Ophthalmologists Report a Fungal Endophthalmitis Outbreak After Cataract Surgery in S. Korea

South Korean ophthalmologists reported a fungal endophthalmitis outbreak after cataract surgery due to contaminated viscoelastic material.

Researchers from the Department of Ophthalmology at Korea University Guro Hospital in Seoul, Korea, under the direction of Seong Woo Kim, MD, PhD, found that early treatment may improve the prognosis of fungal endophthalmitis caused by contaminated medicinal supplies.

According to the Korea Disease Control and Prevention Agency, fungal endophthalmitis is rare, occurring in only 0.002% of cases in South Korea, but it typically has an untreatable clinical course and a poor prognosis for vision.

In October 2020, an unusual outbreak started and spread across the country. It was later determined that contaminated viscoelastic material (sodium hyaluronate) was to blame for the outbreak.

From September 1, 2020, to October 31, 2021, Kim and colleagues conducted a retrospective case series analysis of clinical data from a number of institutions across the nation to determine the epidemiologic and clinical characteristics 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.

Findings of Fungal Endophthalmitis

The Korea Disease Control and Prevention Agency confirmed that the viscoelastic agent was contaminated. Fungal endophthalmitis was found in 265 patients (153 women, 57.7%; 281 eyes; mean age, 65.4 years). After cataract surgery, the diagnosis of fungal endophthalmitis was made on average 24.7 days later.

Clinical signs of fungal endophthalmitis in the patients included vitreous opacity in 75.4% of the patients' eyes, intraocular lens infiltration in 50.9% of cases, and ciliary infiltration in 19.6% of cases.

When cultures were done on 260 of the 281 eyeballs, fungus was found in 39.6% of them, and Fusarium species were found in 86.4% of them.

All patients had pars plana vitrectomy or intravitreal antibacterial and antifungal treatments. Depending on the surgeon's preference, intraocular lenses and lens capsules were removed during vitrectomy.

All of the patients got liposomal amphotericin or recurrent intravitreal antifungal injections postoperatively, at least twice a week, until the infection was deemed to be under control. Patients with infections that were not sufficiently treated were also given prescriptions for systemic antifungals. 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 researchers also noted that 214 eyes (93.9%) experienced disease remission with no evidence of fungal endophthalmitis (or cells in the anterior chamber less than grade 1).

“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,” they concluded.

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