Preventable Surgical Error and Visual Recovery: Case Report of Wrong
Abstract:
Cataract surgery combined with goniotomy is a commonly performed surgery in patients with coexisting cat aracts and glaucoma [1]. Through cataract extraction with Minimally Invasive Glaucoma Surgery (MIGS), patients can get a dual benefit of increasing their visual acuity while also lowering their intraocular pressure (IOP). As rates of blindness from glaucoma are declining with increasing cataract surgery and MIGS due diligence needs to be maintained to prevent complications. However, while rare, the implantation of an in correct intraocular lens (IOL) during these combined procedures is a potential complication that can cause clinical consequences for both visual and glaucoma-related outcomes [2]. This case involves incorrect IOL placement during cataract extraction with concurrent goniotomy. We will highlight key contributing factors, clinical consequences, and strategies for prevention of implanting the wrong IOL. Errors in this case was caused from misidentification of the patient, error in updating IOL in the room during a schedule change and a break in protocol that led to a lack of communication among the surgical team. Strategies to prevent this from happening are discussed.
