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A cluster of fungal endophthalmitis following elective corneal transplantation

Poster Details

First Author: N.Lau UK

Co Author(s):    D. Flanagan   R. Angunawela   R. Manuel   G. Kuit   M. Wilkins        

Abstract Details

Purpose:

We report the clinical course of 6 patients who developed fungal endophthalmitis following routine uncomplicated corneal transplant surgery in a single centre. This is the largest cluster of postkeratoplasty fungal endophthalmitis (PKE) reported in the literature to date.

Setting:

Department of Cornea and External Diseases at Moorfields Eye Hospital, London, United Kingdom.

Methods:

The cluster involved six cases, all surgery took place between 30/6/2016-28/9/2016. All patients had received donor materials sourced from a single eye bank in America. An extensive hospital-wide investigation was initiated to determine the source of infection. Public Health England led an external review panel, with input from the US Centers for Disease Control and Prevention, Atlanta. Patient records for all patients who underwent corneal transplantations during the affected period were reviewed, as were the records of all patients with pre-exisiting corneal transplants who developed infective fungal keratitis and endophthalmitis. The clinical outcomes post-endophthalmitis for all affected patients were determined.

Results:

The incidence rate for infection was 0.71%. 5/6 patients underwent endothelial keratoplasty, one underwent penetrating keratoplasty. Two cases were mate corneas from one donor. Organisms isolated were Candida glabrata, Candida albicans, Purpureocillium liliacinum. The average time to onset of infection was 48 days post-surgery. One patient was asymptomatic. All patients were treated with a combination of intraocular, systemic and topical antifungals. All cases required surgical intervention. 50% of patients underwent removal of grafts. Two patients achieved clinical cure, including one successful re-graft. The patient with Purpureocillium developed perforation and underwent tectonic penetrating keratoplasty. The remaining patients are improving clinically.

Conclusions:

Postkeratoplasty fungal endophthalmitis is rare, but the incidence is rising, particularly following endothelial keratoplasty, and is associated with significant morbidity. Aggressive, prolonged medical therapy and multiple surgical interventions are needed to achieve good outcome. The exact cause of this cluster has not been determined. Possible sources of contamination include donor tissue, the US eye bank, and theatres processes and environment . American donor materials are hypothermically stored in Optisol-GS, which lacks antifungals. Whereas warm organ culture with antifungals is standard practice in Europe. In addition, the increased warming time during endothelial graft preparation may predispose to fungal infection.

Financial Disclosure:

NONE

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