During JANUARY 8-14, 1998, six of eight patients undergoing elective intraocular surgery at a Veterans Affairs medical center (VAMC) in St. Louis, Missouri, developed corneal endothelial decompensation (corneal edema and opacification) 24 hours after surgery. All had been operated on with instruments sterilized by the Abtox Plazlyte system (Abtox, Inc., Chicago, Illinois).1 This report summarizes the results of the investigation of these cases and indicates that using the Abtox Plazlyte system to sterilize opthalmologic surgical equipment led to corneal decompensation. A case was defined as corneal endothelial decompensation within 24 hours after surgery in any patient undergoing intraocular ophthalmic surgery during January 5-14, 1998. To ascertain cases and to determine the background rate of corneal decompensation, medical records of patients undergoing ophthalmic surgery during September 1997-January 1998 were reviewed. Six cases were identified. All patients had post-operative findings of persistent low visual acuity, cloudy corneas with corneal endothelial decompensation, and iris paralysis with dilated pupils. All were male, ranged in age from 43 to 85 years (median: 67 years), and had chronic systemic diseases such as coronary artery disease and hypertension. Four patients had cataract extraction and a posterior chamber intraocular lens implant, one had repositioning of a previously implanted anterior chamber intraocular lens that had become dislocated, and one had a trabeculectomy filtering procedure for glaucoma. All had surgery performed in the same operating room. The duration of surgery ranged from 17 minutes to 3.5 hours (median: 1.5 hours). Post-operative vision (range: 20/400 to Hand Motion) was significantly worse than pre-operative vision (range: 20/40-20/200).
A. Lubniewski, Veterin Affairs Medical Center, St Louis, MO 63125