Eye - Blepharitis (Slight) — DVA claim example (Diagnostic Assessment)

Example document — fictitious patient. Every report published here is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious: names, dates of birth, service numbers, units, locations and treating clinicians have been withheld or altered and all dates changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment — Eye - Blepharitis (Slight)

Example 1 of 1 · fictitious patient (Veteran D)

Example document — fictitious patient. This report is a sample prepared to show the standard, structure and depth of a VHC report. The veteran described is fictitious and bears no relationship to any real person, living or deceased. Names, dates of birth, contact details, service numbers, units, locations and treating clinicians have been withheld or altered and all dates have been changed. It must not be relied upon as a record of any real claim.

Diagnostic Assessment

Eye - Blepharitis (Slight)

SOP Codes: Blepharitis No. 30 of 2019 (Balance of Probabilities), Blepharitis No. 29 of 2019 (Reasonable Hypothesis)

ADF History

The veteran, Airfield Defence Guard, enlisted 29 July 1993, currently serving.

Occupational History

As an Airfield Defence Guard (ADG) in the Royal Australian Air Force, the veteran would have been exposed to various occupational hazards including environmental exposures such as prolonged exposure to sunlight (UV radiation), heat, cold, dust, and potentially other airborne particulates. Health Surveillance Questionnaires consistently note exposure to noise. His role involved physical demands including manual handling of heavy equipment, weapons, ammunition, and field gear. Chemical exposures could include fuels, oils, solvents, and cleaning agents associated with weapons and vehicle maintenance. The role also includes exposure to environmental conditions during deployments to multiple locations including the an overseas area of operations, an overseas area of operations, Papua New Guinea, and an overseas area of operations.

History

The veteran an RAAF Airfield Defence Guard, presented with eye irritation that had been present since Christmas 2016. Initial treatment with Chlorsig eye drops was unsuccessful, and he was subsequently diagnosed with follicular conjunctivitis and slight blepharitis.

Timeline

11 Sep 2012. The veteran presented to the base Health Centre with eye irritation since Christmas, initially right eye then spread to left, with stickiness. He had used Chlorsig with no response. Vision was R 6/5, L 6/5. He was diagnosed with irritation of eyes and prescribed Soframycin eye drops.
13 Sep 2012. The veteran was reviewed by the treating doctor, Ophthalmologist, for urgent referral. He was diagnosed with slight blepharitis in all 4 lids and follicular conjunctivitis. the treating doctor prescribed FML and Tobramycin ointment.
24 Sep 2012. Follow-up with the treating doctor. The conjunctivitis had settled with FML and Tobramycin. the treating doctor noted some chronic blepharitis still present. He advised long-term lash scrubbing as treatment.

Symptoms

At the time of presentation in November 2014, the veteran reported eye irritation that had been present since Christmas, initially affecting the right eye then spreading to the left eye. He also described stickiness in his eyes. The condition did not respond to initial treatment with Chlorsig eye drops.

Following treatment with FML and Tobramycin ointment, the acute symptoms improved, though chronic blepharitis was still noted by the treating doctor at the follow-up appointment on 24 September 2012. Long-term lash scrubbing was recommended as an ongoing management strategy.

Imaging

No specific imaging was performed for this condition. The diagnosis was made based on clinical examination by the treating doctor, Ophthalmologist.

1. What is the formal diagnosis of the condition claimed above? The formal diagnosis is Blepharitis (Slight), which corresponds to DVA SOP Blepharitis No. 30 of 2019 (Balance of Probabilities) and No. 29 of 2019 (Reasonable Hypothesis), with ICD-10 code H01.009 (Blepharitis, unspecified).

Blepharitis is an inflammation of the eyelid margins or glands of the eyelid. It typically presents with itchiness, redness, flaking, and crusting of the eyelids. The condition can be acute or chronic and is classified as anterior blepharitis (affecting the front edge of the eyelid and eyelashes) or posterior blepharitis (affecting the Meibomian glands). Blepharitis can be caused by bacterial infection, skin conditions like seborrheic dermatitis or rosacea, allergies, or environmental irritants.

