Diagnostic Assessment — Visual Refractive Error
Example 1 of 1 · fictitious patient (Veteran DE)
Diagnostic Assessment
Visual Refractive Error
BOP Code: 36 of 2025 (Visual Refractive Error)
RH Code: 35 of 2025 (Visual Refractive Error)
ADF History
Veteran DE, date of birth 10 June 1987, Australian Army, Signaller, enlisted 17 January 2005, medically discharged 12 November 2020. Operational service: Middle East Area of Operations (Iraq), 20 January 2006 to 25 February 2007 (warlike); Afghanistan, 05 March 2010 to 15 November 2010 (warlike); Middle East Area of Operations (Iraq), 10 January 2015 to 03 June 2015 (warlike).
Occupational History
Army signallers operate radio, satellite and data networks in headquarters and in the field. Much of the work is sustained close visual work: monitoring screens and terminals, reading and transcribing message logs, handling cipher material and configuring equipment, often on twelve-hour shifts for months at a time on deployment. Young soldiers who enlist at 17 commonly do this work while still in their late teens.
Field and deployed signallers also install antennas and cable outdoors in desert and mountain environments with intense ultraviolet light, wind and dust, which irritate the eyes and lids and promote eyelid lesions and pterygium. On operations there is a risk of blunt and penetrating eye injury from blast, debris and indirect fire, and specialist eye care is generally available only by evacuation.
History
Veteran DE, an Army signaller, developed myopia with astigmatism in both eyes, worse in the right, on 15 February 2007 at the age of 19, after a year of sustained close screen and log work on warlike service in Iraq. The right eye then worsened repeatedly: from an eyelid mass and pterygium in Afghanistan in 2010, keratoconus, corneal surgery and a corneal transplant from 2011 to 2014, a blast injury in Iraq in 2015 with retinal detachment surgery, lens displacement, cataract and topiramate, and cataract surgery with a tilted, later dislocated, lens implant leaving the eye aphakic in 2019.
Timeline
- 05 Jan 2006 — Pre-deployment medical examination before Iraq, aged 18. Unaided visual acuity was 6/6 in each eye. There was no history of glasses, eye disease or eye injury, and examination of the eyes and lids was normal. The enlistment examination of 17 January 2005 had also recorded 6/6 vision in each eye. "VA 6/6 each eye unaided"
- 19 Feb 2007 — During warlike service in Iraq the veteran presented with four days of blurred distance vision, unable to read vehicle markings and signs. For the previous 13 months he had worked twelve-hour shifts in a headquarters signals centre, reading screens, message logs and cipher documents at 30 to 40 cm for about eight hours a day. Unaided acuity was 6/12 right and 6/9 left, improving with a pinhole. On return, an optometrist on 20 March 2007 measured right -1.75/-0.75 x 180 and left -1.00 DS, and prescribed glasses. "blurred distance vision, myopia"
- 20 Oct 2010 — During warlike service in Afghanistan the veteran was reviewed by the visiting optometrist at the role 3 hospital. He had a firm 8 mm chalazion of the right upper eyelid present since June, and a fleshy right nasal pterygium extending 2.5 mm onto the cornea, after months of antenna and cable work in sun, wind and dust. Right refraction had changed to -2.00/-2.25 x 180, with increased astigmatism. Excision was recommended but no ophthalmologist was available, and lubricants were prescribed. "R chalazion, pterygium, astigmatism up"
- 04 Jul 2011 — Review by an ophthalmologist after right pterygium excision with conjunctival autograft and incision and curettage of the chalazion on 15 February 2011. The veteran reported constant rubbing of the irritated right eye since Afghanistan. Corneal topography showed inferior steepening with a maximum keratometry of 51.8 dioptres and thinning, and right keratoconus was diagnosed. Corneal collagen cross-linking of the right eye was performed on 08 August 2011. "R keratoconus, cross-linking planned"
