Inadvertent Instillation of Hemoccult Developer in the Eye

To the Editor. —Identification of topical ophthalmic medications by colorcoded caps has been of benefit to countless patients. In a recent letter1readers were alerted to the improper use of eye drops by patients who inadvertently interchanged eye drop caps, potentially leading to ocular and systemic injuries. In a hospital setting, similar mistakes are less common. However, we report two cases in which the nonophthalmic preparation Hemoccult (Smith-Kline Diagnostic, Sunnyvale, Calif) was mistaken for an ophthalmic drop and was administered, resulting in acute ocular injury. See also pp 1029 and 1030. Report of Cases.—Case 1. —A 24-year-old woman was undergoing rehabilitation at a local hospital after suffering from a pontine hemorrhage. Five weeks after admission her physical examination showed hemiparesis and ataxia. Ophthalmic examination demonstrated visual acuity of 20/70 OU. Extraocular movements were impaired; the right eye showed an inability to adduct past the midline and the