Saturday, March 19, 2011

Eye couldn't guess!

Quiz for doctors and lay people out there: What is your diagnosis for this eye condition?

Be honest and put your answer as a comment below before looking at this article.

22 comments:

hossein said...

loa loa infecttion?

hossein said...

i was way off base!

Peter Kokolski said...

African eyeworm?

Equbal said...

From Facebook:

EYE couldn't either. Thought it was just ropey secretions from Phlyctenular conjunctivitis! After all, common things happen commonly, don't they?!!!

Peter Kokolski said...

Fantastic!
Lateral thinking at its best!

Paul Levy said...

Thanks, Peter. More on that concept here: http://www.rinkworks.com/brainfood/p/latreal1.shtml

Excerpt:

"Lateral Thinking Puzzles, unlike most puzzles, are inexact. In a sense, they are a hybrid between puzzles and storytelling. In each puzzle, some clues to a scenario are given, but the clues don't tell the full story. Your job is to fill in the details and complete the story. Obviously, there is usually more than one answer to any given puzzle, but, in general, only one solution is truly satisfying.

You can try solving these puzzles on your own -- that's certainly a legitimate way to go about this -- but usually you can have more fun if you involve other people. The way this works is, you look at the answer (maybe you want to try the puzzle on your own first!), then read just the clues to your friends. Your friends must determine the answer by asking questions about it, which you may answer only with yes, no, or doesn't matter. You can adjust the difficulty of the puzzle by varying the initial clues, throwing in red herrings, and so forth."

Anonymous said...

I lost. Guessed filarial worm although it seemed too big.

In retrospect one can see the seed and radicle. This amateur botanist should have known - but, classical case of diagnostic error; library of possibilities was artificially restricted by experience/training!

nonlocal MD

Paul Levy said...

Diagnostic anchoring in play!

Rosie said...

My lay guess is some worm or parasite.

Rosie said...

Wow. Thanks for posting.

Joseph said...

left over stuff from eye surgery....suture needles and some kind of tape??? It would be consistent with the content of the blog over time...(I haven't looked)

Joseph said...

hmmm - fooled by the context!

nasov said...

Now I know that every episode of The Outer Limit was true. Bugs laying eggs in your brain, etc. I'll sleep so well tonight.

Thomas said...

eyePod.

Art Papier MD said...

A great and "fun" "case"!, but more for House on Fox TV than a Blog serious about "patient-centered care, eliminating preventable harm, transparency of clinical outcomes, and front-line driven process improvement"!

The elephant in the room is the large number of preventable diagnostic mistakes around common diseases not exceptionally rare birds like this. In our work in diagnostic decision support and in my work as a dermatologist we see much more error around variants of common disease, diseases that could have been easily diagnosed if the PCP or ED physician had done a thorough physical exam, taken a history and paused to think about the diagnosis. We know that ED care at many institutions often emphasizes either sending the patient safely home, or getting the patient admitted, with resulting diagnostic error and no feedback loops for the physician. Likewise, many PCP's are rushed and do not perform thorough exams, overlying on diagnostic imaging and tests.

We have published a study on cellulitis over-diagnosis, error and resultant risk to the patient. Across the US there is a large and repeated problem with patients being treated with un-necessary IV antibiotics because clinicians prematurely close on cellulitis.

So what's the connection to this blog post? The problem in diagnosis and pattern recognition has little to do with teaching people about rare patterns like this. Unlike the "fascinomas" that keep us physicians curious a blog like this should use visual cases that highlight common diseases that doctors just do not seem to be able to diagnose correctly. People thinking about quality, safety, cost reduction need to get focused on repeated common mistakes!

PS It was a great case though!

Art Papier MD
Associate Professor of Dermatology and Medical Informatics
University of Rochester
Chief Medical Information Officer, Logical Images

Paul Levy said...

Art,

Patience, please. The next post will make you very happy -- exactly along the lines you mention.

But, meanwhile, whoever said this blog had to be serious?! Please don't hold me to that standard.

susannah said...

Looks like a worm, but I can't figure out how it could be. (I tried not to cheat by reading the other comments, so I don't know if this suggestion was already made.)

Nancy said...

Looks like a piece of dental floss that got misplaced!

Hope said...

I should have trusted my instincts! I was going to say mung sprout gone astray....but I peeked because surely that was too simple. Pretty close.

Anonymous said...

My PhD medical microbiologist friend said:

"Thanks. Wow! Even though it looked like the head of a tapeworm, I knew it had to be a filarial form of some sort (Loa or cousin) . . . . WRONG ! "

via nonlocal

Peter said...

Loa Loa infection of the eye.

Scott K. Aberegg, M.D., M.P.H. said...

I said "foregn body" along with parasite as possibilities.

I think failure to "get the answer" has to do with inadequate search for possibilities (search for "Search Inference Framework" on the web, Baron, Jon, or Aberegg, Scott).

Moreover, I think it's so rare and unusual that it is not surprising that folks won't get it, and I would not expect them to.

There was a picture circulating a few years back of a moose in Alaska that was stuck up in some telephone lines 50 feet off the ground. You could have made a "brainteaser" about that one, asking folks what might be causing excesssive tension on the lines after they raised them. And I would not expect anybody to figure it out. I mean, if you include "moose" in your "differential" for excessive tension on telephone lines, you're going to have so much obnoxious stuff in the differential, and its generation is goign to require so much time as to not be worth the effort.

There are cases where, I maintain, you go get it or just go look at it to figure out what it is. No need to do an exhaustive search for all the remote possiblitiies. We do that approach with bronchoscopy all the time. Unexplained dyspnea? Bronch. We know foreign body is a possibility but we don't sit around listing all the types of foreign body it might be.

Reminds me also of a recent "case records of MGH" in the NEJM where there was a foreign body in the pulmonary vein. Patient was a carpenter and it was a staple of some sort. Is it any wonder that nobody "got it" until after they went after it and literally "got it"? Some searches for possibilities are not worth the effort.