FD: FD: DT:D DN: 336/88 STY: PANEL: Bigras; Robillard; Seguin DDATE: ACT: none KEYW: Delay (onset of symptoms); Consequences of injury

Transcription

1 FD: FD: DT:D DN: 336/88 STY: PANEL: Bigras; Robillard; Seguin DDATE: ACT: none KEYW: Delay (onset of symptoms); Consequences of injury (iatrogenic illness, treatment); Hearing loss (traumatic); Cataract. SUM: In December 1973, a 50 year old carpenter fell, striking and severely fracturing his jaw. He underwent surgery immediately and again in June The worker claimed that a cataract and bilateral hearing loss were also related to the compensable accident. There was a delay in onset of eye and ear symptoms until July A medical report requested by the Panel indicated that there was no direct injury to the eye and trauma was unlikely to be the cause of the cataract, considering the long delay in the onset of symptoms. Further, many cataracts begin to develop about the age of 50. Medical reports requested by the Panel concerning hearing loss indicated that hearing loss can be caused by trauma but from a concussion rather than a blow to the face or jaw. The medical evidence also did not support a relationship between the June 1974 surgery and the hearing loss. The worker was not entitled to benefits for hearing loss or visual impairment. PDCON: TYPE:A DIST: IDATE: HDATE: TCO: KEYPER:G. Renaud XREF: COMMENTS:This decision was issued in French TEXT:

2 WORKERS' COMPENSATION APPEALS TRIBUNAL DECISION NO. 336/88 This appeal was heard at Timmins on May 5, 1988, by: J.G. Bigras: Panel Chairman, J. Seguin: Tribunal Member representative of employers, M. Robillard: Tribunal Member representative of workers. THE APPEAL PROCEEDINGS The worker is appealing the decision of Hearings Officer L. Carr dated March 19, The decision denied the worker entitlement to compensation benefits for bilateral hearing loss and a right eye disability which the worker claims to be related to an accident at work on December 10, The worker appeared and was represented by G. Renaud, a lawyer. The accident employer was notified but did not attend. Proceedings were conducted in the French language. THE EVIDENCE The Panel had the Case Description marked as Exhibit # 1. An addendum dated January 26, 1988, was marked as Exhibit # 2. The worker gave oral evidence under oath. After the hearing, the Panel requested medical reports from the Toronto General Hospital relating to the worker's hospitalization and surgery on June 11, These reports were made available to the Panel on October 9, The Panel also directed that the worker's medical file be transmitted to an otolaryngologist who would examine the worker and answer questions regarding the possible relationship between the worker's hearing loss and his accident of December 10, The worker was examined by otolaryngologist Dr. W.H. Kudryk, of the University of Alberta, in Edmonton, on April 13, 1989, and his hearing was tested by audiologist R.I. Evans, at the University of Alberta Hospitals on April 20, On both occasions, the worker was accompanied by a French-English interpreter. The audiology report and Dr. Kudryk's reports of April 24, 1989, and April 27, 1989, were received by the Panel on June 21, All post-hearing materials had been submitted to the worker's representative with an invitation for submissions.