- 12 Sep 2012 — Ophthalmology review for worsening right vision. Right refraction was -4.50/-4.75 x 170, best corrected acuity 6/18. Topography showed progression of keratoconus to a maximum keratometry of 56.0 dioptres, and slit lamp examination showed apical corneal scarring and a nasal scar at the pterygium bed. Rigid contact lenses were not tolerated. He was listed for corneal transplantation. "keratoconus progressing, apical scarring"
- 24 Mar 2014 — Review after right penetrating keratoplasty on 10 June 2013. The graft was clear, but there was high irregular astigmatism with right refraction -3.50/-6.50 x 25 and scarring at the graft-host junction. Selective suture removal was planned. Best corrected acuity was 6/12. "post-graft astigmatism -6.50"
- 30 Jun 2015 — On 02 June 2015, during warlike service in Iraq, the veteran was struck in the right eye by debris from an indirect fire attack, with hyphaema, a subluxed, tilted crystalline lens, a posterior subcapsular cataract and a retinal detachment. He also had a concussion with post-traumatic seizures. He was evacuated and had scleral buckle and vitrectomy repair of the detachment on 05 June 2015. Topiramate was commenced on 18 June 2015 after levetiracetam caused severe mood disturbance. Right refraction on 30 June 2015 was -9.00/-3.50 x 160. "R eye trauma, buckle, myopic shift"
- 20 Oct 2017 — A nuclear cataract was diagnosed in the right eye on 14 April 2017, with a myopic shift to -11.50/-3.25 x 160. On 10 August 2017 he had right cataract surgery, with the lens implant placed in the sulcus because of zonular damage from the 2015 injury. On 20 October 2017 the lens implant was tilted and decentred, with right refraction +1.50/-3.75 x 45 and lenticular astigmatism. "tilted decentred IOL, astigmatism"
- 01 Mar 2019 — The right lens implant dislocated into the vitreous on 08 January 2019 and was removed on 15 February 2019, leaving the eye aphakic until a secondary implant could be planned. Right refraction was +12.50/-2.50 x 90, with anisometropia of more than 10 dioptres compared with the left eye. He was fitted with a contact lens but could not tolerate it in dusty conditions. "R aphakia, hyperopia +12.50"
Symptoms
At onset the veteran had blurred distance vision in both eyes, worse on the right, difficulty reading signs and vehicle markings, and eye strain after shifts. With each worsening of the right eye he had increasing blur, distortion and glare, ghosting of images, and difficulty driving at night and reading screens.
He now has poor, variable vision in the right eye, with marked anisometropia, double images and loss of depth perception when the eye is uncorrected. He cannot drive at night, has difficulty with screens and reading for more than 30 minutes, and relies on his left eye for most tasks.
Imaging
- 04 Jul 2011 — Corneal topography right eye: "Inferior steepening with maximum keratometry 51.8 dioptres and thinnest pachymetry 452 micrometres, consistent with keratoconus."
- 12 Sep 2012 — Corneal topography right eye: "Progression of keratoconus with maximum keratometry 56.0 dioptres and thinnest pachymetry 418 micrometres."
- 03 Jun 2015 — B-scan ultrasound right eye: "Macula-involving retinal detachment. Crystalline lens subluxed inferotemporally and tilted. Vitreous haemorrhage."
- 30 Jun 2015 — Optical biometry right eye: "Axial length 25.6 mm, increased from 24.4 mm before the scleral buckle. Lens tilted and decentred with posterior subcapsular opacity."
- 08 Jan 2019 — B-scan ultrasound right eye: "Posterior chamber lens implant dislocated into the inferior vitreous cavity. Retina attached over the buckle."
Onset Date
The most likely date of onset of this condition is 15 Feb 2007.
At that date the veteran, aged 19, was serving on warlike service in Iraq as a signaller in a headquarters signals centre. Since January 2006 he had worked twelve-hour shifts reading screens, message logs and cipher documents at 30 to 40 cm for about eight hours a day. On 15 February 2007 he noticed that he could not read distant signs and vehicle markings.
