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Safety Alert: Reports of Mydriasert pellets left in situ post cataract surgery

  • 03 Nov 2022
  • RCOphth

Recent evaluation of the data from the National Reporting and Learning System (NRLS) has shown a significant number of reports to the system related to the use of the Mydriasert ophthalmic pellet for pupil dilation. This includes reports of the Mydriasert pellet being left in situ post-surgery and the Mydriasert pellet not being found during post-operative checks. Whilst the harm to the patient is low, it is still possible that patients who had the Mydriasert pellet left in situ post-surgery will suffer from red eye and potential infection. We recommend that departments evaluate their standard operating procedures for the usage of the Mydriasert pellets.

This review should:

  • Ensure that there is a member of the theatre team has the designated role of removing the Mydriasert pellet
  • Decide on the location the Mydriasert pellet is removed i.e. anaesthetic room or theatre
  • Choose a method to record the removal of the Mydriasert pellet as part of the operative report ie note taking, ink stamp etc

The College has worked with Théa pharmaceuticals to develop an infographic which can be used within departments.

Visit the Safety Alerts page for all uptodate information.