3 2 THE NATURE OF THE CASE The worker, a construction carpenter, suffered a severely fractured jaw in a fall at work on December 10, After the accident, surgery was performed in Timmins, but the jawbone remained displaced and further surgery (right temporomandibular arthroplasty) was required in Toronto on June 14, 1974, when the mandible was reshaped to correct a deformity. The worker received temporary total disability benefits from the date of the accident to September 18, He claimed that his hearing and visual loss problems were caused by the accident, but these claims have been denied by the Board. First reports of eye and ear problems were made by family physician Dr. M. Tatartcheff on July 18, The worker was subsequently shown to suffer from bilateral hearing loss. He also developed a cataract in the right eye which was surgically removed in The issue is the worker's entitlement to compensation benefits. Should it be determined that the worker's hearing and visual loss are causally related to the accident, the worker would be entitled to benefits for the impairment of his earning capacity resulting from these physical handicaps. Pursuant to section 3 of the Act, a worker is entitled to compensation for injuries arising out of and in the course of his employment. THE PANEL S REASON The worker was employed as a construction carpenter. On December 10, 1973, he fell from a height of about four feet, striking his underchin on a piece of wood. X-ray examination by Dr. E.R. Harrrigan revealed a fracture of the neck of the right mandibular condyle, with slight displacement. On December 15, 1973, Dental Surgeon Dr. F.A. Pollon, wired together the full upper and lower dentures and placed a head band to immobilize the mandible. On February 7, 1974, further x-ray films showed a seven or eight mm displacement of the condyle in relation to the head of the mandible. The worker was seen by surgeon Dr. John B. Sullivan, of Timmins, who referred him to physician and dental surgeon Dr. R.A. Newton, who specializes in plastic surgery at the Toronto General Hospital. Dr. Newton's diagnosis was that the worker had a old mandibular fracture, subcondylar with right temporal mandibular arthrosis. On June 13, 1974, Dr. Newton performed surgery on the worker's jaw, placing a cushion of silastic in the space below the meniscus and the condyle. A note by Dr. Sullivan dated August 26, 1974, advises the Board that the worker was complaining of paraesthesia around his scar and had pain in the right joint when biting. Examination showed that the scar was clean, dry and non-tender. On July 6, 1981, the worker reported numbness and weakness of the left extremities and was seen by neurologist Dr. C. Tai, in Timmins. The

4 specialist found no neurological deficit but suspected an ischemic attack. 3

5 4 The worker had a similar attack while in church in Edmonton on September 16, 1981, and an angiogram performed on September 17, 1981, by Dr. S. Nakai revealed a high-grade stenosis at the origin of the internal carotid artery, and confirming that the worker had sustained an ischemic attack at that time. The worker testified at the hearing that, following the accident, his right ear would occasionally become blocked and after rubbing the jaw area for an hour, it would clear up. At that time, the sensation was that of "coming closer to a sound". ("comme se rapprocher d'un son"). The worker also stated that for some time after the surgery, he had considerable amount of coagulated blood and pus coming out of his right ear. The worker also stated that his right ear also produced noise, "comparable to the sound of a plane". The worker also testified that he had no problems with his eyes or ears prior to his accident. There is no family history of deafness nor of eye cataracts. He was 52 years of age at the time of his accident in 1973, and had never been required to wear corrective lenses up to that time. On July 18, 1974, the worker's family physician Dr. Tatartcheff reported to the Board that the worker was complaining of pain in the right ear and eye. On September 10, 1974, the worker reported to the Board that he had experienced hearing loss in the right ear and headaches. On February 7, 1975, the worker wrote to the Board reporting that he had become deaf in his right ear and that the sight in his right eye was also being affected. He stated that the problem had arisen since the operation of June 14, The first elements of a causal relationship between an accident and a subsequent condition include factors such as continuity of complaints, symptoms, and medical treatment. In the present case, it is clear that the worker has brought the ear and eye problems to the attention of the Board and of his doctors about a year after his accident and has continued to report his symptoms and complained to the Board. The worker's medical file also shows that he sought medical attention for his right ear condition starting in It was confirmed that he had bilateral neuri-sensorial hearing loss and further examinations have shown that the condition has progressed since that time. The worker also complained of eye problems and it was discovered that he had a cataract in his right eye, a condition for which he underwent surgery in The Panel finds that there is considerable evidence of continuity since We accept that the fact that a year elapsed between the accident and the first report should not be seen as a break in the chain of causation in this case. The worker claims that his eye and ear problems were caused by the surgery which he underwent in June 1974, and, as such, we agree it would be compensable. It has been Board policy, confirmed in numerous Tribunal decisions that benefits are paid for conditions resulting from the accident injury or its sequelae. When a medical procedure necessitated by an accident injury causes a disability, the resulting condition is compensable.

