A faulty autoclave system, lack of trained technicians in the operation theatre (OT) and failure to use fresh needle probes led to the post-operative infections in seven ophthalmic patients at HBT Trauma Care Hospital, according to an inquiry report released on Monday.
‘Protocols flouted’
The report said the patients at the hospital suffered a varying degree of vision loss as surgeons had not used fresh needle probes, which might have led to the formation of cluster infections.
Additional municipal commissioner Idzes Kundan said that Dr. H. Bava, the medical superintendent of the hospital, has been demoted and transferred and Dr. Arun Chaudhari, an honorary eye surgeon, has been terminated. Ms. Kundan said, “The first inquiry revealed negligence on the part of the hospital staff. A second detailed inquiry revealed that the sterilisation protocol was flouted. The doctors had not used fresh needle probes for all patients.” She said further investigation would be carried out by a committee of doctors from the JJ Hospital.
On January 4, seven patients, including two men and five women, were operated at the ophthalmology OT of the hospital. While Dr. Chaudhari was the senior surgeon overseeing the procedures, two speciality medical officers (SMOs) operated on the patients. A nurse, a sister in-charge and an OT assistant were also present. While six patients had undergone cataract procedures, one patient had undergone secondary intraocular lens implantation surgery.
On January 5, when Dr. Chaudhari opened the bandages of the patients, he noticed that they did not have vision in the operated eye and suspected bacterial infection. The inquiry report states that the patients had developed endophthalmitis, an inflammation of the interior of the eye, which leads to loss of vision due to pseudomonas, a severe bacterial infection. The patients were immediately shifted to KEM Hospital in Parel. However, only four of them regained some vision, while the three others are feared to have lost the eyesight completely.
Equipment called phacoemulsification probe is used for cataract surgeries. The needle probe breaks the cataract and aspirates it. Experts say that the instrument has to be thoroughly sterilised and a fresh needle (phaco tip) and a sleeve should be used each time. Dr. Chaudhari pointed that if the infection was due to the tip, the last patient who underwent the secondary intraocular lens implantation surgery should not have been infected as the instrument is not required in the surgery. He said that either the hospital’s autoclave machine was faulty or the untrained OT technician had flouted the protocol. “The OT technician we had was an untrained multi-purpose worker,” said Dr. Chaudhari.
Eye surgeon Dr. T.P. Lahane, who is heading the State’s cataract-free campaign, said that the patients should have been shifted to the JJ Hospital where doctors are trained to operate on patients with endophthalmitis.