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 three, the donor rim culture grew the same organism as was obtained from the anterior chamber or vitreous fluid. The causative organisms in the 3 transmission cases were Streptococcus pneumoniae, group D Streptococcus, and Pseudomonas aeruginosa.
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 fluid.