This date is appropriate because his pre-deployment medical examination of 05 January 2006 recorded unaided vision of 6/6 in each eye with no refractive error, and he first presented on 19 February 2007, four days after the blurring began, with reduced acuity improving on pinhole. Myopia was confirmed by an optometrist on 20 March 2007. It falls within uninterrupted full-time warlike service.
For the close focusing factor, the veteran turned 12 on 10 Jun 1999 and 20 on 10 Jun 2007, so he was aged 12 to 19 throughout; the 1 year before onset runs from 15 Feb 2006 to 15 Feb 2007, during which he focused on screens and documents within 40 cm for about eight hours a day, every day, on deployment.
For the worsening factors, each worsening is dated. For the first worsening on 20 Oct 2010 the eyelid mass and pterygium were present at that date, and appropriate management could not be obtained in Afghanistan from June to November 2010. For the worsening on 12 Sep 2012, the 2 years before run from 12 Sep 2010 to 12 Sep 2012 and include the pterygium excision of 15 Feb 2011 and the cross-linking of 08 Aug 2011, with keratoconus and corneal scarring present. For the worsening on 24 Mar 2014, the 2 years before run from 24 Mar 2012 and include the penetrating keratoplasty of 10 Jun 2013. For the worsening on 30 Jun 2015, the 1 month before runs from 30 May 2015 and includes the eye injury of 02 Jun 2015, the 6 months before run from 30 Dec 2014 and include the scleral buckle and retinal detachment surgery of 05 Jun 2015, the 2 weeks before run from 16 Jun 2015 and include topiramate from 18 Jun 2015, and the tilted, displaced lens and posterior subcapsular cataract were present. The nuclear cataract was present at the worsening on 14 Apr 2017. For the worsening on 20 Oct 2017, the 6 months before run from 20 Apr 2017 and include the cataract surgery of 10 Aug 2017, with the lens implant tilted. The eye was aphakic at the worsening on 01 Mar 2019.
1. What is the formal diagnosis of the condition claimed above?
The formal diagnosis is Visual Refractive Error: bilateral myopia with right astigmatism from 2007 (ICD-10-AM H52.1 and H52.2), with later irregular astigmatism, aphakic hyperopia (H52.0) and anisometropia (H52.3) of the right eye, under the Statements of Principles concerning visual refractive error, Balance of Probabilities No. 36 of 2025 and Reasonable Hypothesis No. 35 of 2025.
Visual refractive error is a group of eye conditions in which the refractive power of the eye's optical system, mainly the cornea and the lens, does not match the length of the eyeball, so that light is not focused on the retina. In myopia the optical power is too strong for the eye's length; in hyperopia it is too weak; in astigmatism it varies around the axis of the eye; and anisometropia is a substantial difference between the two eyes. Myopia commonly develops in adolescence and early adulthood with sustained near work. Refractive error can also be acquired or worsened by disease, surgery and injury of the eyelid, cornea, lens and retina, and by certain drugs.
In this veteran myopia began on 15 February 2007, aged 19, on warlike service in Iraq, and the right eye then worsened on seven documented occasions between 2010 and 2019.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
15 February 2007.
When did the veteran first present to a health / medical provider for this condition?
19 February 2007.
When was the condition confirmed / formally diagnosed?
20 March 2007.
When did the veteran first present to you (or your practice) for this condition?
21 May 2025.
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions?
The diagnosis was made by an optometrist on 20 March 2007 on subjective and objective refraction, which showed right -1.75/-0.75 x 180 and left -1.00 DS, with correction of acuity to 6/6. This is myopia with astigmatism within the Statement of Principles definition of visual refractive error, and it is not presbyopia. Unaided acuity had been 6/6 in each eye on 17 January 2005 and 05 January 2006.
Each worsening of the right eye was documented by repeat refraction and by an ophthalmologist: increased astigmatism with an eyelid mass and pterygium in 2010, keratoconus confirmed on corneal topography in 2011 and 2012, high astigmatism after keratoplasty in 2014, a myopic shift after the 2015 injury and surgery confirmed by an increased axial length on biometry, a further myopic shift with nuclear cataract in 2017, lenticular astigmatism from a tilted implant in 2017, and aphakic hyperopia with anisometropia in 2019.
