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Record number:
383
Adverse Occurrence type:
MPHO Type:
Estimated frequency:
Fungal infection after corneal transplantation is a rare event that occurs at a reported rate between 0.014% and 0.023% for all keratoplasty procedures. The risk of fungal infection is greater following endothelial keratoplasty (EK) due to the additional warming period required for tissue processing which allows fungus to proliferate. A recent ten year study (2011 - 2020) by Wong et al, found the incidence of fungal infection after Descemet Membrane Endothelial Keratoplasty (DMEK) was 3.50 cases per 10,000, with an incidence of fungal keratitis of 1.33 cases per 10,000 and fungal endophthalmitis incidence of 2.17 cases per 10,000, respectively.
Time to detection:
There is a wide range of latency with onset of symptoms occurring weeks to months following surgery. Wong et al, found that fungal infections post DMEK presented at a mean of 33 +/- 38 days after surgery.
Alerting signals, symptoms, evidence of occurrence:
Vision loss occurring over a period of days to weeks with minimal pain until later in the progression of disease. Local inflammation, eye pain, floaters, pus, and the diagnosis is confirmed by positive microbial culture results for the organism. Slit lamp exam may show white to cream colored interface deposits or infiltrates. Fungal endophthalmitis is a clinical diagnosis based on exam findings including the presence of vitreous inflammation in the setting of epidemiologic risk factors.
The correlation of a positive donor rim fungal culture taken at the time of surgery and an increased risk of fungal infection developing in the recipient is estimated to be approximately 11% in a recently published review.
Demonstration of imputability or root cause:
Donor-related endophthalmitis / keratitis is Probable if the same organism was isolated from the patient (cornea/anterior chamber/vitreous) and the donor cornea (storage medium/corneoscleral rim preserved after keratoplasty) or the mated ocular tissue recipient. Imputability is Definite/Certain/Proven if all of these conditions are met.
Imputability grade:
2 Probable
Groups audience:
Keywords:
References:
Suggest new keywords:
Endophthalmitis, infectious keratitis, Candida glabrata, donor rim cultures, corneal transplantation, Penetrating keratoplasty, Deep Anterior Lamellar Keratoplasty.(DALK), Descemet Membrane Endothelial Keratoplasty (DMEK)
Reference attachment:
Suggest references:
AA
Note:
Note for Evi - Unable to add reference 64 as link does not work. Please add:
[64] Cameron JA, Badr IA, Miguel Risco J, Abboud E, Gonnah el-S. Endophthalmitis cluster from contaminated donor corneas following penetrating keratoplasty.
Can J Ophthalmol. 1998 Feb;33(1):8-13. PMID: 9513766
Note: Includes one case of Torulopsis glabrata (now called Candida glabrata) endophthalmitis following penetrating keratoplasty where the same organism was cultured from the recipient eye and the corresponding donor rim.
Also add [1698] Early-Onset Candida glabrata Interface Keratitis after Deep Anterior Lamellar Keratoplasty. Le Q et al. Optom Vis Sci. 92(5):e93-6, 2015 May.
Candida glabrata interface keratitis occurred within 4 days after DALK, confirmed by histopathological exam and microbiologic cultures of the donor graft,
from MG: please see notes above, including merging record 64 with this one
OK DONE (EP)
Expert comments for publication:
Salisbury et al found that doubling the povidone iodine exposure time during the donor corneal recovery process decreased the rate of positive donor corneal rim fungal cultures (P=0.001), positive donor bacterial rim cultures (P=0.04), and postop fungal cultures.
While hypothermic storage solutions may suppress bacterial and fungal growth, the additional warming period necessary for tissue processing of endothelial keratoplasty grafts provides microorganisms an opportunity to multiply in storage media. Common hypothermic corneal storage solutions used in the United States do not contain an antifungal agent, so eye banks may supplement the storage media with amphotericin B to minimize the incidence of clinical infections.