Right Eye - Pterygium — DVA claim example

Diagnostic Assessment — Right Eye - Pterygium

Example 1 of 1 · fictitious patient (Veteran DC)

Diagnostic Assessment

Right Eye - Pterygium

BOP Code: 34 of 2025 (Pterygium)
RH Code: 33 of 2025 (Pterygium)

ADF History

Veteran DC, date of birth 04 May 1977, Australian Army, Royal Australian Engineers, Carpenter (Construction Tradesperson), later cross-trained as a Metalsmith, enlisted 22 January 1996, discharged at own request 30 June 2016. Operational service: East Timor, 20 September 1999 to 23 February 2000 (warlike); Timor-Leste, 26 May 2006 to 15 October 2008 (two consecutive extended attachments to an engineer works troop, operational service); Afghanistan, 12 October 2012 to 28 June 2013 (warlike).

Occupational History

As an engineer construction tradesperson the veteran built and repaired accommodation, defensive structures, bridges and camp infrastructure, working outdoors for most of each working day in tropical and arid sun. Carpentry involved power saws, routers and sanders in open-sided workshops and on construction sites, and from 2005 he also fabricated steel with manual metal arc and MIG welding.

Engineer tradespeople on operations were exposed to intense ultraviolet light, wind-blown dust and sand, sawdust and welding arc flash, frequently without effective eye protection because safety glasses fogged, scratched or were unavailable and welding helmets were shared or improvised. Pterygium, pinguecula, photokeratitis and foreign bodies in the eye are recognised hazards of the trade.

History

Veteran DC, an Army engineer carpenter and metalsmith, developed a nasal pterygium of the right eye on 20 August 2008 during an extended operational attachment in Timor-Leste, after years of unprotected sun exposure and two years of daily arc welding and carpentry without adequate eye protection. The pterygium worsened in 2013 while excision was unavailable during his deployment to Afghanistan, and it was excised with a conjunctival autograft in September 2013.

Timeline

• 02 Feb 1996 — At his enlistment medical examination the veteran's visual acuity was 6/6 in each eye and slit lamp examination of the anterior segments was normal, with no pinguecula or pterygium. He was noted to have grown up in an inland town and to have worked outdoors as a farmhand for two years. No eye disease was recorded. "anterior segments normal, VA 6/6"
• 11 Jan 2000 — On warlike service in East Timor the veteran presented to the regimental aid post with bilateral gritty, red eyes after several weeks building defensive positions and accommodation in full sun. The medical officer diagnosed actinic and dust-related conjunctivitis, noted that he had lost his issued sunglasses and was working without eye protection, and prescribed lubricant drops. A replacement pair of sunglasses was not available through the supply chain. "actinic conjunctivitis, no eye protection"
• 06 Apr 2006 — At his periodic health examination before the Timor-Leste attachment, the medical officer recorded normal visual acuity of 6/6 in each eye and normal anterior segments on pen torch and ophthalmoscope examination, with no conjunctival lesion in either eye. The veteran reported occasional gritty eyes after outdoor work. He was advised to wear his issued sunglasses and safety glasses at all times on construction tasks. "eyes normal, advised eye protection"
• 14 Mar 2007 — During his attachment in Timor-Leste the veteran presented with a painful right eye after welding steel frames for a camp extension. The medical officer diagnosed arc eye (photokeratitis) and recorded that the troop had one serviceable welding helmet between four welders, so that tack welding was routinely done with only a hand shield or sunglasses. He was welding for four to five hours on most working days. Topical antibiotic and cycloplegic drops were given. "arc eye, shared welding helmet"
• 02 Sep 2008 — The veteran presented to the medical officer in Timor-Leste with a fleshy growth on the inner side of the right eye, first noticed by him while shaving on 20 August 2008 and associated with redness and foreign body sensation. Examination showed a triangular fibrovascular lesion extending from the nasal conjunctiva onto the cornea. He had been working in the carpentry shop, where he was covered in sawdust daily, and on welding tasks for the previous two years. "fleshy nasal lesion right eye"
• 18 Nov 2008 — After his return to Australia an ophthalmologist confirmed a primary nasal pterygium of the right eye, with the apex 1.5 mm onto the cornea, firmly adherent to the sclera and merging with the conjunctiva at its base. A pinguecula was present in the left eye. Ultraviolet-blocking wraparound sunglasses, a wide-brimmed hat and lubricants were advised, with review in six months and excision if it progressed. "primary nasal pterygium, 1.5 mm"
• 14 Aug 2012 — At ophthalmology review the right pterygium had advanced to 2.6 mm onto the cornea with episodes of inflammation and 1.0 dioptre of induced astigmatism. The ophthalmologist recommended excision with a conjunctival autograft within three months to prevent further encroachment towards the visual axis. The veteran had been warned for deployment to Afghanistan in October 2012, and the earliest available theatre date fell after his departure. "excision recommended, 2.6 mm"
• 05 May 2013 — On warlike service in Afghanistan the veteran reported increased redness, irritation and blurred vision in the right eye. An ophthalmologist had recommended excision at review in August 2012, but the surgery was deferred because of his deployment and no ophthalmic surgery was available in theatre. On examination by telehealth-supported optometric review the pterygium had advanced to 3.8 mm onto the cornea with 2.25 dioptres of with-the-rule astigmatism. "advanced to 3.8 mm, astigmatism"
• 10 Sep 2013 — After return from Afghanistan the ophthalmologist excised the right pterygium with a conjunctival autograft secured with fibrin glue. Histopathology confirmed pterygium with solar elastosis. Corneal topography before surgery showed induced astigmatism of 2.5 dioptres. The veteran was advised to wear ultraviolet-blocking eye protection outdoors and to avoid unprotected welding. "excision with conjunctival autograft"

