Adverse Occurrence type:
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
74 yr old Female. PK for bullous keratopathy followed by retrocorneal membrane, glaucoma 6 months later (exam:retained Decemet's membr, stromal edema, epith.haze, punctate epithelial erosions).. Regrafted (PK#2): Explanted PK#1 cornea: no Acanthamoeba. 3 weeks later developed inferior stromal keratitis, epithelial defect, hypopyon. Regrafted again (PK#3):Explanted PK#2 cornea: Acanthamoeba cysts and trophozoites. PK using other cornea from donor did not result in infection. PK#3 progressed to enucleation. Histology of cornea of PK#3 showed Acanthamoeba cysts
Demonstration of imputability or root cause:
Level 2 Possible transmission by PK. No other environmental or patient risk factors. No infection from mate cornea. Uncertain origin, thus possibly allograft related.