PC is a 59 year old gentleman with known medical history of type 2 diabetes, hypertension and glaucoma to the right eye. November 21, 2023 PC undergoes cornea transplant from organ donor. Operative notes are included below, but there are no noted complications (However, there is a note that the tissue was "dropped" but cleaned. Not used?) prior to procedure. PC is discharged same day. 3 hours post-surgical, PC has sudden onset of extreme right eye pain. Returns to office next day for post-op follow up and was told that he had increased interocular pressure. He was referred to a higher level of care (vitreoretinal disease specialist) in which he was told that he likely had endophthalmitis. Nov. 22, 2023, they performed intraocular ABX treatment: Vanco/Ceftaz/STK, obtained cultures. He was given drops and instructed to return in 2 days.
Follow up on Nov 25, 2023 reports pain and inflammation. Dx of Vanco-resistant enterococcus faecium but no culture results (those culture results did not come back until 12/1/23). They discussed treatment options with antibiotics and a repeat "tap and inject". Vanc/Ceft injection performed and told to follow up in 2 days for possible surgical intervention.
PC returns Nov 27, 23 and still has persistent inflammation and pain. B-Scan reveals persistent vitreous opacities and debris. They recommend a Pars Plana Vitrectomy and Anterior chamber washout. This was performed on Nov 27, 2023. Op note below.
Multiple post surgical follow-ups report less inflammation, however PC having varying degrees of poor vision. Exam shows 70% gas bubble of the vitreous. Non-reactive pupil. Has been given Prednisone and Zofran. This continues through January of 2024 and we have all follow up visit notes.
PC was informed us that he was told that his retina was “burned out” and has now complete loss a vision to right eye. PC given other surgical options, however declined due to fear of further damage.
Seeking ophthalmologist who is familiar with vitreoretinal disease and performed retinal transplant to review records for this case.
As mentioned, operative notes are below.
Original Corneal Transplant OP note:
A corneal transplant graft wa s first prepared using a Moria
keratome . The corneal button was placed within the artificial
anterior chamber and pumped up with air. A 300 - micron depth
was set on the keratome blade, and the keratome blade was
carried through so as to remove a thick anterior lamellae.
This left behind the posterior lamellae and the endothelium.
The corneal button was then placed back in the solution and
brought over to the main table , awaiting the beginning of the
procedure .
The right eye was prepped and draped in the usual sterile
fashion for eye surgery after local anesthesia was obtained. A
wire speculum was introduced , and a 4-0 silk suture was passed
underneath the superior rectus muscle so as to act as a stay
suture . A conjunctival peritomy was cut superiorly using
Westcott scissors , approximately 6 mm in length at the superior
limbus . Hemostasis was obtained with a bipolar cautery. An
MVR blade was then used to create a self-sealing stab incision
at approximately 9 o ' clock , peripherally .
A 69 Bard-Parker blade was then used to make a 5 mm long groove
at the surgical limbus superiorly. The blade was also used
then to sharply dissect anteriorly into clear stroma. The MVR
was then passed through this tunnel and used to enter the
anterior chamber , going sideway so as to completely open up the
5-mm wound . Healon was instilled inside the anterior chamber
and used to reform it . A modified Sinskey hook was placed in
the anterior chamber and oriented superiorly so as to touch the
endothelial surface of the cornea . An endothelial groove was
then demarcated using the Sinskey , running it around the
optical access so as to separate the central area between 7 to
8 mm .
A vertical scissors was used to make a peripheral iridotomy at
the inferior angle . A Descemet stripper was then placed in the
anterior chamber and used to gently peel away the Descemet
membrane from the central demarcated area , preserving the
peripheral endothelium . All the Healon was removed from the
anterior chamber carefully using the irrigation aspiration
device . The anterior chamber was then filled with air.
A posterior , deep lamellar , and endothelial graft had been
previously prepared using a Moria keratome . This posterior
lamella was then placed in a Troutman punch , and an 8 mm
trephine was u s ed to punch out the central area . This lamellar
deep patch graft was folded with Calibri forceps into a taco
s hape , with the superior aspect overlying the inferior . This
folded graft was then grasped with foldable intraocular lens
insertion forceps and used to insert the graft into the
anterior chamber . A 3 mL syringe filled with filtered air, and
a 27-gauge cannula was then placed in the anterior chamber and
underneath the folded graft so as to help to unfold it using
the filtered air .