Symptoms

At onset the veteran had a visible fleshy growth on the inner aspect of the right eye with redness, a gritty foreign body sensation, watering in wind and sun, and intermittent irritation worse after welding and dusty work. The lesion slowly enlarged over the following years, with episodes of inflammation.

By 2013 he had blurred and distorted vision in the right eye from induced astigmatism, frequent redness and discomfort, and difficulty with glare. Since excision he reports ongoing dryness, glare sensitivity and intermittent irritation of the right eye, with a mild residual corneal scar, and he must wear ultraviolet-blocking sunglasses outdoors. He has stopped welding and avoids dusty work, and his post-service employment as a building supervisor requires him to limit time in direct sun. He uses lubricant drops four to six times a day.

Imaging

• 05 May 2013 — Anterior segment photography and keratometry: "Right nasal pterygium extending 3.8 mm onto the cornea. With-the-rule astigmatism of 2.25 dioptres."
• 27 Aug 2013 — Corneal topography, right eye: "Nasal flattening with induced regular astigmatism of 2.5 dioptres consistent with the pterygium."

Onset Date

The most likely date of onset of this condition is 20 Aug 2008.

At that date the veteran was on operational service in Timor-Leste, attached to an engineer works troop building and maintaining camp infrastructure. He was working daily in the carpentry shop and on welding tasks, outdoors in the tropical sun for most of each day. On that date he first noticed the fleshy growth on the inner side of his right eye.

This date is appropriate because his periodic health examination of 06 April 2006, before the attachment began, recorded normal anterior segments, and he first presented with the lesion to the medical officer on 02 September 2008, thirteen days later. The diagnosis was confirmed by an ophthalmologist on 18 November 2008. The onset falls within continuous full-time service.

For the welding factor, the 2 years before onset run from 20 Aug 2006 to 20 Aug 2008; throughout that period the veteran was on the Timor-Leste attachment and welded for an average of about 22 hours a week, frequently with only a hand shield or sunglasses. For the sawdust factor, the 1 year before onset runs from 20 Aug 2007 to 20 Aug 2008; throughout that period he worked in the carpentry shop for an average of about 24 hours a week, routinely covered in sawdust, without goggles. For the sunlight factors, the cumulative unprotected exposure accumulated from enlistment in January 1996 to onset, including warlike service in East Timor from September 1999 to February 2000 and the Timor-Leste attachment from May 2006, totalling about 9,600 latitude equivalent hours.

For the worsening, the period after onset runs from 20 Aug 2008 to the documented worsening on 05 May 2013. Excision was recommended in August 2012 but could not be obtained during his deployment to Afghanistan from 12 Oct 2012 to 28 Jun 2013, and the pterygium advanced from 2.6 mm at the August 2012 review to 3.8 mm onto the cornea by 05 May 2013, with astigmatism increasing from 1.0 to 2.25 dioptres. Between 18 Nov 2008 and August 2012 it had grown slowly from 1.5 mm to 2.6 mm while the veteran continued outdoor work in Australia.

1. What is the formal diagnosis of the condition claimed above?

The formal diagnosis is Right Eye - Pterygium (ICD-10-AM H11.0), a primary nasal pterygium of the right eye, under the Statements of Principles concerning pterygium, Balance of Probabilities No. 34 of 2025 and Reasonable Hypothesis No. 33 of 2025.

A pterygium is a triangular or wedge-shaped growth of fibrovascular tissue that grows horizontally in the interpalpebral fissure from the conjunctiva onto the cornea. It is firmly united to the cornea at its apex, attached to the sclera in its middle portion and merges with the conjunctiva at its base. It is caused principally by chronic ultraviolet exposure, with contributions from other irritants such as welding light, dust and sawdust. As it advances it causes irritation, redness, cosmetic change, astigmatism and, if it reaches the visual axis, loss of vision. It recurs in a proportion of cases after excision.