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 15 February 2007, 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, including the eye surgery and treatment in Australia. The Reasonable Hypothesis instrument applies to the veteran's warlike service in Iraq in 2006 and 2007, where the condition began, in Afghanistan in 2010, and in Iraq in 2015, where the eye injury occurred.
In both instruments each factor applies to the clinical onset or the clinical worsening of the condition, except the final factor, which applies before worsening. 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 Visual Refractive Error, No. 36 of 2025
Causative factors (clinical onset or clinical worsening)
Factor 9(1): having an acquired eyelid mass of the affected eye at the time of clinical onset or clinical worsening of hyperopia or astigmatism; — MET
- An 8 mm chalazion of the right upper eyelid was present from June 2010 and recorded on 20 October 2010, when right astigmatism had increased from 0.75 to 2.25 dioptres. The mass pressed on the cornea and was present at that worsening of astigmatism. It developed with chronic lid irritation from dust and wind during his duties.
Factor 9(2): having a pterygium of the affected eye at the time of clinical onset or clinical worsening of astigmatism or hyperopia; — MET
- A right nasal pterygium extending 2.5 mm onto the cornea was recorded on 20 October 2010, at the worsening of astigmatism. It followed prolonged outdoor antenna and cable work in intense ultraviolet light, wind and dust during field training in northern Australia from 2008 and in 2010, as part of his duties.
Factor 9(3): having corneal surgery of the affected eye, within the 2 years before clinical onset or clinical worsening; — MET
- The veteran had right pterygium excision with superficial keratectomy and conjunctival autograft on 15 February 2011 and corneal collagen cross-linking on 08 August 2011, both within the 2 years before the worsening documented on 12 September 2012. The surgery was performed and funded by Defence while he was serving.
Factor 9(4): having penetrating keratoplasty (corneal transplantation) of the affected eye, within the 2 years before clinical onset or clinical worsening; — MET
- Right penetrating keratoplasty was performed on 10 June 2013, nine months before the worsening to high irregular astigmatism of 6.50 dioptres documented on 24 March 2014. It was provided by Defence while he was serving.
Factor 9(5): having corneal scarring of the affected eye at the time of clinical onset or clinical worsening; — MET
- Apical corneal scarring from keratoconus and a nasal scar at the pterygium bed were recorded on 12 September 2012, and scarring at the graft-host junction on 24 March 2014, at the worsenings on those dates.
Factor 9(6): having keratoconus of the affected eye at the time of clinical onset or clinical worsening of myopia or astigmatism; — MET
- Right keratoconus was diagnosed on corneal topography on 04 July 2011 and had progressed to a maximum keratometry of 56.0 dioptres at the worsening of myopia and astigmatism documented on 12 September 2012. It followed constant rubbing of the chronically irritated eye during and after service.
Factor 9(7): having scleral buckle surgery of the affected eye, within the 6 months before clinical onset or clinical worsening of myopia or astigmatism; — MET
- Scleral buckle surgery for retinal detachment of the right eye was performed on 05 June 2015, 25 days before the myopic shift documented on 30 June 2015, when axial length had increased from 24.4 to 25.6 mm. The surgery was provided by Defence while he was serving.
Factor 9(8): having a natural or artificial intraocular lens that is tilted or positioned off-centre within the affected eye at the time of clinical onset or clinical worsening; — MET
- The right crystalline lens was subluxed and tilted on 30 June 2015, at the myopic worsening, and the sulcus lens implant inserted on 10 August 2017 was tilted and decentred at the worsening of astigmatism on 20 October 2017.
Factor 9(9): having acquired aphakia (absence of an intraocular lens) at the time of clinical onset or clinical worsening of hyperopia; — MET
- After the lens implant dislocated on 08 January 2019 it was removed on 15 February 2019, and the right eye was aphakic at the worsening to hyperopia of +12.50 dioptres documented on 01 March 2019. The aphakia was acquired through Defence-provided surgery.
