Case series study: Managing a fungal endophthalmitis outbreak

South Korean ophthalmologists, led by Seong Woo Kim, MD, PhD, from the Department of Ophthalmology, Korea University Guro Hospital, Seoul, Korea, reported a fungal endophthalmitis outbreak after cataract surgery resulting from contaminated viscoelastic material.

The investigators found that prompt intervention may improve the prognosis of fungal endophthalmitis caused by contaminated medical products.1

Fungal endophthalmitis is rare, occurring in 0.002% of cases in South Korea, according to the Korea Disease Control and Prevention Agency, but it generally follows an intractable clinical course with poor visual prognosis.

An “unusual” outbreak developed in October 2020, that became a nationwide outbreak and was found to be associated with contaminated viscoelastic material (sodium hyaluronate).

Dr Kim and colleagues conducted a retrospective case series analysis of clinical data from multiple institutions across the country from September 1, 2020, to October 31, 2021, to determine the epidemiologic and clinical features and treatment outcomes of this outbreak after cataract surgery.

The authors collected data from surveys conducted in May and October 2021 from the 100 members of the Korean Retinal Society.

Fungal endophthalmitis findings

The Korea Disease Control and Prevention Agency confirmed that the viscoelastic agent was contaminated.

A total of 265 patients (153 women, 57.7%; 281 eyes; mean age, 65.4 years) were diagnosed with fungal endophthalmitis. The diagnosis fungal endophthalmitis was made a mean of 24.7 days after cataract surgery.

The clinical features of fungal endophthalmitis in the patients included vitreous opacity in 75.4% of eyes, infiltration into the intraocular lens in 50.9%, and ciliary infiltration in 19.6%.

When cultures were performed in 260 of the 281eyes, and fungus was confirmed in 39.6%, and Fusarium species was identified in 86.4%.

All patients were treated with intravitreal antibiotic and antifungal agents with/without pars plana vitrectomy. When vitrectomy was performed, intraocular lenses and lens capsules were removed based on surgeon preference. Postoperatively, all the patients received repeated intravitreal antifungal injections or liposomal amphotericin at least twice weekly, until the infection was considered to be under control. Systemic antifungals also were prescribed for those patients whose infection was not adequately controlled. Patients underwent another surgery if the infection did not response adequately or there was unresponsive inflammation after the repeated intravitreal antifungal injection.

Following treatment, the mean best-corrected visual acuity improved from 0.78 logarithm of the minimum angle of resolution (logMAR) (20/120 Snellen equivalent) to 0.36 logMAR (Snellen equivalent, 20/45 at 6 months.

The investigators also reported that disease remission with no signs of fungal endophthalmitis (or cells in the anterior chamber milder than grade 1) occurred in 214 eyes (93.9%).

They concluded, “The findings of this case series study support the potential benefit of prompt, aggressive surgical intervention that may reduce treatment burden and improve prognosis of fungal endophthalmitis caused by contaminated medical products.”

Reference

1. Kim SW, Kim JH, Choi M, et al. An outbreak of fungal endophthalmitis after cataract surgery in South Korea. JAMA Ophthalmol. Published online January 19, 2023; doi:10.1001/jamaophthalmol.2022.5927