6 5 However, in order to establish a causal relationship, it must be shown, on the preponderance of the medical evidence, that the medical conditions result from the accident or its sequelae. On this issue, the Panel will examine the medical opinions separately as they relate to the worker's eye and the ear problems. (i) Did the worker's eye problem result from the accident? As noted earlier, the worker complained of problems with his right eye to his family physician Dr. Tatartcheff in September According to Dr. J. C. McCulloch, the Board's eye specialist, there is a report on the worker's medical file, dated October 6, 1975, which states that the worker had a right cataract at the time and that it was "not related to the injury". Dr. McCulloch could not make out the signature, but according to a later analysis by Dr. Marcae, this examination report was made by Dr. Nawaz, whose opinions we also review. There are no other records of treatment for the eye condition until the worker saw Dr. A. Nawaz, an ophthalmologist, in Timmins, on November 13, Dr. Nawaz found that a cataract was causing very poor vision in the right eye while the left eye was normal. He wrote: It is probable that his cataract started as a result of the injury to the right side of the face and since then it has gradually deteriorated. However, it appears that Dr. Nawaz was the specialist who had examined the worker in 1975 (when the doctor was practising in Kirkland Lake) and had signed the report referred to by Dr. McCulloch which stated that the right cataract was not related to the accident. On March 22, 1985, Dr. D.W. Bronson, who had then become the worker's family physician, expressed his opinion that, on the basis of Dr. Nawaz's opinion, and due to the severity of the accident of December 10, 1973, it was quite possible that the visual changes can be attributed to the 1973 accident. He added, that "definite proof of this relationship... is extremely difficult." On April 23, 1985, Dr. McCulloch recommended accepting the view of the October 6, 1985, report (he could not make out the physician's signature) over that of Dr. Nawaz which was made nine years later. He stated that, on that basis, he would not relate the cataract to the injury of On January 21, 1988, the Tribunal Counsel Office sent the worker's medical file to Dr. W.G. Macrae, an ophthalmologist in Toronto. Dr. Macrae was asked whether it was possible that the cataract was related to the December 1973 accident, and to explain his view. His answer follows: a) There was no direct injury to the eye or to the cranium in the accident of December 10, 1973.

7 6 b) There was an inordinately long delay before the onset of symptoms which make it highly unlikely that trauma was the cause of his cataract development. The accident happened in December of There was no mention in his preoperative assessment in June of 1974 when he had jaw surgery by Dr. Newton that he had any symptoms of visual impairment and no signs on physical examination of a cataract. When he complained of pain in his eye in July of 1974 [the worker] stated in his letter no associated loss of vision. The first suggestion of a symptom was in February of c) There is discrepancy in the timing associated with the onset of [the worker's] cataract. In his February 7, 1975 letter [the worker] stated that he had lost vision in his right eye since the operation of June 14, This not only is highly unlikely but contrasts sharply with the fact that in his letter of May 28, 1985 he stated that his vision loss was because of the accident of December 10, d) [The worker} had his accident at the age of fifty. Many cataracts develop at the age of fifty and the subsequent history through the various examinations up to and including 1986 indicate that the cataract was slowly progressive, probably nuclear in morphology, and bilateral although much more likely to happen as a result of increasing age as opposed to a specific injury to the eye. There is one apparent discrepancy in the recording which hopefully I can clarify. Dr. Nawaz stated that his first visit with [the worker] was in November of There is a report on file in which there was an uncertainty of the physician because of an illegible signature. This was dated October 6, I have recently discovered in conversation with Dr. Nawaz that he examined [the worker] while he was practising in Kirkland Lake and thereafter destroyed many of his files. His examination of [the worker] in November of 1984 was in Timmins where he is currently residing. It is evident that Dr. Nawaz noted that [the worker] did have a cataract in October of 1975 one and one half years after the accident which did progress significantly over the next nine years but I do not think this alters the evidence in this case which points to a nontraumatic origin of [the worker's] cataract development. On the basis of Dr. Macrae's view that the worker's right cataract is not related to a trauma, and on the evidence that there were discrepancies between Dr. Nawaz's reports of 1975 and 1984, we find, on the preponderance of the