Factor 9(10): having acquired displacement of the intraocular lens at the time of clinical onset or clinical worsening; — MET
- Traumatic subluxation of the right crystalline lens, ectopia lentis, was shown on B-scan ultrasound on 03 June 2015 and was present at the worsening on 30 June 2015. The lens implant later also dislocated into the vitreous on 08 January 2019.
Factor 9(11): having an acquired nuclear cataract of the affected eye at the time of clinical onset or clinical worsening of myopia; — MET
- A nuclear cataract of the right eye was diagnosed on 14 April 2017, with a myopic shift to -11.50 dioptres at that date. Nuclear cataract is a recognised consequence of the vitrectomy performed on 05 June 2015.
Factor 9(12): having cataract surgery of the affected eye, within the 6 months before clinical onset or clinical worsening; — MET
- Right cataract surgery was performed on 10 August 2017, ten weeks before the worsening of astigmatism documented on 20 October 2017. It was provided by Defence while he was serving.
Factor 9(13): having surgery for retinal detachment of the affected eye, within the 6 months before clinical onset or clinical worsening of myopia or astigmatism; — MET
- Vitrectomy and scleral buckle surgery for right retinal detachment were performed on 05 June 2015, within the 6 months before the myopic worsening documented on 30 June 2015.
Factor 9(14): having blunt or penetrating trauma to the affected eye during the 1 month before clinical onset or clinical worsening; — MET
- On 02 June 2015 the veteran's right eye was struck by debris, causing hyphaema, lens subluxation and retinal detachment. This was 28 days before the worsening documented on 30 June 2015. The injury occurred in the course of his duties.
Factor 9(15): taking any of the following medications (which cannot be ceased or substituted in the long term) within the 2 weeks before clinical onset or clinical worsening of myopia; (a) acetazolamide; (b) chlortalidone/chlorthalidone; (c) daratumumab; (d) indapamide; (e) methazolamide; (f) metronidazole; (g) pilocarpine; (h) topiramate; (i) zonisamide. — MET
- Topiramate was commenced on 18 June 2015 for post-traumatic seizures, 12 days before the myopic worsening documented on 30 June 2015. The neurologist recorded that it could not be ceased or substituted in the long term because levetiracetam had caused severe mood disturbance and other agents were contraindicated. It was prescribed by Defence while he was serving.
Worsening factors
Factor 9(16): inability to obtain appropriate clinical management for visual refractive error before clinical worsening. — MET
- From June to November 2010 the veteran's enlarging chalazion and pterygium could not be treated, because no ophthalmologist was available, and excision was delayed until 15 February 2011. Over that period right astigmatism increased from 0.75 to 2.25 dioptres, documented on 20 October 2010. Under Brew v Repatriation Commission (1999) this is an inability to obtain appropriate clinical management.
Reasonable Hypothesis — Statement of Principles concerning Visual Refractive Error, No. 35 of 2025
Causative factors (clinical onset or clinical worsening)
Factor 9(1): having an acquired eyelid mass of the affected eye at the time of clinical onset or clinical worsening of hyperopia or astigmatism; — MET
- The right upper eyelid chalazion developed in June 2010 during warlike service in Afghanistan, with chronic lid irritation from dust and wind, and was present at the worsening of astigmatism on 20 October 2010.
Factor 9(2): having a pterygium of the affected eye at the time of clinical onset or clinical worsening of astigmatism or hyperopia; — MET
- The right nasal pterygium grew onto the cornea during warlike service in Afghanistan in 2010, with intense ultraviolet light, wind and dust during antenna work, and was present at the worsening of astigmatism on 20 October 2010.
Factor 9(3): having corneal surgery of the affected eye, within the 2 years before clinical onset or clinical worsening; — MET
- Pterygium excision on 15 February 2011 and cross-linking on 08 August 2011 treated the pterygium and keratoconus that arose from warlike service in Afghanistan, within the 2 years before the worsening on 12 September 2012.
