Adverse Occurrence type:
Three of six Streptococcus pneumonia contaminated corneas caused significant infection
Alerting signals, symptoms, evidence of occurrence:
Of 6 corneas contaminated by Streptococcus pneumoniae from 3 donors, three resulted in endophthalmitis in recipients (latency in days not reported).Two patients required vitrectomy and intravitreal injection of antibiotics. Two recovered vision but one lost vision. According to the authors, cases were not reported until "an alert surgeon appreciated that an unusual problem was developing as soon as he saw his 2nd patient with this rare infection".
Demonstration of imputability or root cause:
Level 4. Certain. Concordance between donor tissue and recipient infection isolates showed Streptococcus pneumonia an organism that is rarely observed on stored cornea tissue.