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The Images in Clinical Medicine section of the New England Journal of Medicine (NEJM) is prime real estate for physicians and others wanting to share a compelling picture with their colleagues. But earlier this month, an eye specialist in Michigan saw double when he looked at the Dec. 5, 2019, installment of the feature.
Depicted was a picture from a pair of eye specialists in India who claimed to have seen a case of a person who’d suffered retinal bleeding after having been struck in the eye by a tennis ball:
A 24-year-old man presented with pain, swelling, and decreased vision in his right eye after it had been struck by a tennis ball. Examination showed a retinal hemorrhage. Physical examination of the right eye showed a visual acuity of 20/400, with an intraocular pressure of 20 mm Hg (reference range, 10 to 21) and a sluggish pupillary response to light. The left eye appeared normal, with a visual acuity of 20/20 and an intraocular pressure of 18 mm Hg. Slit-lamp examination of the right eye showed edema of the eyelid, conjunctival congestion, and a normal anterior chamber, cornea, and lens. On examination of the fundus, however, the foveal reflex was absent owing to the presence of a retinal hemorrhage at the macula (arrowhead) that measured approximately 5 disk diameters. A D-shaped subhyaloid hemorrhage (arrow) was also seen below the fovea and above the inferior arcade. A pars plana vitrectomy with internal tamponade was performed. At the 8-week follow-up visit, the patient’s visual acuity in the right eye had improved to 20/30, and examination of the fundus showed resolution of the retinal hemorrhage and a normal foveal reflex.
But Rajesh Rao, of the Kellogg Eye Center at the University of Michigan, called foul. Rao knew he’d seen the picture before — in a different journal, from a different person, illustrating a totally different eye problem. In fact, Rao, had even posted a copy of the image on his Instagram page back in March 2019. So he contacted NEJM, which retracted it swiftly. According to the notice, dated December 23:
We would like to retract the Image in Clinical Medicine entitled “Retinal Hemorrhage from Blunt Ocular Trauma,” which was published in the December 5, 2019, issue of the Journal. The image had been previously published elsewhere.
Jitender Jinagal, M.S., F.I.C.O., F.A.I.C.O.
Poonam Dhiman, M.Optom.
Government Medical College and Hospital, Chandigarh, India
The statement includes the following editor’s note:
The clinical details associated with the retracted Image in Clinical Medicine do not reflect those of the originally published case.
As Rao posted on Twitter, the image belonged to Mark Clark, of Wake Forest University. Clark even won an award for the picture at the 2014 annual meeting of the Ophthalmic Photographers’ Society, taking home first place in the category of Color Fundus Wide Field. That earned it a spot on the cover of the December 2015 issue of Ophthalmology, where Rao is social media retina editor.
As Rao wrote in a letter to the editor that NEJM declined to publish:
The image appearing in NEJM is copied exactly from [his March Instagram post], with identical cropping and image filter. Thus, the case records prived by Jinagal and Dhiman, such as the cause of injury, details of the ocular examination, surgical management, and post-operative course are spurious.
‘I would have preferred that NEJM publish the letter to the editor…’
In an email to Retraction Watch, Rao told us that one of his tasks as the retina social media editor for Ophthalmology and other journals belonging to the American Academy of Ophthalmology, he makes quizzes based on interesting images:
On March 28, 2019 I posted the following https://www.instagram.com/p/BvjtlP3ggh4/?igshid=zavldspmednv . On the week of 5 Dec 2019, I was made aware that the identical image was published in print at NEJM. I recognized the image immediately, and knew the provenance as stated in NEJM was inauthentic, and that the case records were likely falsified. To be honest I am not sure how I remembered the image, but I knew I had posted it, with proper attribution to the original author and Journal (AAO Journal: Ophthalmology) about 8 months earlier. I think it was the color palette and shape and multi-layer location of the hemorrhage that made it memorable.
I would have preferred that NEJM publish the letter to the editor that enabled their recognition of the problem. I think it would have been important to include, inasmuch as this case of plagiarism might not have been found without my efforts, which actually took some time to review the case, including searching my own Instagram posts, that of AAO Journal Cover Art Gallery in order to identify the true author of the original content.
Moreover, since the image was directly copied from an Instagram post, with identical filters and cropping, I think it would have been valuable for the reader, and instructive in general how content can be duplicated, plagiarized and falsified, directly from social media, despite peer review and editorial consideration in a top journal such as NEJM.
When I asked the Journal why they rejected our letter, they replied: “We are very grateful that you let us know about this case as soon as you recognized it, and we have acted quickly on the information you provided by issuing a retraction today. Still, we do not generally publish letters to the editor about a retraction when the problem is clear, as it is in this case.”
Nevertheless, it is laudable that they retracted the image so quickly, in response to my letter, despite their not publishing the actual letter that made them aware of the plagiarism of the image and falsification of the case records.
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