Diagnostic Assessment — Bilateral Conjunctivitis
Example 1 of 1 · fictitious patient
Diagnostic Assessment Bilateral Conjunctivitis BOP Code: 77 of 2020 (Conjunctivitis) RH Code: 76 of 2020 (Conjunctivitis)
ADF History
The veteran, date of birth [withheld], Royal Australian Air Force, Airfield Defence Guard, 16 November 1985 to 1 September 1992
Occupational History
Conjunctivitis (bacterial or viral) is commonly acquired in communal living environments such as service vessels and barracks, where close quarters and shared facilities facilitate transmission of infectious agents
History
The veteran's first documented episode of conjunctivitis was on 22 February 1986 at an airbase, when he complained of burning behind the eyes in the sun and his eyes going red, with no discharge; the eyes were mildly injected and the medical officer diagnosed allergic conjunctivitis [CHART REVIEW document].
He later had bilateral conjunctivitis during service at an airbase.
He presented with a 4-day history of gritty eyes and waking with eyes stuck shut.
Examination revealed bilateral red sclera and multiple pustules on the inner surfaces of both eyelids, consistent with bacterial conjunctivitis
Timeline
22 Feb 1986 — JR the veteran presented at an airbase complaining of burning behind the eyes in the sun, with his eyes going red and no discharge.
On examination the eyes were mildly injected. "Allergic conjunctivitis" Date during service at an airbase (exact date not clearly documented) — ABSR the veteran presented with a 4-day history of gritty eyes.
He reported waking up with his eyes stuck shut.
Examination demonstrated bilateral red sclera and multiple pustules on the inner surfaces of both eyelids.
Chloromycetin drops were prescribed four-hourly and Chloromycetin ointment at night. "Conjunctivitis"
Symptoms
In February 1986 (an airbase), burning behind the eyes in the sun and red eyes without discharge, with mildly injected eyes on examination (allergic conjunctivitis).
Subsequently (an airbase), bilateral gritty eyes, crusting on waking (eyes stuck shut), red sclera, and multiple pustules on the inner eyelid surfaces bilaterally, consistent with bacterial conjunctivitis
Imaging
No imaging related to this condition
1. What is the formal diagnosis of the condition claimed above?
Bilateral Conjunctivitis (ICD-10: H10.33).
Conjunctivitis is inflammation of the conjunctiva characterised by redness, discharge, and discomfort.
The presence of bilateral pustules suggests bacterial aetiology
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? On or before 22 February 1986, when he reported burning behind the eyes in the sun and red eyes at an airbase [CHART REVIEW document] When did the veteran first present to a health / medical provider for this condition? 22 February 1986, medical officer at an airbase [CHART REVIEW document] When was the condition confirmed / formally diagnosed? 22 February 1986, clinical diagnosis of allergic conjunctivitis by the medical officer at an airbase [CHART REVIEW document]; conjunctivitis diagnosed again during service at an airbase When did the veteran first present to you (or your practice) for this condition? 29 March 2017
3. How was this diagnosis confirmed?
Clinical diagnosis of allergic conjunctivitis by the medical officer at an airbase on 22 February 1986, based on burning behind the eyes in the sun, red eyes without discharge and mildly injected eyes on examination [CHART REVIEW document].
Subsequent clinical diagnosis by the medical officer at an airbase based on bilateral red sclera with pustules on inner eyelid surfaces [CHART REVIEW document]
4. What do you consider to be the cause(s) of the condition in this veteran?
Legislation: The clinical onset of this condition was before 13 February 2006 (see
Date of Clinical Onset
Below), and it did not arise on warlike or non-warlike deployment (the veteran had no deployments).
This is therefore a DRCA claim.
Statements of Principles do not apply to DRCA claims, so there are no binding SOP factors for this condition.
The factors of the relevant Statements of Principles are applied below by analogy, as a guide to the causes of this condition that are recognised in the medical-scientific literature, and every factor of both the Balance of Probabilities and the Reasonable Hypothesis instruments is addressed.
Under the DRCA the question is whether the injury or disease arose out of, or in the course of, the veteran's ADF service, or (for a disease or an aggravation) whether that service contributed to it to a significant degree.
Plausible links to service outside the SOP factors are set out below.
The absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Conjunctivitis, No.