8 7 medical evidence, that there is no causal relationship between the worker's right cataract condition subsequent to September 1974 and his compensable accident of December 10, (ii) Is the hearing loss in the right ear causally related to the accident of December 10, 1973? The worker had complained of hearing problems and pain in the right ear shortly after the surgery of June 11, However, he was referred to otolaryngologist Dr. L.F. Ah-Fat for examination only on June 2, Dr. Ah-Fat diagnosed a bilateral high-frequency sensori-neural hearing loss. Tests showed an average hearing level for the speech frequencies to be 25 decibels on the left side and 40 decibels on the right. Dr. Ah-Fat added: "I am unable to relate his hearing loss to his accident". The Board's hearing specialist Dr. M.A. Haley, in a note dated August 12, 1975, wrote that it was considered that the worker's hearing loss was bilateral and more typical of deafness from exposure to high noise levels. (This latter possibility was not at issue before this Panel.) On January 5, 1988, the worker's file was sent by the Tribunal's Medical Liaison Officer to Dr. P.W. Alberti, otolaryngologist-in-chief at Mount Sinai Hospital in Toronto. Dr. Alberti stated that hearing loss can be caused by trauma, but from a concussion rather than a blow to the face or jaw. The doctor was asked to comment on the type of hearing loss suffered by the worker. Dr. Alberti reviewed the worker's work history. He noted that the progression of bilateral hearing loss from 1975 and 1985 follows the patterns of the ageing process. His final and most important point was that long lag between the hearing loss and the injury was not indicative of a trauma-induced hearing loss since "mischief in the ear" produces its worse effects immediately after and is usually followed by a recovery later. Dr. Alberti concluded: It is thus my opinion that (the worker's) hearing loss is much more likely to be caused by noise or causes unknown that by this injury. Indeed, I believe the injury described is quite unlikely to be the cause of the hearing loss. Following the hearing, the Panel asked that the worker be examined with a view of answering specific questions from the Panel. The worker now resides in Edmonton and the examination was conducted on April 13, 1989, by Dr. William Kudryk, an otolaryngologist at the Walter McKenzie Centre of the University of Alberta Hospital. The Panel had asked Dr. Kudryk to describe the worker's symptoms as regards his right ear. Dr. Kudryk's reply in his letter of April 24, 1989, was: The patient underwent an audiometric assessment at the University of Alberta Hospital Audiology Clinic on April 20th, This shows a bilateral sensorineural hearing

9 8 loss considerably worse in the right ear. His middle ear function is normal. He had pure tone averages of 80 decibels on the right side as opposed to 37 decibels on the left. The Panel also inquired about the cause of the worker's symptoms and specifically asked Dr. Kudryk whether it appeared from the records and from the worker's history that there is any relationship between the right temporomandibular joint surgery and the present symptoms. Dr. Kudryk's reply of April 24, 1989, was: With regard to the specific points that you asked, the patient is complaining of hearing loss of the right ear as well as numbness about the right ear. As to the cause of these symptoms I do not feel that the trauma which he sustained in December 1973 is the cause of this. His hearing levels were established by Dr. Ah-Fat in 1975 and his hearing was at the 40 decibel level at that time. He has had a progressive hearing loss and in all likelihood this has been due to vascular impairment to the cochlea. This is supported by the fact that the patient has had central ischemic problems and has required carotid endarterectomy. In reviewing the surgical reports, I could see nothing of note that would indicate that the surgery could have contributed to his hearing loss. Also supporting this is the fact that the external auditory canal and middle ears are completely normal. Only if these areas were violated could the surgery be blamed for his continuing hearing loss. On April 27, 1984, Dr. Kudryk dispatched a two-paragraph letter, first indicating that a French-English interpreter had been present for the worker's examination and his hearing tests. Secondly, Dr. Kudryk added another explanation for his view that the jaw surgery of June 1974 did not cause his hearing loss: I have reviewed the consultation sheets which indicates that the right ear canal was filled with blood and it was impossible to see the site of any tear. On the bottom of the consultation sheet (at a later date) it is noted that the ear was much improved. It was cleansed free of blood and the tympanic membrane appeared intact and mobile. Without a doubt, the blood that was in his ear simply spilled over from the time of surgery as that incision goes very close to the external auditory canal. I would also stress that his hearing tested almost a year later showed his hearing level to be at 40 decibels which is considerably better than what it is at this time. Therefore my opinion remains the same that the surgery for the temporomandibular joint in no way has contributed to his hearing loss.

