Adverse Occurrence type:
Time to detection:
Alerting signals, symptoms, evidence of occurrence:
Three possible bacterial transmissions were found during a review of endophthalmitis following 1,876 cases of corneal transplantation. Four (0.2%) developed infectious endophthalmitis, within 72 hours. In all three the donor rim culture grew the same organism as was obtained from the anterior chamber or vitreous. The causative organisms in the three cases of transmission were Streptococcus pneumoniae, group D Streptococcus, and Pseudomonas aeruginosa. One of the three cases of transmission involved Pseudomonas aeruginose was also reported by Insler et al (1985). In this case, a 74 yr old female developed a small central epithelial defect on postop day 1. On day 3 a hypopyon developed at the inferior graft interface with injection. A pars plana vitrectomy was performed. The vitreous sample and the donor rim sample grew identical Pseusomonas aeruginosa. She improved after antibiotics. In a separate case study, resistance to gentamicin, an antiobiotic routinely used in cornea transport medium, was demonstrated.
Demonstration of imputability or root cause:
Level 3. Likely bacterial infection transmitted from contaminated donor cornes. The donor rim culture grew the same organism as was obtained from the recipient's anterior chamber or vitreous.