Drugs for intraocular use should be stored separately from eye products for external use.
So says the report of an inquiry into the injection of the eyes of 20 cataract patients with a product intended for external use instead of an intraocular formulation. The report also recommends that, because they have no clinical use in ophthalmic theatres, eye-drops containing preservatives should not be stocked and should only be supplied on individual prescriptions. One of 10 other recommendations calls for urgent consideration of the revision of labelling regulations to give greater prominence to the fact that a product is for external use only.
The inquiry, commissioned by East Sussex, Brighton and Hove health authority, concerned operations carried out at the British United Provident Association Gatwick Park hospital on behalf of Brighton Health Care NHS trust. Between February 8 and 27, 1999, 20 patients were injected with preserved methylcellulose eye-drops instead of an unpreserved intraocular formulation. Some experienced cloudy vision or pain as a result of the error.
Although 11 patients made a full recovery, seven still had blurred vision in December, 1999, and two had been given penetrating corneal grafts.
The report concluded that the prime cause of the mistake was a misunderstanding between the NHS trust surgeon and the BUPA theatre nurses.
"Gatwick Park Inquiry", East Sussex, Brighton and Hove Health Authority, 36-38 Friars Walk, Lewes BN7 2PB.