CORNEAL DAMAGE SECONDARY TO BENZALKONIUM CHLORIDE INTRAOCULAR USE

The goal to eliminate human error from health care is laudable but obviously impossible to achieve. That human error will continue to be part of the problems facing healthcare delivery is obvious. That we learn from the events of human error is not always certain. It is for that reason that Liu and co-workers are to be congratulated for candidly and openly describing the inadvertent use of benzalkonium chloride during cataract surgery and the corneal damage that resulted. Nineteen patients received hydroxypropyl methylcellulose preserved with benzalkonium chloride during phacoemulsification. This resulted in severe corneal oedema. In most cases this striate keratopathy spontaneously cleared. However, varying degrees of stromal thickening persisted. Penetrating keratoplasty was necessary in two patients and postoperative results were good. This study reminds us how important it is to clearly label …