Significant events in vitreoretinal surgery

Significant events relating to the operation of the service such as significant delays in treatment which may have affected visual outcome adversely should be reported via local reporting mechanisms.

Infective endophthalmitis is one of the most serious potential complications of vitreoretinal surgery because it can result in a very poor visual outcome or even loss of the eye. It fortunately occurs rarely and the risk can be minimised by a range of measures, but never completely eliminated. In most cases, the patient’s eyelids are the source of infection, but a range of external causes such as incomplete sterilisation of instruments needs to be considered, particularly if there is any suspicion of a cluster of cases. The College publishes advice on the investigation and management of a cluster of cases of endophthalmitis in a unit.

“Wrong site” (eg wrong eye) surgery is classified by the NHS as a “never event” and must always be reported and investigated fully using root cause analysis techniques.   The College recommends routine use of a preoperative checklist such as the WHO / NPSA “safer surgery” checklist to reduce the likelihood of such events.