Intended for healthcare professionals

Rapid response to:

Practice Lesson of the week

Misdiagnosis of angle closure glaucoma

BMJ 2006; 333 doi: (Published 30 November 2006) Cite this as: BMJ 2006;333:1157

Rapid Response:

Is the lesson fair?

In the 'Lesson for the week', the authors cover an important issue that is particularly relevant to my own practice as a urological trainee due to its link with anti-cholinergic therapy.

I do feel however that although there may be deficits in the care of the described patients, some of the judgements on the care seem harsh to say the least.

In both case 1 and 2, the patients developed sudden onset, severe unilateral headache. Visual problems did not manifest in the second case till the day after admission. When faced with a patient complaining of sudden onset severe unilateral headache, it would be a brave clinician who did not arrange an "inappropriate computed tomography scan" or other "unnecessary investigations" to exclude intra-cranial pathology but instead to await specialist ophthalmological input, especially given that the authors recognise the difficulties in dealing with both patients due to poor history and lack of mobility.

Interestingly, it would appear that the misdiagnosis of patient 2 was not made by the medical team who requested these "unnecessary investigations", but instead by the ophthalmologist whose opinion was sought due to suspicion of ophthalmic cause for her symptoms. It would seem that the main deficit in this lady's care came not from the medical teams lack of knowledge of acute angle glaucoma but instead from false reassurance from the reviewing ophthalmologist

It is easy to criticise case management with the benefit of hindsight, but it should be remembered that cases are not so clear at the time of presentation as they are six months done the line when the case notes are reviewed, especially when in cases such as these, key signs and symptoms have not manifested at time of initial assessment.

Competing interests: None declared

Competing interests: No competing interests

04 December 2006
Jeremy E Oates
Clinical research Fellow
Hope Hospital, Salford. M6 8HD