10 9

11 10 On the basis of the medical opinion that there is no relationship between the worker's injury or the subsequent jaw surgery and the present hearing loss in the right ear, we are unable to find any causal link between the worker's accident of December 10, 1983, and the worker's subsequent hearing loss. (ii) Conclusion Having found that neither the worker's eye condition nor his hearing loss are causally related to his compensable accident of December 10, 1973, we are unable to grant any entitlement to this worker. We note that the Panel does not doubt the worker's credible testimony that he does have some pain residual from his jaw surgery, but our investigation involved only the effects of the accident on the worker's hearing and visual impairment which were found not to be involved with this pain. We also note that we have not examined the issue of a possible hearing loss due to industrial noise exposure, nor were any arguments made or evidence adduced on that issue. THE DECISION The appeal is denied. DATED at Toronto, this 23rd day of August, SIGNED: J.G. Bigras, J. Seguin, M. Robillard.

12 11 TRIBUNAL D'APPEL DES ACCIDENTS DU TRAVAIL DÉCISION NO 336/88 Cet appel a été entendu à Timmins le 5 mai 1988 par: J.G. Bigras : Président du jury J. Séguin : Membre du Tribunal, représentant les employeurs, M. Robillard : Membre du Tribunal, représentant les travailleurs. L'INSTANCE EN APPEL Le travailleur en appelle de la décision du commissaire d'audience L. Carr, datée du 19 mars Dans cette décision, il s'est vu refuser le droit à des indemnités pour surdité bilatérale et incapacité de l'oeil droit, invalidités imputables, selon le travailleur, à un accident de travail survenu le 10 décembre Le travailleur et son avocat, G. Renaud, étaient présents à l'audience. L'employeur au moment de l'accident a été dûment avisé de l'audience mais ne s'y est pas présenté. L'audience s'est tenue en français. LA PREUVE Le jury avait la Description de cas, inscrite comme pièce à l'appui no 1. Un addenda, daté du 26 janvier 1988, a été inscrit comme pièce à l'appui no 2. Le travailleur a fait une déposition sous serment. Après l'audience, le jury a demandé les rapports médicaux de l'hôpital général de Toronto qui avaient trait à l'hospitalisation et à l'intervention chirurgicale subie par le travailleur le 11 juin Le jury a reçu ces rapports le 9 octobre Le jury a aussi demandé que le dossier médical du travailleur soit transmis à un otolaryngologiste qui, après l'avoir examiné, pourrait déterminer s'il est possible que la surdité du travailleur soit reliée à son accident du 10 décembre Le travailleur a été examiné par un otolaryngologiste, le docteur W.H. Kudryk, de l'université d'alberta, à Edmonton, le 13 avril 1989, et c'est un audiologiste, R.E. Evans, des Hôpitaux de l'université d'alberta, qui a effectué les examens auditifs, le 20 avril Le travailleur s'est présenté aux deux examens, accompagné d'un interprète anglais-français. Le rapport d'audiologie et les rapports du Dr Kudryk du 24 avril 1989 et du 27 avril 1989, ont été remis au jury le 21 juin Tout le matériel reçu après audience a été remis au représentant du travailleur afin qu'il présente ses observations, s'il le jugeait bon.

