Eye banking error: report of a donor cornea with a soft contact lens left in place.
OBJECTIVE
To report the first known case of a donor cornea being examined and shipped with a soft contact lens in place.


METHODS
Case Report.


RESULTS
Surgery was cancelled, the two involved eye-banks were notified, and the patient underwent successful keratoplasty 2 days later.


CONCLUSIONS
Eye banking is essential to the practice of Ophthalmology. Rarely, errors occur despite the strict protocols and procedures that have been instituted over the years. These errors force us to reevaluate and update those policies as technology rapidly advances. We present here the first reported case of donor ocular tissue being examined and then shipped with a contact lens on the cornea. It is possible that there are other errors that are not published. It behooves us to disclose these and to discuss any of these errors openly to allow us to maintain confidence in our local eye banks, and to help us practice the safest medicine possible for our patients.
Ehrenhaus
Michael P
MP
UCSD Shiley Eye Center, La Jolla, CA, USA. westcoasteyedoc@aol.com
Schanzlin
David J
DJ
Weissman
Laurence
L
Grasso
Cono
C
D000328:Adult; D003263:Contact Lenses, Hydrophilic; D003315:Cornea; D005125:Eye Banks; D005260:Female; D006801:Humans; D015948:Keratoplasty, Penetrating; D019300:Medical Errors; D008875:Middle Aged; D014019:Tissue Donors