In the veteran case, the blepharitis was described as "slight" and affected all four eyelids. It occurred concurrently with follicular conjunctivitis. The condition partially responded to treatment with FML (a topical steroid) and Tobramycin (an antibiotic) ointment, though chronic blepharitis was still noted at follow-up, requiring ongoing management with eyelid hygiene (lash scrubbing).

2. For each diagnosis identified, please also provide the following dates: When did the veteran first experience symptoms attributable to this condition? The veteran first experienced symptoms attributable to blepharitis around Christmas 2016 (approximately late October 2014), as documented in his presentation to the base Health Centre on 11 September 2012.

When did the veteran first present to a health / medical provider for this condition? The veteran first presented to a health provider for this condition on 11 September 2012 at the base Health Centre, where he reported eye irritation since Christmas, initially in the right eye then spreading to the left eye, with stickiness.

When was the condition confirmed / formally diagnosed? The condition was formally diagnosed as "slight blepharitis in all 4 lids" on 13 September 2012 by the treating doctor, Ophthalmologist, following referral from the base Health Centre.

When did the veteran first present to you (or your practice) for this condition? 04 November 2017

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results. The diagnosis of blepharitis was confirmed through clinical examination by the treating doctor, Ophthalmologist, on 13 September 2012. The key symptoms included eye irritation, stickiness of the eyes, and symptoms initially affecting the right eye then spreading to the left eye. These symptoms had been present since Christmas 2016 and had not responded to Chlorsig eye drops.

Upon examination, the treating doctor identified "slight blepharitis in all 4 lids" along with follicular conjunctivitis. The diagnosis was made based on the clinical appearance of the eyelids and conjunctiva. No specific laboratory investigations or imaging studies were performed or required for this diagnosis, as blepharitis is typically a clinical diagnosis made through physical examination.

The diagnosis was further supported by the partial response to appropriate treatment with FML (a topical steroid) and Tobramycin (an antibiotic) ointment, and the observation of "some chronic blepharitis" still present at follow-up on 24 September 2012, necessitating advice for long-term lash scrubbing.

4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.

having an infection of the affected eyelid at the time of the clinical onset of blepharitis (BOP Factor 1, RH Factor 2)

The veteran was diagnosed with "follicular conjunctivitis" concurrently with the blepharitis, indicating an infectious process affecting the eye region. MET
The concurrent diagnosis of follicular conjunctivitis strongly suggests an infectious etiology, as follicular conjunctivitis is typically caused by bacterial or viral pathogens that can simultaneously affect the eyelid margins.
The response to antibiotic treatment (Tobramycin) further supports an infectious component to the blepharitis.
The SOP definition for "infection of the affected eyelid" includes bacterial, viral, or fungal infection involving the skin, hair follicles, or glands of the affected eyelid, which is consistent with the clinical presentation in this case.

having an irritant substance exposure to the region of the affected eye at the time of the clinical onset of blepharitis (BOP Factor 9, RH Factor 10)

As an Airfield Defence Guard, the veteran was routinely exposed to environmental irritants including dust, smoke, and chemicals during his duties. MET
The Health Surveillance Questionnaires in the veteran records consistently note exposure to environmental factors, including potential irritants.
Given the veteran service in various deployment locations, including the an overseas area of operations and an overseas area of operations where environmental dust and particulate matter are prevalent, exposure to ocular irritants would have been unavoidable.
The bilateral nature of the condition (affecting all four eyelids) is consistent with environmental exposure rather than a localized traumatic event.
The timing of symptom onset around Christmas coincides with the Australian summer period, when outdoor activities and exposure to environmental irritants may have increased.

having an infestation of the affected eyelid region, due to a parasite from the specified list of parasites, at the time of the clinical onset of blepharitis (BOP Factor 2, RH Factor 3)

There is no evidence in the medical records of an infestation with Demodex folliculorum, Demodex brevis mites, or Phthirus pubis lice affecting the eyelids. NOT MET

having a smallpox immunisation within the two weeks before the clinical onset of blepharitis (BOP Factor 3, RH Factor 4)

There is no evidence in the medical records that the veteran received a smallpox immunization in the two weeks prior to the onset of blepharitis symptoms around Christmas 2016. NOT MET

having seborrhoeic dermatitis of the periocular region at the time of the clinical onset of blepharitis (BOP Factor 4, RH Factor 5)

