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Adverse Occurrence type:
Time to detection:
2- 5 days
Alerting signals, symptoms, evidence of occurrence:
Case 1: impaired vision, lid chemosis, conjunctival injection, hyphema, diffuse infiltration and necrosis of host cornea and loose sutures, complete melt of the graft leading to enucleation, which showed Gram positive rods. C. perfringens grew from donor rim and storage medium. Patient corneal culture and intraoperative culture grew C. perfringens. Case 2: severe mucopurulent drainage, conjunctival injection and eye pain. Intravitreal sample cultured: no growth but patient was treated with antibiotics. C. perfringens grew from donor rim and storage medium, but the recipient refused enucleation. Facial and lid cellulitus developed leading to enucleation on POD 13, showing extensive Gram positive rods throughout the globe. Case 3: pain, visual blurring and hypopyon. Culture of patient vitreous and acqueous showed no growth. Culture of donor rim and storage medium showed six bacterial species plus rare C. perfringens. Treatment with antibiotics was successful.
Demonstration of imputability or root cause:
Cases 1 and 2: Good evidence for transmission of C. perfringens from the cornea. C. perfringens grew from corneal donor 1 rim and storage fluid as well as from many bones and tendons recovered from same donor. Both corneal recipients had aggressive infection and enucleation showing extensive Gram negative rods in the globe. In Case 1, corneal and intraoperative cultures grew C. perfringens. Case 3: A case of C. perfringens endophthalmitis was not proven. No good evidence shown that the cornea transmitted C. perfringens. The recipient had a presumed bacterial infection with negative cultures. Culture of donor rim and storage medium showed six bacterial species plus rare C. perfringens.
The correct reference is: Hou JH, Tannan A, Rubenstein JB, Lopez OI, McCoy K,Epstein RJ, Grostern RJ, Sugar J. Clostridium perfringens Endophthalmitis After Penetrating Keratoplasty With Contaminated Corneal Allografts: A Case Series. Cornea 2015; 34: 23-27