77 of 2020) Factor 9(1): having blepharitis of the affected eye at the time of the clinical onset of conjunctivitis — NOT MET - No blepharitis was recorded at the onset; on 22 February 1986 the medical officer at an airbase found only mildly injected eyes without discharge and diagnosed allergic conjunctivitis.
Factor 9(2): having an infection of the conjunctiva of the affected eye at the time of the clinical onset of conjunctivitis — NOT MET - At the clinical onset on or before 22 February 1986 the eyes were mildly injected without discharge, and the medical officer diagnosed allergic, not infective, conjunctivitis; bacterial infection of the conjunctiva was first recorded in January 1992.
Factor 9(3): having a condition of the affected eye from the specified list of conditions at the time of the clinical onset of conjunctivitis — NOT MET - No disorder of the nasolacrimal duct or gland, ectropion, exophthalmos or lid retraction has been recorded; the veteran's only other eye history is a childhood left squint repair and a refractive error, neither of which is on the specified list.
Factor 9(4): having a condition that causes chronic lack of sufficient lubrication and moisture on the surface of the affected eye at the time of the clinical onset of conjunctivitis — NOT MET - No dry-eye condition or other cause of chronic lack of lubrication of the ocular surface was recorded at or before 22 February 1986, and none was found at his ophthalmological reviews of 1987, 1988 and 1989.
Factor 9(5): having ocular or periocular exposure to an allergen within the 24 hours before the clinical onset of conjunctivitis — MET - On 22 February 1986, three months after enlisting as an adult Airfield Defence Guard, the veteran told the medical officer at an airbase of burning in the eyes in the sun, with the eyes going red and no discharge; the eyes were mildly injected, and allergic conjunctivitis was diagnosed and treated with Antistine-Privine antihistamine drops.
Allergic conjunctivitis is an immune reaction of the conjunctiva to an allergen in contact with the eye and develops within minutes to hours of that contact, so the ocular exposure occurred within the 24 hours before the clinical onset.
The allergen was not identified, but recruit barracks and outdoor training exposed him daily to airborne allergens such as dust, mites and pollens.
Factor 9(5A): having a sensitising exposure to an allergen before the clinical onset of conjunctivitis — MET - Allergic conjunctivitis, diagnosed at an airbase on 22 February 1986, is an IgE-mediated reaction that can occur only after an earlier exposure to the same allergen has sensitised the immune system, and that sensitising exposure produces no symptoms.
The reaction then follows re-exposure within minutes to hours, well within the two weeks the definition allows.
The diagnosis therefore establishes a sensitising exposure to an allergen before the clinical onset on or before 22 February 1986.
No eye allergy was declared at his enlistment medical on 14 September 1985, and the sensitisation may have occurred before enlistment or in his first three months of service, after he moved from an airbase to recruit training in Western Australia.
Factor 9(6): having an autoimmune disease at the time of the clinical onset of conjunctivitis — NOT MET - No autoimmune disease has been recorded at any time, and nothing in the veteran's history suggests one.
Factor 9(7): having graft versus host disease at the time of the clinical onset of conjunctivitis — NOT MET - Graft versus host disease follows stem cell or bone marrow transplantation, which the veteran has never undergone.
Factor 9(8): having diabetes mellitus at the time of the clinical onset of conjunctivitis — NOT MET - the veteran's diabetes mellitus was diagnosed in 2022, about 36 years after the clinical onset of conjunctivitis on or before 22 February 1986, and urinalysis during service was normal.
Factor 9(9): having topical medication applied to the affected eye within the 48 hours before the clinical onset of conjunctivitis — NOT MET - No medication was applied to the eyes before the onset; the Antistine-Privine drops were first prescribed at the consultation of 22 February 1986, after the symptoms had begun.
Factor 9(10): taking a drug from the specified list of drugs for at least the seven days before the clinical onset of conjunctivitis — NOT MET - No drug from the specified list is recorded in the seven days before 22 February 1986 or at any earlier time.
Factor 9(11): taking a drug which is associated in the individual with the development of conjunctivitis during drug therapy and either: (a) the improvement of conjunctivitis within seven days of discontinuing or tapering drug therapy; or (b) the redevelopment of conjunctivitis on rechallenge with the same drug; where treatment with the drug continued for at least the seven days before the clinical onset of conjunctivitis — NOT MET - No drug has been associated in the veteran with the development of conjunctivitis, and no improvement on withdrawal or recurrence on rechallenge of any drug has been recorded.
