Record number:
399
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Both of the donor's corneas caused C perf infection.
Time to detection:
1 day
Alerting signals, symptoms, evidence of occurrence:
Two cornea recipients developed severe endophthalmitis within 24 hours of transplantation of corneas contaminated with C. perfringens. Case 2: On the first postop day there was decreased visual acuity and this progressed to severe endophthalmitis. Culture of intraocular fluid grew C. perfringens.The donor had died of disseminated colon cancer, body refrigerated 3 hr after death, eyes recovered 8 hr after death, stored in gentamicin and streptomycin and used within 48 hours of storage. Cultures of the cornea prior to surgery and of each patient's intraocular fluid after developing signs of infection grew Clostridium perfringens.
Demonstration of imputability or root cause:
Level 4. Certain. The same organism was found on the donor cornea before surgery and in the patient's infected eye.
Imputability grade:
3 Definite/Certain/Proven
Keywords:
Suggest references:
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