The pterygium began on 20 August 2008 during operational service in Timor-Leste, was confirmed by an ophthalmologist in November 2008, worsened during warlike service in Afghanistan in 2013 and was excised in September 2013.

2. For each diagnosis identified, please also provide the following dates:

When did the veteran first experience symptoms attributable to this condition?

20 August 2008.

When did the veteran first present to a health / medical provider for this condition?

02 September 2008.

When was the condition confirmed / formally diagnosed?

18 November 2008.

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

09 April 2025.

3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?

The diagnosis was confirmed by an ophthalmologist on slit lamp examination on 18 November 2008, which showed a triangular fibrovascular lesion in the nasal interpalpebral fissure of the right eye, extending 1.5 mm onto the cornea, firmly united to the cornea at its apex, adherent to the sclera through its middle portion and merging with the conjunctiva at its base. It was not a pseudo-pterygium (there was no history of corneal ulceration or chemical injury and a probe could not be passed beneath it) and was distinct from the pinguecula in the left eye. This meets the Statement of Principles definition of pterygium.

Histopathology of the excised tissue on 10 September 2013 confirmed pterygium with solar elastosis. The worsening was documented by measurement of corneal encroachment and by keratometry and corneal topography in 2013.

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.

Legislation: the clinical onset of this condition was on 20 August 2008, after 1 July 2004, during continuous full-time service. This is a Military Rehabilitation and Compensation Act 2004 (MRCA) claim and the Statements of Principles apply. The Balance of Probabilities instrument applies to peacetime service. The Reasonable Hypothesis instrument applies to the veteran's warlike service in East Timor in 1999 and 2000, his operational service in Timor-Leste from 2006 to 2008, during which the welding, sawdust and much of the sunlight exposure occurred and the condition began, and his warlike service in Afghanistan in 2012 and 2013, during which the condition worsened.

Each factor must be related to the person's relevant service. Under the beneficial approach required by the legislation, the absence of documentation does not mean that an event or exposure did not occur: lack of evidence is not evidence of lack.

Balance of Probabilities — Statement of Principles concerning Pterygium, No. 34 of 2025

Causative factors

Factor 9(1): having sunlight exposure to the eye which is not protected by clothing, ultraviolet-blocking sunglasses, or other physical barrier, for a cumulative period of at least 4,500 latitude equivalent hours before clinical onset; — MET

- From enlistment on 22 January 1996 to the onset on 20 August 2008 the veteran worked outdoors as an engineer tradesperson for an average of about six hours a day, five to six days a week, on construction tasks in Queensland and the Northern Territory between operational deployments. Issued sunglasses were frequently lost, scratched or not worn because they fogged in the heat, and his unit health records of 11 January 2000 and 14 March 2007 document work without eye protection. His peacetime outdoor work at bases in northern Australia, at latitudes of about 12 to 19 degrees south, amounted to approximately 5,200 latitude equivalent hours of unprotected exposure before onset, exceeding the 4,500 hours required, before any operational exposure is counted. The exposure arose from the outdoor duties of his trade.

Worsening factors

Factor 9(2): inability to obtain appropriate clinical management for pterygium before clinical worsening; — MET

- The ophthalmologist recommended excision of the pterygium on 14 August 2012 because it was advancing. The veteran was then deployed from 12 October 2012 to 28 June 2013 and could not obtain the surgery, which was unavailable in theatre and could not be scheduled before departure. During that period the pterygium advanced from 2.6 mm to 3.8 mm onto the cornea, documented on 05 May 2013, and the induced astigmatism increased from 1.0 to 2.25 dioptres. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management, and it preceded and contributed to the worsening.

Reasonable Hypothesis — Statement of Principles concerning Pterygium, No. 33 of 2025

Causative factors

Factor 9(1): having sunlight exposure to the eye which is not protected by clothing, ultraviolet-blocking sunglasses, or other physical barrier, for a cumulative period of at least 2,250 latitude equivalent hours before clinical onset; — MET

- On warlike service in East Timor from 20 September 1999 to 23 February 2000 the veteran built defensive positions and accommodation in full sun for eight to ten hours a day, seven days a week, after losing his issued sunglasses; the medical officer recorded actinic conjunctivitis and work without eye protection on 11 January 2000. On operational service in Timor-Leste from 26 May 2006 to the onset on 20 August 2008 he again worked outdoors for six to eight hours a day at a latitude of about 8.5 degrees south, close to the equator. These operational periods alone amount to approximately 4,400 latitude equivalent hours of unprotected eye exposure before onset, well above the 2,250 hours required.