Factor 9(12): having ocular or periocular exposure to an irritant substance within the 24 hours before the clinical onset of conjunctivitis — NOT MET - There is no record of ocular or periocular exposure to an irritant chemical in the 24 hours before 22 February 1986, and the medical officer attributed the burning, red eyes to allergy rather than to a chemical.
Factor 9(13): having mustard gas exposure to the affected eye within the 24 hours before the clinical onset of conjunctivitis — NOT MET - There is no record of mustard gas exposure, and nothing in the veteran's service history suggests it.
Factor 9(14): having a foreign body in contact with the affected conjunctiva within the 24 hours before the clinical onset of conjunctivitis — NOT MET - No foreign body in either eye was recorded in the 24 hours before 22 February 1986, and the bilateral, sun-provoked symptoms and the diagnosis of allergic conjunctivitis do not suggest one.
Factor 9(15): having an injury to the conjunctiva of the affected eye within the 24 hours before the clinical onset of conjunctivitis — NOT MET - No injury to either conjunctiva was recorded in the 24 hours before 22 February 1986; the rugby tackle three days earlier caused a lumbar strain, with no eye involvement.
Factor 9(16): undergoing a course of therapeutic radiation for cancer, where the region of the affected eye was in the field of radiation, at the time of the clinical onset of conjunctivitis — NOT MET - the veteran has never undergone radiotherapy for cancer, and nothing in his history suggests it.
Factor 9(17): having a benign or malignant neoplasm affecting the conjunctiva or eyelid margin of the affected eye at the time of the clinical onset of conjunctivitis — NOT MET - No neoplasm of the conjunctiva or eyelid margin has been recorded; the benign naevus and epidermal cyst excised from the left eyebrow in February 1990 lay on the eyebrow, not the lid margin.
Factor 9(18): being in an immunocompromised state as specified at the time of the clinical onset of conjunctivitis — NOT MET - In February 1986 the veteran was a healthy adult with no immunosuppressive drug, malignancy, chronic renal failure, HIV infection, severe malnutrition or transplant, so he was not immunocompromised as specified.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Conjunctivitis, No.
76 of 2020) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(1): having blepharitis of the affected eye at the time of the clinical onset of conjunctivitis — NOT MET - No blepharitis was recorded at the onset; on 22 February 1986 the medical officer at an airbase found only mildly injected eyes without discharge and diagnosed allergic conjunctivitis.
Factor 9(2): having an infection of the conjunctiva of the affected eye at the time of the clinical onset of conjunctivitis — NOT MET - At the clinical onset on or before 22 February 1986 the eyes were mildly injected without discharge, and the medical officer diagnosed allergic, not infective, conjunctivitis; bacterial infection of the conjunctiva was first recorded in January 1992.
Factor 9(3): having a condition of the affected eye from the specified list of conditions at the time of the clinical onset of conjunctivitis — NOT MET - No disorder of the nasolacrimal duct or gland, ectropion, exophthalmos or lid retraction has been recorded; the veteran's only other eye history is a childhood left squint repair and a refractive error, neither of which is on the specified list.
Factor 9(4): having a condition that causes chronic lack of sufficient lubrication and moisture on the surface of the affected eye at the time of the clinical onset of conjunctivitis — NOT MET - No dry-eye condition or other cause of chronic lack of lubrication of the ocular surface was recorded at or before 22 February 1986, and none was found at his ophthalmological reviews of 1987, 1988 and 1989.
Factor 9(5): having ocular or periocular exposure to an allergen within the 24 hours before the clinical onset of conjunctivitis — MET - On 22 February 1986 the medical officer at an airbase diagnosed allergic conjunctivitis of both eyes (burning and redness in the sun, no discharge, mildly injected eyes) and prescribed Antistine-Privine antihistamine drops.
Allergic conjunctivitis is a reaction of the conjunctiva to an allergen in contact with the eye that begins within minutes to hours of the contact, so ocular exposure to an allergen, unidentified but encountered in the barracks and outdoor training environment of recruit life, occurred within the 24 hours before the clinical onset.
Factor 9(5A): having a sensitising exposure to an allergen before the clinical onset of conjunctivitis — MET - The allergic conjunctivitis diagnosed on 22 February 1986 is an immune reaction that requires prior sensitisation by an earlier, symptom-free exposure to the same allergen, with symptoms following re-exposure within minutes to hours, well inside two weeks.
