Diagnostic Assessment — Right Eye - Abrasion
Example 1 of 1 · fictitious patient
Diagnostic Assessment Right Eye — Abrasion BOP Code: 38 of 2025 (Cut, Stab, Abrasion and Laceration) RH Code: 37 of 2025 (Cut, Stab, Abrasion and Laceration)
ADF History
The veteran, date of birth [withheld], Royal Australian Navy, Marine Technician, 11 July 1987 to 26 April 1994
Occupational History
On 16 May 1993, while serving at a frigate, the veteran was cutting timber with a circular saw at 10:45 on a working day; the Daily Injury Record does not state whether he was on duty, but the time, the use of eye protection and same-day treatment by the establishment's medical staff indicate a work task.
Despite wearing eye protection, foreign body injuries to the eyes are a recognised occupational hazard of working with power tools and timber
History
The veteran sustained a foreign body injury to the right eye on 16 May 1993 whilst cutting timber with a circular saw at a frigate, despite wearing eye protection.
Examination revealed a small, shallow abrasion at the centre of the pupil.
No foreign bodies were identified on inspection
Timeline
16 May 1993 — ABSR the veteran, as a young adult, sustained a foreign body injury to the right eye whilst cutting timber with a circular saw at a frigate.
He was wearing eye protection at the time.
The right eye was washed with eyestream.
Amethocaine drops were instilled for anaesthesia.
Fluorescein drops were applied for examination.
A small, shallow abrasion at the centre of the pupil was identified.
No foreign bodies were seen on inspection.
Chloromycetin drops were prescribed.
The eye was covered for 4 hours.
He was reviewed by the a frigate Area Nurse. "Foreign body injury, right eye"
Symptoms
At the time of injury, the veteran experienced acute right eye pain and irritation following the foreign body injury from the circular saw.
A corneal abrasion was identified at the centre of the pupil
Imaging
No imaging related to this condition
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Right Eye Corneal Abrasion / Foreign Body Injury (ICD-10: T15.01XA / S05.00XA).
A corneal abrasion is a scratch or defect on the surface of the cornea, commonly caused by foreign bodies, direct trauma, or contact with particulate matter from power tools
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition? 16 May 1993 [ [CHART REVIEW document], pages 5 6] When did the veteran first present to a health / medical provider for this condition? 16 May 1993 When was the condition confirmed / formally diagnosed? 16 May 1993 When did the veteran first present to you (or your practice) for this condition? 20 November 2018
3. How was this diagnosis confirmed?
Clinical diagnosis by the medical officer at a frigate using fluorescein staining, which demonstrated a small shallow abrasion at the centre of the pupil [ [CHART REVIEW document], pages 5 6]
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 8 October 2007 (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.
Definition: A corneal abrasion interrupts the continuity of the corneal epithelium, which is external, exposed tissue of the eye rather than epidermis, and so falls within the SOP definition of a wound of the epidermis or other external or exposed tissue.
It was caused by a foreign body entering the eye while he was cutting timber with a circular saw, which is not one of the excluded mechanisms.
Causative Factors — Balance of Probabilities (Statement of Principles concerning Cut, Stab, Abrasion and Laceration, No.
38 of 2025) Factor 9(1): having direct physical trauma to the affected site at the time of the cut, stab, abrasion or laceration — MET - The Daily Injury Record completed at a frigate on 16 May 1993 documents that at 10:45 that day a foreign body entered the veteran's right eye while he was cutting timber with a circular saw, despite his wearing eye protection.
Fluorescein examination showed a small, shallow abrasion at the centre of the pupil, with no foreign body remaining.
The impact of the foreign body on the cornea was direct physical trauma to the affected site, and it produced the abrasion at that moment.
Causative Factors — Reasonable Hypothesis (Statement of Principles concerning Cut, Stab, Abrasion and Laceration, No.
37 of 2025) 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 direct physical trauma to the affected site at the time of the cut, stab, abrasion or laceration — MET - On 16 May 1993 a foreign body struck the veteran's right eye while he was cutting timber with a circular saw, and the Daily Injury Record of that date documents a small, shallow corneal abrasion at the centre of the pupil.
This was direct physical trauma to the affected site at the time of the abrasion.
Other Plausible Links to Service Although the Daily Injury Record of 16 May 1993 does not state whether the veteran was on duty, the circumstances point to a work task at a frigate, the establishment in which he was serving: the accident occurred at 10:45 on a Wednesday, within normal working hours; he was cutting timber with a power saw while wearing eye protection, consistent with workplace safety practice; and he was treated by the establishment's medical staff that day and placed on light duty for one day.
On the balance of probabilities the injury was sustained in the course of his employment as a member of the Navy.
Conclusion the veteran's right corneal abrasion was caused by a foreign body entering the eye while he was cutting timber with a circular saw on 16 May 1993, which satisfies the SOP factor of direct physical trauma to the affected site; there is no other cause.
The injury occurred during normal working hours while he was serving at a frigate and using a power saw with eye protection, circumstances that indicate a work task, so on the balance of probabilities it arose in the course of his service; it was treated promptly and there is no record of any lasting effect.
The % contribution of the causes is 100% and significant.
Worsening Factors In the alternative, if the veteran's right corneal abrasion is found not to have arisen out of his service, the following factors address whether service rendered after its clinical onset on 16 May 1993 aggravated it or contributed to it in a material degree through any inability to obtain appropriate clinical management before a clinical worsening.
Worsening Factors — Balance of Probabilities (Statement of Principles concerning Cut, Stab, Abrasion and Laceration, No.
38 of 2025) Factor 9(2): inability to obtain appropriate clinical management for cut, stab, abrasion or laceration before clinical worsening — NOT MET - Applying Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), there was no inability to obtain appropriate clinical management: the eye was irrigated, examined and treated on the day of injury, there was no later presentation or clinical worsening, and his vision was 6/6 in each eye at discharge on 26 April 1994.
Worsening Factors — Reasonable Hypothesis (Statement of Principles concerning Cut, Stab, Abrasion and Laceration, No.
37 of 2025) 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(2): inability to obtain appropriate clinical management for cut, stab, abrasion or laceration before clinical worsening — NOT MET - Assessed objectively and subjectively as Brew v Repatriation Commission (Full Federal Court, 10 September 1999) requires, the veteran obtained immediate and appropriate treatment for the abrasion at a frigate on 16 May 1993, and no clinical worsening followed; there was no inability to obtain appropriate clinical management
Sequelae
No specific sequelae documented.
The veteran has a pre-existing left congenital esotropia (post-surgical) assessed during service by the treating doctor in July 1989, with virtually no stereopsis
Unintended Consequence
Not an unintended consequence of medical management
Inability to Attain Appropriate Medical Management
Not applicable
Date of Clinical Onset
Right eye abrasion is an acute condition.
Its date of clinical onset is the date of the injury or illness itself, as recorded in the contemporaneous service record.
Later investigations, reviews and imaging record the investigation, treatment or confirmation of the condition; they are not the date of clinical onset.
Date of injury / illness: 16 May 1993 — foreign body injury to the right eye whilst cutting timber with a circular saw at a frigate [ [CHART REVIEW document], pages 6 7].
Date of clinical onset: 16 May 1993.
This date falls within the veteran's ADF service (11 July 1987 26 April 1994).
In-service events and exposures before this date relate to clinical onset, and those after it to clinical worsening