13 12 LA NATURE DU CAS Le travailleur, charpentier dans la construction, s'est fracturé la mâchoire lors d'une chute en cours d'emploi, le 10 décembre Après l'accident, il a subi une intervention chirurgicale à Timmins mais l'os maxillaire ne s'est pas replacé et il a fallu qu'il subisse une nouvelle intervention chirurgicale (arthroplastie temporo-mandibulaire droite) à Toronto, le 14 juin 1974, au cours de laquelle la mâchoire a été façonnée afin d'en corriger la déformation. Le travailleur a reçu des prestations d'invalidité totale temporaire à partir de la date de l'accident jusqu'au 18 septembre Il a déclaré que ses problèmes de déficiences auditive et visuelle étaient le résultat de l'accident mais la Commission lui a refusé des indemnités. Les premiers rapports relatifs à ces déficiences auditive et visuelle viennent du médecin de famille du travailleur, le docteur M. Tatartcheff et datent du 18 juillet On a établi, par la suite, que le travailleur souffrait de surdité bilatérale. Il a aussi souffert d'une cataracte à l'oeil droit pour laquelle il a été opéré en La question en appel est celle du droit du travailleur à des indemnités. Si on établit la preuve que les déficiences auditive et visuelle du travailleur ont un rapport de causalité avec l'accident en question, le travailleur aura droit à des indemnités pour diminution de la capacité de gain reliée à ces incapacités physiques. En vertu de l'article 3 de la Loi, un travailleur a droit à une indemnité pour lésions corporelles survenant du fait et au cours de son emploi. LES MOTIFS DU JURY Le travailleur était employé comme charpentier. Le 10 décembre 1973, il est tombé d'une hauteur d'environ quatre pieds et s'est heurté le menton contre un madrier. Les examens radiologiques effectués par le Dr E.R. Harrigan ont révélé une fracture ainsi qu'un léger déplacement du col du condyle mandibulaire droit. Le 15 décembre 1973, un dentiste, le Dr F.A. Pollon, a procédé à un cerclage des dentiers supérieur et inférieur et a entouré la tête du travailleur d'un bandeau pour immobiliser le mandibule. Le 7 février 1974, d'autres radiographies ont révélé un déplacement de sept ou huit millimètres du condyle par rapport au sommet du mandibule. Le travailleur a été examiné par un chirurgien de Timmins, le Dr John B. Sullivan qui l'a recommandé au Dr R.A. Newton, médecin et dentiste, spécialiste en chirurgie plastique à l'hôpital général de Toronto. Le diagnostic du Dr Newton a établi que le travailleur souffrait d'une ancienne fracture mandibulaire subcondylienne avec arthrose mandibulaire temporale droite. Le 13 juin 1974, le Dr Newton a pratiqué une intervention chirurgicale sur la mâchoire du travailleur et a placé un coussinet de silastique dans l'espace situé sous le ménisque et le condyle. Dans une note datée du 26 août 1974, le Dr Sullivan a avisé la Commission que le travailleur se plaignait de paresthésie autour de la cicatrice et qu'il ressentait une douleur à l'articulation droite lorsqu'il mordait. Un examen a