A sensitising exposure to an allergen therefore occurred before the clinical onset, whether before enlistment (no eye allergy was declared on 14 September 1985) or during his first months of recruit training at an airbase.
Factor 9(6): having an autoimmune disease at the time of the clinical onset of conjunctivitis — NOT MET - No autoimmune disease has been recorded at any time, and nothing in the veteran's history suggests one.
Factor 9(7): having graft versus host disease at the time of the clinical onset of conjunctivitis — NOT MET - Graft versus host disease follows stem cell or bone marrow transplantation, which the veteran has never undergone.
Factor 9(8): having diabetes mellitus at the time of the clinical onset of conjunctivitis — NOT MET - the veteran's diabetes mellitus was diagnosed in 2022, about 36 years after the clinical onset of conjunctivitis on or before 22 February 1986, and urinalysis during service was normal.
Factor 9(9): having topical medication applied to the affected eye within the 48 hours before the clinical onset of conjunctivitis — NOT MET - No medication was applied to the eyes before the onset; the Antistine-Privine drops were first prescribed at the consultation of 22 February 1986, after the symptoms had begun.
Factor 9(10): taking a drug from the specified list of drugs for at least the seven days before the clinical onset of conjunctivitis — NOT MET - No drug from the specified list is recorded in the seven days before 22 February 1986 or at any earlier time.
Factor 9(11): taking a drug which is associated in the individual with the development of conjunctivitis during drug therapy and either: (a) the improvement of conjunctivitis within seven days of discontinuing or tapering drug therapy; or (b) the redevelopment of conjunctivitis on rechallenge with the same drug; where treatment with the drug continued for at least the seven days before the clinical onset of conjunctivitis — NOT MET - No drug has been associated in the veteran with the development of conjunctivitis, and no improvement on withdrawal or recurrence on rechallenge of any drug has been recorded.
Factor 9(12): having ocular or periocular exposure to an irritant substance within the 24 hours before the clinical onset of conjunctivitis — NOT MET - There is no record of ocular or periocular exposure to an irritant chemical in the 24 hours before 22 February 1986, and the medical officer attributed the burning, red eyes to allergy rather than to a chemical.
Factor 9(13): having mustard gas exposure to the affected eye within the 24 hours before the clinical onset of conjunctivitis — NOT MET - There is no record of mustard gas exposure, and nothing in the veteran's service history suggests it.
Factor 9(14): having a foreign body in contact with the affected conjunctiva within the 24 hours before the clinical onset of conjunctivitis — NOT MET - No foreign body in either eye was recorded in the 24 hours before 22 February 1986, and the bilateral, sun-provoked symptoms and the diagnosis of allergic conjunctivitis do not suggest one.
Factor 9(15): having an injury to the conjunctiva of the affected eye within the 24 hours before the clinical onset of conjunctivitis — NOT MET - No injury to either conjunctiva was recorded in the 24 hours before 22 February 1986; the rugby tackle three days earlier caused a lumbar strain, with no eye involvement.
Factor 9(16): undergoing a course of therapeutic radiation for cancer, where the region of the affected eye was in the field of radiation, at the time of the clinical onset of conjunctivitis — NOT MET - the veteran has never undergone radiotherapy for cancer, and nothing in his history suggests it.
Factor 9(17): having a benign or malignant neoplasm affecting the conjunctiva or eyelid margin of the affected eye at the time of the clinical onset of conjunctivitis — NOT MET - No neoplasm of the conjunctiva or eyelid margin has been recorded; the benign naevus and epidermal cyst excised from the left eyebrow in February 1990 lay on the eyebrow, not the lid margin.
Factor 9(18): being in an immunocompromised state as specified at the time of the clinical onset of conjunctivitis — NOT MET - In February 1986 the veteran was a healthy adult with no immunosuppressive drug, malignancy, chronic renal failure, HIV infection, severe malnutrition or transplant, so he was not immunocompromised as specified.
Other Plausible Links to Service The infective recurrences of January 1992 arose at an airbase during a run of respiratory infections recorded that year: purulent tonsillitis with painful ears and sore eyes on 16 November 1991, an upper respiratory infection with right otitis media and left conjunctivitis on 21 January 1992, the bilateral purulent conjunctivitis that followed, and a further upper respiratory infection and influenza-like illness on 27 and 11 April 1992.
Bacterial conjunctivitis spreads by direct and indirect contact through hands, towels and shared surfaces, and it often accompanies upper respiratory and middle-ear infections caused by the same organisms.
