Adverse Occurrence type:
Time to detection:
24 - 48 hours
Alerting signals, symptoms, evidence of occurrence:
Loss of visual acuity; ocular pain; mucopurulent discharge; conjunctival hyperemia; corneal ulcer
Demonstration of imputability or root cause:
Streptococcus pneumoniae type 14 cultured from conjunctiva in both patients (with same antibiotic resistance profile and partial gentamycin resistance) but no donor tissue was cultured; Same surgeon performed both procedures in the 1988 case; contamination of the corneal grafts with Streptococcus pneumoniae could have occurred before harvest, at harvest, during storage, or at time of transplantation. Streptococcus pneumonie cultured from donor and two recipients' eyes in the 1989 report, but typing and antibiogram not performed. Different surgeons, preservation medium contained gentamycin.