Patient Safety and Surgical Governance
A 71-year-old woman with diabetes attends three days after uncomplicated phacoemulsification of her right eye on your Monday list in Abu Dhabi. She has increasing pain and blurred vision since yesterday. Visual acuity is hand movements, there is a 2 mm hypopyon, fibrin in the anterior chamber and no red reflex, and B-scan ultrasound shows dense vitreous opacities with an attached retina. That morning, a second patient from the same list has been referred with similar symptoms. How would you manage this?
What the panel is testing: The panel is testing urgent management of acute post-operative endophthalmitis using the evidence, and the consultant's governance response to a possible cluster.
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Knowledge: This is acute post-cataract endophthalmitis until proven otherwise, most often caused by coagulase-negative staphylococci from the patient's own flora. The main differential is toxic anterior segment syndrome, which usually appears within 12 to 48 hours with limbus-to-limbus corneal oedema and less pain. The Endophthalmitis Vitrectomy Study found that immediate vitrectomy benefited patients presenting with light perception only. Those with hand movements or better did as well with vitreous tap and intravitreal antibiotics, although its findings in diabetic patients were less clear. Two cases from one list raise the possibility of a common source, such as contaminated solutions, instruments or a breach in sterile technique.
Management: I would perform a vitreous tap or biopsy today and send samples for Gram stain, culture and, where available, PCR. I would inject intravitreal vancomycin 1 mg in 0.1 mL and ceftazidime 2.25 mg in 0.1 mL, using separate syringes. I would start intensive topical antibiotics and steroids and cycloplegics, and review her within 24 hours, proceeding to vitrectomy if she deteriorates. I would see the second patient urgently and treat in the same way. I would notify the infection control team and suspend the use of the same batch of solutions, viscoelastic and intracameral antibiotics from that list, keeping them for testing. I would review sterilisation records and the theatre process and check on all other patients from the list.
Ethics and communication: I would tell both patients clearly that they have a serious infection related to the surgery, what is being done and what the likely outcomes are, and I would not minimise the event. I would document the disclosure and treatment. If investigation identifies a system failure, patients should be informed of the findings. Protecting future patients takes priority over protecting the reputation of the unit.
Likely panel follow-up questions
- What did the Endophthalmitis Vitrectomy Study show and what are its limitations today?
- How do you distinguish toxic anterior segment syndrome from infection?
- What is the evidence for intracameral cefuroxime prophylaxis?
- What steps would you take before reopening the theatre list?
Pitfalls in this case
- Treating with topical antibiotics alone
- Delaying intravitreal antibiotics until culture results are available
- Not considering a cluster or leaving the list running unchanged
- Failing to disclose the complication honestly
Reference: Endophthalmitis Vitrectomy Study Group, Results of the Endophthalmitis Vitrectomy Study (Archives of Ophthalmology, 1995); ESCRS Guidelines for Prevention and Treatment of Endophthalmitis Following Cataract Surgery (2013, updated 2018)