The close-contact conditions of a service establishment, with shared working spaces, messes and ablution facilities, favour the transmission of such infections, and it is reasonable to conclude that the infective conjunctivitis was contracted in the course of his service and contributed to by its conditions.
The first episode arose at an airbase on or before 22 February 1986, three months after the veteran enlisted as a young adult and moved from an airbase to the Airfield Defence Guard training establishment in Western Australia; at his enlistment medical on 14 September 1985 he declared no eye allergy, only a childhood squint operation.
The allergic conjunctivitis developed while he was living in recruit barracks and training outdoors, and its symptoms were provoked by the sun during the outdoor activity his training required, so it arose in the course of his employment as a member.
Outdoor exposure to sun, glare and wind, which irritates the ocular surface, remained part of his duties ashore and at sea as an Airfield Defence Guard, and his eyes stayed sensitive to glare from 1987 to 1992, when sunglasses were advised and tinted spectacles were later prescribed.
Conclusion the veteran's conjunctivitis began at an airbase on or before 22 February 1986, three months into his service as an adult Airfield Defence Guard, as allergic conjunctivitis of both eyes caused by ocular exposure to an allergen to which he had been sensitised, with symptoms provoked by the sun during outdoor training (factors 9(5) and 9(5A)).
It recurred at an airbase in January 1992 as bacterial conjunctivitis, first of the left eye and then of both eyes, arising with an upper respiratory infection and otitis media in the close-contact service environment (factor 9(20)), and was managed with drops alone, without investigation or specialist referral, even when it spread despite treatment (factor 9(37)).
Whether the 1992 episodes are regarded as recurrences of the 1986 condition or as a new infective conjunctivitis with its own onset at an airbase, every recorded episode arose during his ADF service from exposures encountered in the course of that service.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's conjunctivitis is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset (on or before 22 February 1986) aggravated it or contributed to it in a material degree.
The recorded clinical worsenings are the recurrences at an airbase in January 1992, in the left eye on 21 January 1992 and then in both eyes with pustules on the inner lid surfaces; the injected conjunctivae noted on 24 July 1986, at an examination after he had been drinking, were not diagnosed as conjunctivitis.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Conjunctivitis, No.
77 of 2020) Factor 9(19): having blepharitis of the affected eye at the time of the clinical worsening of conjunctivitis — NOT MET - The January 1992 records describe pustules on the inner (conjunctival) surfaces of the lids and eyes stuck shut by discharge, but no inflammation of the lid margins, and the medical officer diagnosed conjunctivitis, not blepharitis.
Factor 9(20): having an infection of the conjunctiva of the affected eye at the time of the clinical worsening of conjunctivitis — MET - On 21 January 1992 at an airbase, during an upper respiratory infection with sore throat, blocked sinuses, heavy rhinorrhoea and right otitis media, the veteran's left eye was red and stuck closed in the morning; the medical officer diagnosed conjunctivitis and prescribed Chloromycetin (chloramphenicol) drops with oral Keflex.
An undated an airbase record from about January 1992 then documents several days of gritty eyes, markedly red sclerae, both eyes stuck shut on waking and multiple pustules on the inner lid surfaces, treated with four- hourly Chloromycetin drops and ointment at night.
These are the features of a bacterial infection of the conjunctiva, present in the affected eyes at the time of the clinical worsening during service.
Factor 9(21): having a condition of the affected eye from the specified list of conditions at the time of the clinical worsening of conjunctivitis — NOT MET - No disorder of the nasolacrimal duct or gland, ectropion, exophthalmos or lid retraction was recorded at the time of the January 1992 recurrences or at any other time.
Factor 9(22): having a condition that causes chronic lack of sufficient lubrication and moisture on the surface of the affected eye at the time of the clinical worsening of conjunctivitis — NOT MET - No dry-eye condition or other cause of chronic lack of lubrication of the ocular surface was recorded at the time of the January 1992 recurrences, and the ophthalmologist attributed his sensitivity to glare to his fair complexion and blue eyes, not to dryness.
Factor 9(23): having ocular or periocular exposure to an allergen within the 24 hours before the clinical worsening of conjunctivitis — NOT MET - The January 1992 recurrences were infective, with matted eyes and pustules, arising with an upper respiratory infection and treated with antibiotics; no allergic features or allergen exposure were recorded in the 24 hours before them.