Factor 9(4): having penetrating keratoplasty (corneal transplantation) of the affected eye, within the 2 years before clinical onset or clinical worsening; — MET
- Penetrating keratoplasty on 10 June 2013, for keratoconus that followed eye rubbing from deployment-related irritation in Afghanistan, was within the 2 years before the worsening on 24 March 2014.
Factor 9(5): having corneal scarring of the affected eye at the time of clinical onset or clinical worsening; — MET
- Scarring at the pterygium bed, from the pterygium acquired on warlike service in Afghanistan, and apical keratoconic scarring were present at the worsening on 12 September 2012, and graft-host junction scarring at the worsening on 24 March 2014.
Factor 9(6): having keratoconus of the affected eye at the time of clinical onset or clinical worsening of myopia or astigmatism; — MET
- Keratoconus followed persistent rubbing of the right eye, irritated by dust, chalazion and pterygium during warlike service in Afghanistan, and was present at the worsening of myopia and astigmatism on 12 September 2012.
Factor 9(7): having scleral buckle surgery of the affected eye, within the 6 months before clinical onset or clinical worsening of myopia or astigmatism; — MET
- The scleral buckle of 05 June 2015 repaired a retinal detachment caused by the eye injury on warlike service in Iraq on 02 June 2015, and was within the 6 months before the myopic worsening on 30 June 2015.
Factor 9(8): having a natural or artificial intraocular lens that is tilted or positioned off-centre within the affected eye at the time of clinical onset or clinical worsening; — MET
- The crystalline lens was tilted by zonular rupture from the injury on warlike service in Iraq and was tilted at the worsening on 30 June 2015, and the lens implant, placed in the sulcus because of that zonular damage, was tilted and decentred at the worsening on 20 October 2017.
Factor 9(9): having acquired aphakia (absence of an intraocular lens) at the time of clinical onset or clinical worsening of hyperopia; — MET
- The lens implant dislocated on 08 January 2019 because of zonular damage from the 2015 injury on warlike service in Iraq and was removed, leaving the eye aphakic at the hyperopic worsening on 01 March 2019.
Factor 9(10): having acquired displacement of the intraocular lens at the time of clinical onset or clinical worsening; — MET
- The crystalline lens was displaced by the injury on warlike service in Iraq on 02 June 2015 and remained displaced at the worsening on 30 June 2015.
Factor 9(11): having an acquired nuclear cataract of the affected eye at the time of clinical onset or clinical worsening of myopia; — MET
- The nuclear cataract followed vitrectomy for the retinal detachment caused on warlike service in Iraq, and was present at the myopic worsening on 14 April 2017.
Factor 9(12): having an acquired posterior subcapsular cataract of the affected eye at the time of clinical onset or clinical worsening of myopia; — MET
- A traumatic posterior subcapsular cataract formed after the eye injury on warlike service in Iraq on 02 June 2015, worsened by postoperative steroid drops, and was present at the myopic worsening on 30 June 2015.
Factor 9(13): having cataract surgery of the affected eye, within the 6 months before clinical onset or clinical worsening; — MET
- Cataract surgery on 10 August 2017 treated cataract resulting from the injury on warlike service in Iraq and the surgery that followed it, within the 6 months before the worsening on 20 October 2017.
Factor 9(14): having surgery for retinal detachment of the affected eye, within the 6 months before clinical onset or clinical worsening of myopia or astigmatism; — MET
- Retinal detachment surgery on 05 June 2015, for a detachment caused on warlike service in Iraq, was within the 6 months before the myopic worsening on 30 June 2015.
Factor 9(15): whilst aged 12-19 years, focusing on objects within 40 cm of the eyes at least 2 hours a day for at least 1 year before clinical onset or clinical worsening of myopia; — MET
- From 20 January 2006, aged 18 and 19, the veteran worked twelve-hour shifts in a signals centre on warlike service in Iraq, reading screens, message logs and cipher documents at 30 to 40 cm for about eight hours a day. This continued throughout the year before onset, from 15 February 2006 to 15 February 2007, while he was aged 12 to 19, and myopia began on 15 February 2007.