There is no evidence in the medical records of the veteran having seborrhoeic dermatitis affecting the periocular region. NOT MET

having rosacea of the periocular region at the time of the clinical onset of blepharitis (BOP Factor 5, RH Factor 6)

There is no evidence in the medical records of the veteran having rosacea affecting the periocular region. NOT MET

having psoriasis of the periocular region at the time of the clinical onset of blepharitis (BOP Factor 6, RH Factor 7)

There is no evidence in the medical records of the veteran having psoriasis affecting the periocular region. NOT MET

having discoid lupus erythematosus of the periocular region at the time of the clinical onset of blepharitis (BOP Factor 7, RH Factor 8)

There is no evidence in the medical records of the veteran having discoid lupus erythematosus affecting the periocular region. NOT MET

having ocular or periocular exposure to an allergen within the 48 hours before the clinical onset of blepharitis (BOP Factor 8, RH Factor 9)

There is no specific evidence in the medical records of the veteran having exposure to a known allergen in the 48 hours before the onset of blepharitis symptoms. NOT MET

having mustard gas exposure to the region of the affected eye at the time of the clinical onset of blepharitis (BOP Factor 10, RH Factor 11)

There is no evidence of mustard gas exposure in the veteran records. NOT MET

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 blepharitis (BOP Factor 11, RH Factor 12)

There is no evidence that the veteran underwent therapeutic radiation for cancer. NOT MET

having a benign or malignant neoplasm affecting the affected eyelid at the time of the clinical onset of blepharitis (BOP Factor 12, RH Factor 13)

There is no evidence of eyelid neoplasm in the veteran records. NOT MET

having dry eye disease at the time of the clinical onset of blepharitis (BOP Factor 13, RH Factor 14)

There is no specific diagnosis of dry eye disease in the veteran records. NOT MET

being in an immunocompromised state as specified at the time of the clinical onset of blepharitis (BOP Factor 14, RH Factor 16)

There is no evidence that the veteran was in an immunocompromised state. NOT MET

taking oral isotretinoin or oral acitretin for a continuous period of at least one year before the clinical onset of blepharitis(BOP Factor 15, RH Factor 17)

There is no evidence that the veteran was taking oral isotretinoin or oral acitretin. NOT MET

having diabetes mellitus at the time of the clinical onset of blepharitis (RH Factor 15 only)

There is no evidence that the veteran had diabetes mellitus. NOT MET

being a prisoner of war at the time of the clinical onset of blepharitis (RH Factor 1 only)

The veteran was not a prisoner of war. NOT MET

inability to obtain appropriate clinical management for blepharitis (BOP Factor 29, RH Factor 33)

The veteran promptly sought medical care for his eye symptoms on 11 September 2012, was referred to an ophthalmologist, and received appropriate treatment with FML and Tobramycin ointment. NOT MET

Sequelae

Based on the available medical evidence, the blepharitis does not appear to be a sequela of another primary condition. While it occurred concurrently with follicular conjunctivitis, it is not clear from the records which condition may have preceded the other, or if they developed simultaneously due to a common cause.

Unintended Consequence

Based on the available medical evidence, the blepharitis does not appear to be an unintended consequence of medical treatment. There is no documentation of prior medical interventions that could have caused the blepharitis as a side effect or complication.

Inability to Attain Appropriate Medical Management

There is no evidence of an inability to attain appropriate medical management for this condition. The veteran was able to access care at the base Health Centre on 11 September 2012, was appropriately referred to an ophthalmologist (the treating doctor), was seen by the specialist within two days, received appropriate treatment (FML and Tobramycin ointment), and had appropriate follow-up (24 September 2012). The management appears to have been timely and in accordance with standard medical practice for blepharitis.

The Full Federal Court in Brew v Repatriation Commission (14 May 1993) established that "inability" to obtain treatment encompasses not only a physical inability but also psychological, emotional, or circumstantial factors that might prevent seeking treatment. In this case, there is no evidence of any barriers to healthcare that would satisfy this criterion.

The % contribution of the causes is 100% and significant

5. Please provide a Health Summary and a medication / prescribing history. -see attached report

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