14 révélé que la cicatrice était nette, sèche et indolore. 13

15 14 Le 6 juillet 1981, le travailleur s'est plaint d'engourdissement et de faiblesse dans les membres gauches et a été examiné par un neurologue de Timmins, le Dr C. Tai. Le spécialiste n'a découvert aucune faiblesse neurologique mais a pensé qu'il s'agissait probablement d'un accès ischémique. Le travailleur avait souffert d'une crise semblable alors qu'il était à l'église à Edmonton, le 16 septembre Le 17 septembre 1981, les angiographies effectuées par le Dr S. Nakai ont révélé un retrécissement marqué à la naissance de la carotide interne; ceci confirmait le fait que le travailleur avait souffert d'un accès ischémique à ce moment-là. Au cours de l'audience, le travailleur a témoigné qu'à la suite de l'accident, il arrivait que son oreille droite se bouche et qu'elle se débloquait s'il se frottait la mâchoire pendant une heure. La sensation qu'il éprouvait alors était "comme se rapprocher d'un son". Le travailleur a aussi déclaré que pendant un certain temps après la chirurgie, une quantité considérable de sang coagulé et de pus sortaient de son oreille droite. Le travailleur a ajouté que son oreille droite faisait un bruit "comparable au son d'un avion". Le travailleur a témoigné n'avoir eu aucun problème oculaire ni auditif avant son accident. Il n'y a aucune hérédité de surdité ni de cataracte dans sa famille. Il avait 52 ans au moment de l'accident de 1973 et n'avait jamais eu besoin de lunettes jusqu'à cette date. Le 18 juillet 1974, le médecin de famille du travailleur, le Dr Tatartcheff, a rapporté à la Commission que le travailleur se plaignait de douleur dans l'oreille et l'oeil droits. Le 10 septembre 1974, le travailleur a rapporté à la Commission qu'il avait souffert de surdité à l'oreille droite et de maux de tête. Le 7 février 1975, le travailleur a écrit à la Commission en disant qu'il était devenu sourd de l'oreille droite et que la vue de son oeil droit s'affaiblissait elle aussi. Il a dit que le problème résultait de l'opération chirurgicale du 14 juin Les premières bases sur lesquelles on s'appuie pour établir un lien de causalité entre un accident et un état pathologique subséquent sont la continuité des plaintes, les symptômes et le traitement médical. Dans le cas qui nous occupe, il est évident que le travailleur a porté ses problèmes d'ouïe et de vue à l'attention de la Commission et de ses médecins environ un an après son accident et qu'il a ensuite continué à se plaindre et à rapporter ses symptômes à la Commission. Le dossier médical du travailleur indique aussi qu'il a commencé à se faire soigner l'oreille droite dès On a confirmé qu'il souffrait de surdité neuro-sensorielle bilatérale et il a été démontré, au cours d'examens subséquents, que cet état s'était aggravé depuis lors. Le travailleur se plaignait aussi de problèmes oculaires et on a découvert qu'il avait une cataracte à l'oeil droit pour laquelle il a subi une intervention chirurgicale en Le jury constate que les preuves de continuité des symptômes depuis 1974 sont abondantes. Nous reconnaissons que le fait qu'une année entière se soit écoulée entre l'accident et le premier rapport ne doit pas être considéré comme une interruption dans la chaîne de causalité du cas en question. Le travailleur déclare que ses problèmes auditifs et oculaires résultent de l'intervention chirurgicale de juin 1974 et, comme tels, nous sommes d'accord

16 qu'ils seraient indemnisables. Les politiques de la Commission, confirmées 15

17 16 par de nombreuses décisions du Tribunal, reconnaissent qu'on doit payer des indemnités dans les cas d'états pathologiques résultant de lésions dues à l'accident ou à ses suites. Lorsque des interventions médicales rendues nécessaires par une lésion accidentelle entraînent une invalidité, l'état pathologique qui en découle est indemnisable. Afin toutefois d'établir un lien de causalité, il faut démontrer que, par la prépondérance de la preuve médicale, l'état pathologique du travailleur dérive bien de l'accident ou de ses suites. Pour répondre à cette question, le jury examinera séparément les opinions médicales qui ont trait aux problèmes oculaires et celles qui ont trait aux problèmes auditifs du travailleur. (i) Les problèmes oculaires du travailleur découlent-ils de l'accident? Comme on l'a déjà noté, le travailleur s'est plaint de déficience à l'oeil droit à son médecin de famille, le Dr Tatartcheff, en septembre D'après le docteur J.C. McCulloch, spécialiste de la vue de la Commission, il existe, dans le dossier médical du travailleur, un rapport daté du 6 octobre 1975 qui dit que le travailleur avait une cataracte à l'oeil droit à ce moment-là et qu'elle n'avait rien à voir avec l'accident. Dr McCulloch n'a pas pu déchiffrer la signature mais, à la suite d'une autre analyse faite par le Dr Macrae, on a déterminé que le rapport d'examen avait été écrit par le Dr Nawaz dont nous examinons aussi l'opinion. Il n'existe aucun autre rapport de traitement pour déficience oculaire jusqu'au moment où le travailleur a consulté le docteur A. Nawaz, un ophthalmologue de Timmins, le 13 novembre Le Dr Nawaz a constaté que les troubles de vision à l'oeil droit étaient dus à une cataracte mais que l'oeil gauche, lui, était normal. Il a écrit: Cette cataracte a probablement débuté à la suite de la lésion au côté droit du visage et s'est, depuis lors, aggravée. Il semble pourtant que ce soit le Dr Nawaz qui ait examiné le travailleur en 1975 (alors qu'il était médecin à Kirkland Lake) et qui ait signé le rapport mentionné par le Dr McCulloch qui dit que la cataracte droite n'est pas reliée à l'accident. Le 22 mars 1985, le Dr D.W. Bronson, qui était alors le médecin de famille du travailleur, a déclaré, qu'en se basant sur l'opinion du Dr Nawaz et en considérant la gravité de l'accident du 10 décembre 1973, il était fort possible que les changements oculaires du travailleur puissent être attribués à l'accident de Il a ajouté qu'il est extrêmement difficile d'établir une preuve irréfutable de ce lien de causalité. Le 23 avril 1985, le Dr McCulloch a recommandé d'accepter les opinions du rapport du 6 octobre 1975 (dont il ne pouvait déchiffrer la signature) plutôt que celles du Dr Nawaz qui remontaient à neuf ans. Il a déclaré que, en s'appuyant sur ces conclusions, la cataracte n'avait aucun rapport avec l'accident de 1973.