Factor 9(16): having blunt or penetrating trauma to the affected eye during the 1 month before clinical onset or clinical worsening; — MET
- The right eye was struck by debris from an indirect fire attack on warlike service in Iraq on 02 June 2015, 28 days before the worsening documented on 30 June 2015.
Factor 9(17): taking any of the following medications (which cannot be ceased or substituted in the long term) within the 2 weeks before clinical onset or clinical worsening of myopia; (a) acetazolamide; (b) chlortalidone/chlorthalidone; (c) daratumumab; (d) indapamide; (e) methazolamide; (f) metronidazole; (g) pilocarpine; (h) topiramate; (i) zonisamide. — MET
- Topiramate, commenced on 18 June 2015 for post-traumatic seizures following the concussion sustained on warlike service in Iraq, could not be ceased or substituted, and was taken within the 2 weeks before the myopic worsening on 30 June 2015.
Worsening factors
Factor 9(18): inability to obtain appropriate clinical management for visual refractive error before clinical worsening. — MET
- During warlike service in Afghanistan from June to November 2010 no ophthalmologist was available to excise the chalazion and pterygium, and the right astigmatism worsened before definitive surgery could be obtained in February 2011.
The % contribution of the causes is 100% and significant.
Sequelae
The repeated worsening of the right eye has left marked anisometropia with loss of binocular vision and depth perception, glare and double vision. This has contributed to headaches, a fall on stairs and restriction from night driving. These are sequelae of the accepted condition and should be considered in any related claim.
Unintended Consequence
Met. Several worsenings followed treatment provided and paid for by Defence while the veteran was serving: high astigmatism after penetrating keratoplasty, myopia from the scleral buckle and topiramate, lenticular astigmatism from the tilted lens implant and hyperopia from aphakia after explantation. These are unintended consequences of that treatment (section 6A of the DRCA and the equivalent provisions of the MRCA).
Inability to Attain Appropriate Medical Management
MET. From June to November 2010, during warlike service in Afghanistan, the veteran's enlarging right chalazion and pterygium could not be treated because no ophthalmologist was available, and he continued outdoor work in sun and dust with lubricants only. Right astigmatism increased threefold before excision in February 2011, and keratoconus followed. Applying the objective and subjective tests in Brew v Repatriation Commission (Full Federal Court, 10 September 1999, Merkel J), the unavailability of specialist treatment on operations amounts to an inability to obtain appropriate clinical management.
5. Please provide a Health Summary and a medication / prescribing history.
See attached report.
References
- 17 Jan 2005, Enlistment medical examination, Medical Officer
- 05 Jan 2006, Pre-deployment medical examination, Medical Officer, Garrison health centre
- 19 Feb 2007, Role 2 medical facility record, Medical Officer, Iraq
- 20 Mar 2007, Optometry assessment, Optometrist
- 20 Oct 2010, Optometry review, Role 3 hospital, Afghanistan
- 15 Feb 2011, Operation report, Ophthalmologist
- 04 Jul 2011, Ophthalmology consultation and corneal topography, Ophthalmologist
- 12 Sep 2012, Ophthalmology review and corneal topography, Ophthalmologist
- 10 Jun 2013, Operation report, Corneal surgeon
- 24 Mar 2014, Ophthalmology review, Corneal surgeon
- 05 Jun 2015, Operation report, Vitreoretinal surgeon
- 18 Jun 2015, Neurology consultation, Neurologist
- 30 Jun 2015, Ophthalmology review and biometry, Vitreoretinal surgeon
- 14 Apr 2017, Ophthalmology review, Ophthalmologist
- 10 Aug 2017, Operation report, Cataract surgeon
- 20 Oct 2017, Ophthalmology review, Cataract surgeon
- 01 Mar 2019, Ophthalmology review, Vitreoretinal surgeon
- Statement of Principles concerning Visual Refractive Error (Balance of Probabilities) No. 36 of 2025, Repatriation Medical Authority
- Statement of Principles concerning Visual Refractive Error (Reasonable Hypothesis) No. 35 of 2025, Repatriation Medical Authority
