Diagnostic Error High in Corneal Referrals, Study Finds

A total of 13 distinct diagnoses were identified in this study which were initially referred in as dry eye disease, some of which were blepharitis, band keratopathy (pictured), senile furrow degeneration, corneal edema and epiphora. Photo: Joseph Shovlin, OD. Click image to enlarge. Subspecialty practices, particularly at academic medical centers, exist to provide tertiary care and expertise that’s unavailable in community-based practices. Still, such practices function more smoothly—and patients receive care most appropriately—when the presumed diagnosis of the referring doctor is correct. According to a recent paper published in American Journal of Ophthalmology, there’s substantial room for improvement.This retrospective investigation included all consecutive new patient referrals to a tertiary care academic cornea clinic, totaling 118 patients’ medical records to extract diagnoses determined by both referring and referral providers. In total, diagnostic error rate was 42%. A small majority (51%) of these cases were attributed to ambiguity in diagnostic terminology, “such as use of the term ‘dry eye’ for a patient with ocular neuropathic pain or ‘DED’ for patients with ocular rosacea,” the researchers wrote in their paper.Ineffective treatment was found to be caused by common diagnostic errors of missing ocular neuropathic pain—despite absence of ocular surface disease —as well as failing to identify exposure keratopathy, especially as a consequence of nocturnal lagophthalmos. All diagnostic error cases were found to be the fault of failure in history-taking or physical examination. Both optometrists and ophthalmologists were found to have erred in diagnosis.The authors of the study elaborated on their findings in the paper, emphasizing that certain diagnoses were overrepresented, with dry eye disease being the most common misdiagnosis; they speculate this was due to the over-inclusivity of classification for the condition. Some errors entailed assessing depth of corneal lesions, conducting key exams like the Schirmer test and interpreting patient histories differentiating neurotrophic keratopathy and neuropathic pain. With this information, the authors add that “because the history and physical exam are key to the diagnosis of many corneal conditions, our study highlights the need to bolster these skills during medical training.”Also based on their data, the investigators propose a distinct subcategory of diagnostic error to describe cases that are correctly classified but incomplete or imprecise diagnosis delayed or affected management. They propose “diagnostic ambiguity” as a label for such cases. As an example, the investigators again point to dry eye, explaining that this label may be accurately applied to a patient but it is not sufficiently specific to direct subsequent management. Anchoring on dry eye symptoms as highly specific for keratitis sicca could have biased referring providers toward the broad dry eye disease category, they suggested, in turn causing incomplete questioning on the provider side and omission of gathering needed data.Related to the potential biases at play, the authors posit: “We identified ambiguous diagnostic language as an important type of diagnostic error and found that this leads to delay in successful therapy to the same extent as outright misdiagnosis.” Addressing cognitive biases during ophthalmological and optometric training “may be an actionable strategy to prevent error and harmful effects on patients,” they suggest.Click here for the journal source. Kao AH, Gilbert C, Safi M, Margolis TP, Stunkel L. Characterizing diagnostic error in referrals to an academic cornea and external disease practice. Am J Ophthalmol. October 7, 2025. [Epub ahead of print]. This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.