Factor 9(24): having an autoimmune disease at the time of the clinical worsening of conjunctivitis — NOT MET - No autoimmune disease has been recorded at any time, and nothing in the veteran's history suggests one.
Factor 9(25): having graft versus host disease at the time of the clinical worsening of conjunctivitis — NOT MET - Graft versus host disease follows stem cell or bone marrow transplantation, which the veteran has never undergone.
Factor 9(26): having diabetes mellitus at the time of the clinical worsening of conjunctivitis — NOT MET - Diabetes mellitus was diagnosed in 2022, three decades after the recorded recurrences of January 1992, and no clinical worsening of conjunctivitis has been recorded since its diagnosis.
Factor 9(27): having topical medication applied to the affected eye within the 48 hours before the clinical worsening of conjunctivitis — MET - On 21 January 1992 the medical officer at an airbase prescribed Chloromycetin (chloramphenicol) drops four times a day for the veteran's red, matted left eye.
The undated an airbase record that followed, from about January 1992, documents a clinical worsening, with both eyes markedly red and stuck shut on waking and pustules on the inner lid surfaces, and increased the drops to four-hourly with ointment at night, showing that the drops were in use as the worsening developed.
Topical medication was therefore applied to the affected eye within the 48 hours before the clinical worsening, although the infection the drops were treating remained the principal driver of the worsening.
Factor 9(28): taking a drug from the specified list of drugs for at least the seven days before the clinical worsening of conjunctivitis — NOT MET - No drug from the specified list was taken in the seven days before the January 1992 recurrences; temazepam (Normison), a benzodiazepine, was first prescribed in May 1992, and lorazepam only after service, with no worsening of conjunctivitis recorded in either period.
Factor 9(29): taking a drug which is associated in the individual with: (a) the worsening of conjunctivitis during drug therapy; and (b) the improvement of conjunctivitis within seven days of discontinuing or tapering drug therapy; where treatment with the drug continued for at least the seven days before the clinical worsening of conjunctivitis — NOT MET - No drug has been associated in the veteran with a worsening of conjunctivitis followed by improvement within seven days of stopping or tapering it.
Factor 9(30): having ocular or periocular exposure to an irritant substance within the 24 hours before the clinical worsening of conjunctivitis — NOT MET - No ocular exposure to an irritant chemical was recorded in the 24 hours before the January 1992 recurrences, which arose with an upper respiratory infection and had the features of bacterial infection.
Factor 9(31): having mustard gas exposure to the affected eye within the 24 hours before the clinical worsening of conjunctivitis — NOT MET - There is no record of mustard gas exposure, and nothing in the veteran's service history suggests it.
Factor 9(32): having a foreign body in contact with the affected conjunctiva within the 24 hours before the clinical worsening of conjunctivitis — NOT MET - The only recorded eye foreign-body incident, to the right eye on 22 September 1991 while cutting timber with a circular saw (no foreign body was found), occurred four months before the January 1992 recurrences, outside the 24-hour window.
Factor 9(33): having an injury to the conjunctiva of the affected eye within the 24 hours before the clinical worsening of conjunctivitis — NOT MET - The small corneal abrasion of the right eye sustained on 22 September 1991 while cutting timber with a circular saw occurred four months before the January 1992 recurrences, outside the 24-hour window, and no other eye injury was recorded.
Factor 9(34): undergoing a course of therapeutic radiation for cancer, where the region of the affected eye was in the field of radiation, at the time of the clinical worsening of conjunctivitis — NOT MET - the veteran has never undergone radiotherapy for cancer, and nothing in his history suggests it.
Factor 9(35): having a benign or malignant neoplasm affecting the conjunctiva or eyelid margin of the affected eye at the time of the clinical worsening of conjunctivitis — NOT MET - The benign dermal naevus and epidermal cyst excised from the left eyebrow in February 1990 did not involve the conjunctiva or eyelid margin and were removed two years before the January 1992 recurrences; no other ocular neoplasm is recorded.
Factor 9(36): being in an immunocompromised state as specified at the time of the clinical worsening of conjunctivitis — NOT MET - In January 1992 the veteran had no immunosuppressive drug, malignancy, chronic renal failure, HIV infection, severe malnutrition or transplant, and his full blood count in 1991 was normal, so he was not immunocompromised as specified.