The wound was completely closed using 2 interrupted bow-tie 10-0
nylon sutures , placing the knots within the wound so they would
not be exposed . The wound was tested and found to be
watertight . The anterior chamber was then filled with air
through the superior wound , and if necessary through t he side
port stab incision , as the graft itself was centered over the
pupil, so as to replace all the aqueous in the anterior chamber
with air. Once I was satisfied as to the centration and position of the new graft , the stay suture was removed .
A subconjunctival injection of Solu-Medrol and Kefzol was given
superiorly . The eye was patched and shielded , and the patient
wa s sent to the recovery area while still in a supine position
Note, that during the preparation of the tissue, the cornea itself fell
anterior, surface forward onto a clean cover. The tissue was picked up and
rinsed with the antibiotic solution, the anterior aspect of the cornea was not
used.
PPV, etc OP NOTE:
The patient was brought back to
ophthalmic operating room where appropriate blood pressure and
cardiac monitoring were established. The patient underwent
retrobulbar injection of 4% lidocaine and 0.75% of Marcaine in a
1:1 mix under mild IV sedation. He was then prepped and draped
in a typical sterile fashion for ophthalmic surgery. A 25-gauge
infusion trocar and cannula were inserted in the inferotemporal
quadrant approximately 3.5 mm infusion cannula was confirmed to be in the appropriate position prior to initiating infusion. Superonasal and superotemporal
trocars were now inserted again approximately 3.5 mm posterior to the limbus. The
to the limbus. At this point, some posterior
wound used for the corneal transplant was confirmed. A 10-0
nylon suture was passed through this wound to seal it water
tight and to provide further stability. After this wound was
revised and stabilized, attention was now turned again to the
anterior chamber. A paracentesis was now made using a 15-degree
blade. A balanced saline solution was irrigated through the
anterior chamber loosening up some of the inflammatory material
and fibrin. The vitrectomy instrument was now inserted into the
anterior chamber and used to evacuate any residual fibrinous
material and inflammatory debris. This improved the view into
the eye. The light pipe and vitrector were now inserted into
the anterior mid vitreous cavity behind intraocular lens. A
concentrated sample of fluid was now collected into the syringe
using vitrectomy instrument. This sample of fluid was now sent
for immediate culture. Once it was done, the vitrectomy
continued under wide field visualization using the BIOM lens
system. The vitreous dissection was now extended out to the
periphery in all directions as far as safely possible. A great
deal of inflammatory material was now removed from the vitreous
cavity in this process. As the inflammatory material was
removed, the retina was now finally instability of the scleral
visualized. There was patchy vasculitis and inflammation throughout the retina. There
was moderate posterior segment inflammation. The retina did not
show diffuse severe inflammatory involvement. There were also
no signs of focal retinal infection. At this point, the
vitrectomy instrument was used to continue aspirating any
residual inflammatory material from the posterior segment.
Additional balanced saline solution was now irrigated through
the anterior chamber through the paracentesis site. After this
was done, an air-fluid exchange was now initiated. At this
point, a small amount of residual fluid was left in the eye.
The superonasal and superotemporal trocars were now removed. An
SF6 gas exchange was then performed. In this process, approximately 45 mL of 24% SF6 gas was irrigated through the vitreous cavity while venting through a
venting needle. Once this was done, the infusion cannula
associated trocar was then removed. All the wounds were
inspected and confirmed to be well sealed, and the eye
maintained normal intraocular pressure. Intraocular injection
of additional antibiotics was now performed. A reduced dose of
intraocular antibiotics was now performed. First, vancomycin
with a concentration of 1 mg per 0.1 mL was used. A reduced
dose of 0.05 mg was now injected into the eye through the
vitreous cavity using a 30-gauge needle inserted through the
pars plana. Ina similar fashion, ceftazidime with
concentration of 2.25 mg/0.1 mL was now injected. Again, a
reduced half dose was now used so 1.125 mg of the ceftazidime
was injected into the vitreous cavity through needle inserted
through the pars plana. Again, this was done without
complication. The eye maintained again a normal intraocular
pressure. All the wounds were reinspected and again remained
well sealed. Subconjunctival injection of additional
antibiotics and Decadron was then performed. Sub-Tenon's
Kenalog injection was also performed for chronic postoperative
inflammation control. Antibiotic ointment was then placed in
the eye, and the eye was patched in typical fashion per
ophthalmic surgery. The patient tolerated the procedure well
and was transferred to the recovery room in good condition.