18 17

19 18 Le 21 janvier 1988, le bureau des conseillers juridiques du Tribunal a envoyé le dossier médical du travailleur au Dr W.G. Macrae, un ophtalmologue de Toronto. On a demandé au Dr Macrae s'il était possible que la cataracte soit reliée à l'accident de décembre 1973 et d'expliquer son point de vue. Voici sa réponse: (a) L'accident du 10 décembre 1973 n'a causé aucune lésion directe à l'oeil ni au crâne. (b) Il s'est écoulé une période de temps anormale avant l'apparition des symptômes, ce qui rend pratiquement impossible la relation de causalité entre le trauma et la cataracte. L'accident est survenu en décembre Lors des évaluations pré-chirurgicales, en juin 1974, au moment de la chirurgie mendibulaire par le Dr Newton, il n'est fait aucune mention de quelque symptôme que ce soit de déficience oculaire et l'examen physique ne révèle aucun signe de cataracte. Lorsqu'il se plaint, en juillet 1974, de douleurs à l'oeil, le travailleur ne parle dans sa lettre d'aucune perte de vision. Il fait pour la première fois allusion à ce symptôme en février (c) Il y a une contradiction dans la période de temps qui entoure l'apparition de la cataracte du travailleur. Dans sa lettre du 7 février 1975, le travailleur déclare qu'il avait perdu la vue à l'oeil droit depuis l'opération du 14 juin Non seulement ceci est très peu probable mais c'est en contradiction avec le fait que, dans sa lettre du 28 mai 1985, il déclare que sa perte de vision est le résultat de l'accident du 10 décembre (d) Le travailleur a eu cet accident à l'âge de cinquante ans. Plusieurs cataractes se développent à l'âge de cinquante ans et les nombreux examens subséquents effectués, y compris ceux de 1986, indiquent que la cataracte a progressé lentement; elle était vraisemblablement d'une morphologie nucléaire et bilatérale quoique plus vraisemblablement le résultat du processus de vieillissement plutôt que des suites d'une blessure particulière à l'oeil. Il existe une contradiction indiscutable dans le dossier que je peux peut-être éclaircir. Le Dr Nawaz a déclaré que sa première rencontre avec le travailleur avait eu lieu en novembre Dans le dossier, il y a un rapport dont on n'est pas sûr de l'auteur, la signature du médecin étant illisible. Ce rapport est daté du 6 octobre J'ai récemment découvert, au cours d'une conversation avec le Dr Nawaz, qu'il avait examiné le

20 travailleur lorsqu'il exerçait sa profession à Kirkland 19