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Sir,

We report the case of a 75-year-old patient who suffered an unusual complication during routine phacoemulsification cataract surgery under peribulbar block.

Case report

Towards the end of routine phacoemulsification cataract surgery after insertion of the intraocular lens implant, the anterior chamber was irrigated using balanced salt solution loaded in a 2 ml non-luer lock polypropylene syringe (Becton Dickinson, ref 300185) with a 27G Rycroft cannula (Steriseal, ref 1273A) attached. During the injection, the cannula became disinserted from the syringe with sufficient force to pass behind the lens implant, through the posterior lens capsule and vitreous and into the inferotemporal retina.

The result was an immediate vitreous haemorrhage. At this point, the cannula was retrieved and the eye closed. A B scan revealed vitreous and subretinal haemorrhage with probable retinal tear.

Six days later the patient underwent vitrectomy, and at the time of surgery an inferotemporal retinal detachment and accompanying tear, presumably caused by the Rycroft cannula 6 days previous, was noted; this was repaired with vitrectomy cryotherapy and gas tamponade. At the most recent follow-up (1 month following the original injury), visual acuity was 6/60 and the retina remains flat with some thin subretinal haemorrhage.

Comment

It is the responsibility of the surgeon to check that cannulae/needles are appropriate for the task in hand and well secured before use. It is expected that the scrub nurse also follows the above procedure. Despite adherence to these recommendations an accident occurred. While not belittling the importance of the above, we believe that safety in the operating theatre could be improved if only syringes with a luer lock are used while performing intraocular surgery. We recognise that if not appropriately fitted, cannulae can still detach from the luer lock system.

This case has been reported to the Medical Devices Agency.