Fungal Endophthalmitis Outbreak after Cataract Surgery, South Korea, 2020

Abstract

A lthough the number of cataract surgery procedures is increasing globally because of an aging population, the incidence of postoperative endophthalmitis is declining because hygiene and surgical environments have improved (1,2). Postsurgical fungal endophthalmitis is difficult to diagnose because symptoms, such as decreased vision and eye pain, are nonspecific (3). Most cases of postoperative endophthalmitis are caused by bacteria, and ≈75% occur within 1 week after surgery (4). Because the symptoms of bacterial and fungal endophthalmitis are similar, intraocular fluid culture is crucial for an accurate diagnosis (5). Preventing serious complications such as vision loss requires immediate diagnosis, vitrectomy, and long-term antifungal therapy (6,7).Postoperative endophthalmitis rarely occurs in South Korea; only ≈63 cases are reported per 100,000 cataract surgeries (8). However, the Korean Ophthalmological Society (KOS) recognized a sudden increase in endophthalmitis cases after cataract surgeries during September-November 2020, when ≈100 cases were reported nationwide. Cases included clinical findings of fungal endophthalmitis, including isolation of Fusarium species. Thus, in November 2020, KOS informed the Korea Disease Control Agency (KDCA), which promptly collaborated with the Korea Ministry of Food and Drug Safety (KMFDS) to investigate the unusual increase in fungal endophthalmitis, identify the cause, and recommend control measures.During the epidemiologic investigation, KMFDS collected commercially available samples of ocular viscoelastic devices (OVDs) from 6 manufacturers to conduct quality testing. OVDs are substances injected under the cornea to maintain the shape of the eye during cataract surgery and remain in the eyeball until the last step of surgery, when the OVD is removed. Thus, contaminated OVDs can cause intraocular infection. We describe an outbreak of fungal endophthalmitis after cataract surgery and confirmation of the cause through epidemiologic and microbiologic investigations. Materials and Methods Outbreak DeterminationTo determine whether the cases reported by KOS could be classified as an outbreak, KDCA analyzed data from Health Insurance Review and Assessment

Major outbreak of endophthalmitis after cataract surgery: a retrospective cohort in northern Brazil

“…The most common etiological agents identified in endophthalmitis after cataract surgery are gram-positive, especially negative coagulase Staphylococcus, followed by gramnegative and, less commonly, fungi [19,20,21] . A systematic review of studies conducted in India .…”

“…The occurrence of contamination by microorganisms can be associated with different causes, such as, for example, contamination of the ocular viscoelastic device [19] , vials used in surgeries [24] , pre-filled syringes of saline solution [25] . Or it may be related to the surgeon's experience [6] , number of surgeries performed [6] and failures in work processes, with emphasis on the inadequate processing of surgical instruments [4] .…”

“…The most common etiological agents identified in endophthalmitis after cataract surgery are gram-positive, especially negative coagulase Staphylococcus, followed by gram-negative and, less commonly, fungi [19,20,21] . A systematic review of studies conducted in India found that the most common microorganisms in endophthalmitis after cataract surgery were Staphylococcus, followed by Gram-negative bacilli of Pseudomonas species [15] .…”

Outbreaks of Fungal Infections in Hospitals: Epidemiology, Detection, and Management

“…Another nosocomial cluster of 14 cases of FOSC endophthalmitis occurring after cataract surgery arose where the viscoelastic filling material was identified as the most likely source of infection [264]. Of note, a large nationwide outbreak of Fusarium endophthalmitis post cataract surgery involving 156 cases (62 confirmed and 94 probable) occurred in South Korea [254]. The suspected source was ocular viscoelastic devices from a single manufacturer (Table 3).…”