Proper postoperative management was reviewed with the patient
prior to discharge. Followup evaluation will be coordinated
through my office.
Files:
No questions yet!
Do you believe there might have been medical error?
As a cornea surgeon, I am concerned about the two main items. Obviously, the mishandling of the prepared tissue on the back table needs to be explored further. The explanation that the anterior portion of the tissue "fell onto a clean cover" is unclear to me where and when this happened. If the tissue fell on a sterile surface, that is what I would have documented. I am assuming this tissue fell onto a "clean" but not sterile surface, which would have precluded the tissue from being used. Cornea tissue is valuable and expensive, plus the patient would have significant corneal edema while waiting for another piece of tissue (may take a couple days). However, that would have been the most appropriate course of action if there is any doubt about the sterility of the tissue. Second, during the vitrectomy operative report, it was noted that the posterior aspect of the corneal incision needed an additional suture. This fact makes me concerned that the original incision may not have been water tight. This can be another source of the infection. Once the patient has a severe post-operative infection, the treatment guidelines usually follow the visual acuity. If the vision is better than Light Perception, then tap and inject is appropriate. However, at Light Perception, classically a vitrectomy would have been performed initially. I was not able to see visual acuity measurements, details that would help the analysis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This case sounds like endophthalmitis following DSAEK surgery for endothelial dystrophy. This is usually a very successful surgery, but does have the risk of infection. However, the possible contamination of the corneal tissue, along with a potentially compromised wound, could increase the risk substantially. Further details regarding the location of the contamination, the exact piece of the tissue that was contaminated, the potential availability of replacement tissue, and the visual acuity during post-operative treatment would help elucidate the causative effect of the medical decisions/treatment.
What makes you a good expert for this case?
Cornea Fellowship trained, performed about one hundred DSAEK procedures.
How often do you encounter cases similar to this one in your practice?
DSAEK has been the most popular cornea transplant procedure over the past decade. While I no longer perform the procedure, its "sister" procedure (DMEK) has taken over the bulk of the cornea transplants. performed by my younger associate surgeon. We see 10+ cases per month in our office.
Do you believe there might have been medical error?
It all comes down to the dropping of the corneal tissue. Rinsing with an antibiotic solution would not suffice even if it appears to have landed endothelium up, and it is not clear what the surgeon means by “clean.” This is a very aggressive bug that presented very early, and the prognosis is very poor. The surgeries otherwise look to be within the standard of care.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
See above. The patient’s problem was from an infection and the medical error may have cuased the infection.
What makes you a good expert for this case?
I have done about 2,500 corneal transplants during and after my corneal fellowship and I am now a full-time vitreoretinal surgeon.
How often do you encounter cases similar to this one in your practice?
I see about one to two endophthalmitis cases per month.
Do you believe there might have been medical error?
Based on the first operative report, there seemed to be an uncomplicated procedure. The surgeon noted that the wound in the eye was watertight, which makes infection much less likely. The only open question is what was meant when the surgeon indicated that the cornea fell on a “clean cover.” If the corneal tissue touched anything that was not sterile, then it would need to have been discarded. If the surgeon did not discard the cornea after it touched and unsterile surface, then this would amount to negligence because it might have resulted in contamination of bacteria onto tissue that was later transplanted into the eye. The key question, then, is what the surgeon meant by the term “clean cover”. If the clean cover was not a sterile surface, then it would be negligent to implant anything that touched that surface into the eye because it would raise the risk of infection.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
There is a good case to be made for causation if the corneal tissue touched something that was not sterile prior to being implanted into the eye. Therefore, it very much depends on what was meant by “clean cover”.
What makes you a good expert for this case?
I am a board-certified ophthalmologist and vitreoretinal surgeon. I specialize in treating disorders of the retina and vitreous, including endophthalmitis.
How often do you encounter cases similar to this one in your practice?
I treat cases of endophthalmitis frequently in my practice, around once a month.
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