Factor 9(37): inability to obtain appropriate clinical management for conjunctivitis — MET - the veteran presented with conjunctivitis on 22 February 1986, 21 January 1992 and again about January 1992, and each time was treated promptly but with eye drops alone, without a conjunctival swab, culture or ophthalmological referral, even when the infection spread from the left eye to both eyes, with pustules on the inner lid surfaces, despite chloramphenicol drops. an airbase had been unable to locate his medical record in September 1991, so the officers treating him in January 1992 may not have had his earlier eye history.
Recurrent presentations managed conservatively without investigation or specialist referral indicate an inability to obtain appropriate clinical management, assessed objectively as well as subjectively (Brew v Repatriation Commission, Full Federal Court, 10 September 1999, Merkel J).
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Conjunctivitis, No.
76 of 2020) the veteran had no operational deployments.
The Reasonable Hypothesis standard applies only to operational service, so these factors are assessed for completeness and, like the Balance of Probabilities factors, by analogy only.
Factor 9(19): having blepharitis of the affected eye at the time of the clinical worsening of conjunctivitis — NOT MET - The January 1992 records describe pustules on the inner (conjunctival) surfaces of the lids and eyes stuck shut by discharge, but no inflammation of the lid margins, and the medical officer diagnosed conjunctivitis, not blepharitis.
Factor 9(20): having an infection of the conjunctiva of the affected eye at the time of the clinical worsening of conjunctivitis — MET - The recurrences at an airbase in January 1992 were infective: on 21 January 1992 the left eye was red and stuck closed in the morning during an upper respiratory infection with otitis media, and an undated record from about January 1992 documents both eyes markedly red and stuck shut on waking, with pustules on the inner lid surfaces, treated with chloramphenicol drops and ointment.
A bacterial infection of the conjunctiva of the affected eyes was therefore present at the time of the clinical worsening.
Factor 9(21): having a condition of the affected eye from the specified list of conditions at the time of the clinical worsening of conjunctivitis — NOT MET - No disorder of the nasolacrimal duct or gland, ectropion, exophthalmos or lid retraction was recorded at the time of the January 1992 recurrences or at any other time.
Factor 9(22): having a condition that causes chronic lack of sufficient lubrication and moisture on the surface of the affected eye at the time of the clinical worsening of conjunctivitis — NOT MET - No dry-eye condition or other cause of chronic lack of lubrication of the ocular surface was recorded at the time of the January 1992 recurrences, and the ophthalmologist attributed his sensitivity to glare to his fair complexion and blue eyes, not to dryness.
Factor 9(23): having ocular or periocular exposure to an allergen within the 24 hours before the clinical worsening of conjunctivitis — NOT MET - The January 1992 recurrences were infective, with matted eyes and pustules, arising with an upper respiratory infection and treated with antibiotics; no allergic features or allergen exposure were recorded in the 24 hours before them.
Factor 9(24): having an autoimmune disease at the time of the clinical worsening of conjunctivitis — NOT MET - No autoimmune disease has been recorded at any time, and nothing in the veteran's history suggests one.
Factor 9(25): having graft versus host disease at the time of the clinical worsening of conjunctivitis — NOT MET - Graft versus host disease follows stem cell or bone marrow transplantation, which the veteran has never undergone.
Factor 9(26): having diabetes mellitus at the time of the clinical worsening of conjunctivitis — NOT MET - Diabetes mellitus was diagnosed in 2022, three decades after the recorded recurrences of January 1992, and no clinical worsening of conjunctivitis has been recorded since its diagnosis.
Factor 9(27): having topical medication applied to the affected eye within the 48 hours before the clinical worsening of conjunctivitis — MET - Chloramphenicol drops were prescribed four times a day for the left eye on 21 January 1992, and the undated an airbase record that followed, from about January 1992, records the spread to both eyes with pustules and increased the drops to four-hourly, showing that they were being applied as the worsening developed.
Topical medication was therefore applied to the affected eye within the 48 hours before the clinical worsening, although the infection remained its principal driver.
Factor 9(28): taking a drug from the specified list of drugs for at least the seven days before the clinical worsening of conjunctivitis — NOT MET - No drug from the specified list was taken in the seven days before the January 1992 recurrences; temazepam (Normison), a benzodiazepine, was first prescribed in May 1992, and lorazepam only after service, with no worsening of conjunctivitis recorded in either period.
