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Incorrect IOL never events – an update

30 August 2018

NHS England fed back from their Never Event response meeting highlighting a recent occurrence in a UK ophthalmic unit:

A patient was admitted to the hospital for cataract and ocular lens replacement. All WHO checks were completed prior to surgery as per protocol. An intraocular lens was chosen prior to start of surgery by surgeon and cross checked by scrub nurse. The trust was in a transition period between lens providers and two sets of biometry measurements were in the notes, one for the previously used lens type and one for the new lens type. The IOL selection was made from a biometry printout which pertained to the previously used lens type and not the current lens type. After surgery was completed the surgeon realised that an error had occurred. As patient had still not left theatre, a decision was made to immediately exchange the lens. The corrective surgery was completed with correct lens inserted. The patient was informed about exchange of IOL and the rationale behind it. Appropriate treatment and close follow up has been arranged at discharge. A duty of candour exercise was completed.

The College recommends that surgeons follow the ‘Correct IOL implantation in cataract surgery’ guidelines.

Specifically remember:

It is very important that the surgical plan is clearly verbalised during WHO surgical safety checks with the team including confirmation of the IOL make and model, as well as power in dioptre for the planned IOL, which should all match the IOL label/box and the biometry print out.

Be particularly careful if:

  • you offer several different IOL types such as multifocals and torics in addition to monofocals
  • have multiple different brands of IOL used
  • are changing, or have recently changed over to a different brand or supplier of lenses