea
5 Social History Medications: NKA - HCTZ 25 mg. daily- Lisinopril 10 mg. daily- Levothyroxime 100 mcg. daily- Lovastatin 40 mg. daily- Citalopram 20 mg. daily- D units daily- B mcg dailyNKANo alcohol, tobacco, or other drug abuseNeeds help with most ADLs
6 Family HistoryFather – died recently of complications of diabetes, renovascular hypertension, chronic renal disease, ischemic heart diseaseMother – died in 1980s of metastatic breast cancerAunt – died recently of complications of diabetes and heart failure
7 ROS No recent URI symptoms No headache No fever No known head or eye traumaNo known abuse issues
8 Physical Examination BP 130/80 Pulse 64 RR 16 Temp 97.4 Weight 170# Height 4’7”BMI 39.5 kg/m2No known narcotic or elicit drug useNo tobacco use
9 Physical Examination cont. Gen – obese, Downs phenotype, constantly rubbing her right eyeHEENT-visual acuity – not able to access-examiner difficulty on observing right eye-right eye red with conjunctival suffusion-brief look at cornea- no problem-fundus exam impossible-fluorescein staining – NA-slit lamp exam - NA
10 Physical Examination cont. Neck – shortChest – clearHeart – RRR with no murmurAbdomen – obese, no organomegalyExtremities – mild pretibial edemaNeuro – wheelchair bound; residual neurologic sequelae of mild left hemiparesis
11 Assessment Right red eye – conjunctivitis, iritis or corneal abrasion Downs SyndromeObesity
12 PlanUnsure of correct diagnosis, I referred her to an ophthalmologist.
13 Clinical Course Ophthalmologist 1. He did eye exam the following morning andprescribed eye drops.2. She returned to see him in 4 days.a. Ophthalmologist was apparently unable to adequate exam.b. With suspicion for underlying pathology, he took her tosurgery for exam under anesthesia and found a cornealperforation.c. Evisceration (not enucleation) procedure was performed.d. Prosthetic ball was placed into scleral husk
14 Later Clinical Course Patient would not leave eye guard in place. The ophthalmologist subsequently removed the ball from the scleral husk.The scleral husk was left in place and will atrophy.
15 QuestionAny ideas as to what was the underlying problem with this patient’s eye?
27 Words of WisdomThere is nothing more humbling than the practice of medicine.Continuing Medical Education
28 Bibliographygoogleimages.com IMB low jpg (picture of corneal hydrops)googleimages.com CLS0610 (picture of Munson’s sign)Graber ML, Franklin N, Gordon R. Diagnostic Error in Internal Medicine. Arch Intern Med. 2005;165(13): [PMID: ]. Grewal S, Laibson PR, Cohen EJ. Acute hydrops in the corneal ectasias: associated factors and outcomes. Trans AM Ophthalmology Society 1997; 97:Groopman J. How Doctors Think Houghton Mifflin(picture of keratoconus)MKSAP 15, American College of PhysiciansRedelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005;142(2): [PMID: ]. Rothschild JM, Landrigan CP, Cronin JW, et al. The Critical Care Safety Study: The incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33(8): [PMID: ]. Tuft SJ, Gregory, Wm, Buckley RJ. Acute corneal hydrops. Ophthalmology: Oct. 1994:Vidyarthi A, Arora V, Schnipper J, Wall S, Wachter R. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1(4): [PMID: ].