Factor 9(29): taking a drug which is associated in the individual with: (a) the worsening of conjunctivitis during drug therapy; and (b) the improvement of conjunctivitis within seven days of discontinuing or tapering drug therapy; where treatment with the drug continued for at least the seven days before the clinical worsening of conjunctivitis — NOT MET - No drug has been associated in the veteran with a worsening of conjunctivitis followed by improvement within seven days of stopping or tapering it.
Factor 9(30): having ocular or periocular exposure to an irritant substance within the 24 hours before the clinical worsening of conjunctivitis — NOT MET - No ocular exposure to an irritant chemical was recorded in the 24 hours before the January 1992 recurrences, which arose with an upper respiratory infection and had the features of bacterial infection.
Factor 9(31): having mustard gas exposure to the affected eye within the 24 hours before the clinical worsening of conjunctivitis — NOT MET - There is no record of mustard gas exposure, and nothing in the veteran's service history suggests it.
Factor 9(32): having a foreign body in contact with the affected conjunctiva within the 24 hours before the clinical worsening of conjunctivitis — NOT MET - The only recorded eye foreign-body incident, to the right eye on 22 September 1991 while cutting timber with a circular saw (no foreign body was found), occurred four months before the January 1992 recurrences, outside the 24-hour window.
Factor 9(33): having an injury to the conjunctiva of the affected eye within the 24 hours before the clinical worsening of conjunctivitis — NOT MET - The small corneal abrasion of the right eye sustained on 22 September 1991 while cutting timber with a circular saw occurred four months before the January 1992 recurrences, outside the 24-hour window, and no other eye injury was recorded.
Factor 9(34): undergoing a course of therapeutic radiation for cancer, where the region of the affected eye was in the field of radiation, at the time of the clinical worsening of conjunctivitis — NOT MET - the veteran has never undergone radiotherapy for cancer, and nothing in his history suggests it.
Factor 9(35): having a benign or malignant neoplasm affecting the conjunctiva or eyelid margin of the affected eye at the time of the clinical worsening of conjunctivitis — NOT MET - The benign dermal naevus and epidermal cyst excised from the left eyebrow in February 1990 did not involve the conjunctiva or eyelid margin and were removed two years before the January 1992 recurrences; no other ocular neoplasm is recorded.
Factor 9(36): being in an immunocompromised state as specified at the time of the clinical worsening of conjunctivitis — NOT MET - In January 1992 the veteran had no immunosuppressive drug, malignancy, chronic renal failure, HIV infection, severe malnutrition or transplant, and his full blood count in 1991 was normal, so he was not immunocompromised as specified.
Factor 9(37): inability to obtain appropriate clinical management for conjunctivitis — MET - the veteran's three in-service presentations with conjunctivitis (22 February 1986, 21 January 1992 and about January 1992) were managed with drops alone, without swab, culture or ophthalmological referral, even when the infection spread to both eyes despite treatment, and an airbase had been unable to locate his medical record in September 1991.
On the principles in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), under which inability is assessed objectively as well as subjectively, this amounts to an inability to obtain appropriate clinical management
Sequelae
No specific sequelae documented
Unintended Consequence
Not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
This applies only to worsening.
MET — The veteran presented with conjunctivitis on 22 February 1986, 21 January 1992 and again about January 1992, and each time was treated promptly but with eye drops alone, without a conjunctival swab, culture or ophthalmological referral, even when the infection spread from the left eye to both eyes, with pustules on the inner lid surfaces, despite chloramphenicol drops. an airbase had been unable to locate his medical record in September 1991, so the officers treating him in January 1992 may not have had his earlier eye history.
Recurrent presentations managed conservatively without investigation or specialist referral indicate an inability to obtain appropriate clinical management, assessed objectively as well as subjectively (Brew v Repatriation Commission, Full Federal Court, 10 September 1999, Merkel J)
Date of Clinical Onset
Bilateral conjunctivitis is an infective condition.
Its date of clinical onset is the date on which it first appeared, which is no later than the date on which it was first recorded in the service medical records.
Later treatment, investigation or imaging does not alter the date of clinical onset.
First documented: 22 February 1986 — conjunctivitis of both eyes diagnosed at an airbase [CHART REVIEW document].
The later records, including the further episodes treated at an airbase, do not alter the date of clinical onset.
As the condition was already present when it was first documented, its clinical onset was no later than that date.
Date of clinical onset: on or before 22 February 1986.
This date falls within the veteran's ADF service (16 November 1985 1 September 1992).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