Factor 9(2): having exposure of the affected eye to electric arc welding light, while welding without appropriate eye protection, such as a welding helmet or welding mask, for an average of at least 20 hours per week, for at least the 2 years before clinical onset; — MET

- During his operational attachment in Timor-Leste the veteran welded steel frames, roofing trusses and security fencing for an average of about 22 hours a week throughout the 2 years before onset, from 20 August 2006 to 20 August 2008. The troop had one serviceable welding helmet between four welders, so he routinely tack welded with a hand shield or sunglasses only, and on 14 March 2007 the medical officer treated him for arc eye of the right eye and recorded the inadequate eye protection. The welding was a direct requirement of his operational duties.

Factor 9(3): having heavy exposure of the unprotected eye to sawdust, in an environment where the person is covered in sawdust, for an average of at least 20 hours per week, for at least the one year before clinical onset; — MET

- Throughout the 1 year before onset, from 20 August 2007 to 20 August 2008, the veteran worked in an open-sided carpentry shop on the Timor-Leste attachment for an average of about 24 hours a week, cutting, routing and sanding timber for accommodation and furniture. Dust extraction was not available and goggles were not issued, and his section commander's statement records that the carpenters finished each shift covered in sawdust. The medical officer noted daily sawdust exposure when he presented with the lesion on 02 September 2008.

Worsening factors

Factor 9(4): inability to obtain appropriate clinical management for pterygium before clinical worsening; — MET

- Excision of the pterygium was recommended on 14 August 2012, but the veteran was deployed on warlike service in Afghanistan from 12 October 2012 to 28 June 2013, where no ophthalmic surgery was available. The surgery was delayed for more than a year, during which the pterygium advanced from 2.6 mm to 3.8 mm onto the cornea and the induced astigmatism increased from 1.0 to 2.25 dioptres, documented on 05 May 2013. This is an inability to obtain appropriate clinical management arising from operational service, and it preceded and contributed to the worsening.

The % contribution of the causes is 100% and significant.

Sequelae

The right eye pterygium is a direct consequence of the veteran's occupational exposures as an engineer tradesperson. Its sequelae are the induced astigmatism, the residual corneal scarring after excision, chronic ocular surface irritation and dry eye, and the risk of recurrence requiring further surgery. The pinguecula of the left eye, which arose from the same exposures, should be considered for a separate claim. Ongoing management includes annual ophthalmic review, ultraviolet-blocking eye protection and lubricants, and re-excision if the pterygium recurs.

Unintended Consequence

Not met as a cause of onset. The post-operative dry eye and residual corneal scar following the excision of 10 September 2013, performed and paid for by the Commonwealth, are unintended consequences of that treatment and should be considered as part of the accepted condition (section 6A of the DRCA and the equivalent provisions of the MRCA).

Inability to Attain Appropriate Medical Management

MET. The ophthalmologist recommended excision of the pterygium in August 2012, but the veteran was deployed to Afghanistan from 12 October 2012 to 28 June 2013, where no ophthalmic surgery was available and surgery could not be scheduled before departure. During that period the pterygium advanced from 2.6 mm to 3.8 mm onto the cornea and the induced astigmatism increased from 1.0 to 2.25 dioptres, which persisted after excision as a corneal scar. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), operational constraints that prevent recommended surgery amount to an inability to obtain appropriate clinical management, and this materially contributed to the worsening.

5. Please provide a Health Summary and a medication / prescribing history.

See attached report.

References

1. 02 Feb 1996, Enlistment medical examination, Medical Officer, Recruiting centre
2. 11 Jan 2000, Deployed health record, Medical Officer, Regimental aid post, East Timor
3. 06 Apr 2006, Periodic health examination, Medical Officer, Garrison health centre
4. 14 Mar 2007, Deployed health record, Medical Officer, Timor-Leste
5. 02 Sep 2008, Deployed health record, Medical Officer, Timor-Leste
6. 18 Nov 2008, Specialist consultation, Ophthalmologist
7. 14 Aug 2012, Specialist review and surgical recommendation, Ophthalmologist
8. 05 May 2013, Optometric review with telehealth ophthalmology advice, Afghanistan
9. 27 Aug 2013, Corneal topography report, Ophthalmologist
10. 10 Sep 2013, Operation report and histopathology, Ophthalmologist and Pathologist
11. Statement of Principles concerning Pterygium (Balance of Probabilities) No. 34 of 2025, Repatriation Medical Authority
12. Statement of Principles concerning Pterygium (Reasonable Hypothesis) No. 33 of 2025, Repatriation Medical Authority