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 Table of Contents  
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 484-488

A case series of donor tissue-transmitted keratitis and endophthalmitis following Descemet stripping automated endothelial keratoplasty: Management and outcomes

Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India

Date of Submission24-May-2020
Date of Acceptance29-Dec-2020
Date of Web Publication02-Jul-2021

Correspondence Address:
Prof. Radhika Tandon
Cornea, Cataract and Refractive Surgery Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_1637_20

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Donor-transmitted infection is one of the most dreaded complications after cornea transplant. We report four cases of fulminant graft infection with endophthalmitis following descemet stripping automated endothelial keratoplasty (DSAEK); all of these resulted from donor contamination by multidrug-resistant gram-negative bacteria (Pseudomonas in two cases, Proteus and Enterobacter in the other two). All donor corneas were retrieved in hospital premises, either ward or mortuary suggesting a possible nosocomial origin of these microorganisms. All four patients required surgical intervention for control of infection and had dismal clinical outcomes. Furthermore, in three cases, mate cornea also showed similar contamination, and additional two of these recipients also developed graft infection indicating an infection rate as high as 86%. This case series highlights an important issue of fulminant nosocomial donor cornea-related infections, possible despite standard precautions, with emergence of multidrug-resistant virulent pathogens. Adequate training of eye bank and health-care personnel and ensuing stringent protocols for retrieval and storage of corneas may help in reducing such sight-threatening adverse reactions and also consequent further ramifications.

Keywords: Donor-related graft infection, DSAEK, multidrug-resistant organisms

How to cite this article:
Mukhija R, Jain V, Yadav S, Vanathi M, Tandon R. A case series of donor tissue-transmitted keratitis and endophthalmitis following Descemet stripping automated endothelial keratoplasty: Management and outcomes. Indian J Ophthalmol Case Rep 2021;1:484-8

How to cite this URL:
Mukhija R, Jain V, Yadav S, Vanathi M, Tandon R. A case series of donor tissue-transmitted keratitis and endophthalmitis following Descemet stripping automated endothelial keratoplasty: Management and outcomes. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 28];1:484-8. Available from: https://www.ijoreports.in/text.asp?2021/1/3/484/319982

Graft infection and endophthalmitis, resulting from donor-to-host transmission, albeit uncommon, are devastating complications after any corneal transplant.[1],[2] This can occur despite stringent protocols for donor procurement and storage; after all, the donor corneal tissue can only be decontaminated and not sterilized, thereby making it a potential source of infection.[3],[4] Further, presence of an interface and a posterior lamella render cases of post endothelial keratoplasty infections difficult to treat because of poor accessibility to the site of infection and inadequate penetration of therapeutic drugs.[5],[6] Herein, we report four cases of infective keratitis and endophthalmitis post descemet stripping automated endothelial keratoplasty (DSAEK) that were attributable to multidrug-resistant (MDR) organisms transferred from the donor tissue.

  Case Series Top

This is a retrospective case series in a tertiary care hospital set-up. The study adhered to the tenets of the declaration of Helsinki. All tissues were retrieved in tertiary care hospital setting (three pairs from mortuary and one pair from ward) via in-situ corneoscleral rim excision under standard aseptic precautions and processing was performed in eye bank in accordance with the guidelines.[7] The site was cleaned with 10% povidone-iodine solution and the same was applied on the ocular surface for 3 min. The donor tissues were stored in a commercial medium (Cornisol, Aurolab, Madurai, India) containing gentamicin and streptomycin antibiotics. The tissues were refrigerated and warmed once for performing specular microscopy; they were kept at ambient room temperature for 15–30 min prior to use in surgery.

All keratoplasty cases were performed by experienced cornea surgeons and donor tissue was prepared in the operation theatre using automated microkeratome before the surgery by respective surgeon. The remnant donor corneoscleral rim along with anterior cap were divided into two parts and sent for bacterial and fungal cultures. The mean donor age years with was 24.3 ± 6.9 years (range: 18–32 years). The case-wise donor details, along with those of mate cornea, culture, and sensitivity results are summarized in [Table 1].
Table 1: Case-wise donor cornea details, their donor rim cultures and sensitivity testing and corresponding cultures from host tissue specimens

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An overview of the recipient details and clinical outcomes of the four cases along with details of cases where mate cornea was used are summarized in [Table 2]. As all the mate corneas were used in a different surgical team, clinical outcomes on follow-up are not available and only relevant details as per hospital records have been reported. Further, in order to maintain anonymity of the patients, the age group, instead of the actual age is mentioned.
Table 2: Case-wise recipient details, management and clinical outcomes

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In all the above cases, eye bank was notified and adverse events were reported as per standard protocol. Further, in view of occurrence of such fulminant MDR clinical infections, a “Recall procedure” involving review of all surgical practices including the donor retrieval practices was initiated by the Hospital Infection control department; however, no breach in standard aseptic precautions was noted. All cases that occurred in operation theatre during the specific days of each surgery were actively traced; fortunately, no other patient experienced a similar catastrophic event.

  Discussion Top

Donor-to-host-transmitted infections are one of the most dreaded complications following any keratoplasty procedure. Despite stringent protocols for aseptic donor tissue procurement and storage, positive donor rim cultures, as high as 12% have been reported; however, only a small proportion translate to clinical infection.[8] And therefore, taking cost-effectiveness into consideration, donor corneoscleral rims are not routinely subjected to microbiological culture.[9],[10] As a hospital protocol, our eye bank sends rim cultures for tissues where the death-preservation time (DPT) is more than 8 h or in cases where it is difficult to determine the exact DPT. Amongst the four cases discussed, a pre-operative rim culture was sent for the tissue used in case 2; however, no microbial growth was noted. After occurrence of post-operative infections and isolation of respective organisms from donor rims, the commercial media, per se, were not retrospectively tested for microbial contamination. However, it is unlikely that the source of contamination was the media, as there were no similar episodes of infection resulting from tissues transplanted in the other media from respective batches.

Increased risk of fungal contamination of donor corneas processed in advance for endothelial keratoplasty has been reported in a recent study, the probable mechanism postulated as increased room temperature exposure during processing.[11] However, in our study, all grafts for DSAEK were prepared using automated microkeratome by respective operating surgeons in the operation theatre. Longer preservation time in storage media has also been linked with higher rates of fungal contamination.[12] One out of four cases that had an additional fungal contamination had the longest preservation time (144 h vis-à-vis a range of 24–115 h for other cases).

One interesting finding common to the four cases is that donor bacterial cultures revealed MDR gram-negative bacteria in all. All tissues were retrieved from young donors in high-volume multispecialty tertiary care hospitals, either in the mortuary or ward. Owing to the huge patient load in populated countries with relatively lesser resources such as ours, tissue retrieval is often performed in the same room or theater where autopsies take place; even the possibility of a simultaneous post-mortem in another body cannot be completely ruled out. Increasing antibiotic resistance in hospital-acquired microorganisms and the so-called superbugs are known facts.[13] These reasons may explain the contamination of donor tissues with MDR gram-negative organisms. If true, this represents an alarming trend, as hospital-based cornea retrieval program contributes to a large number of eye donations.

With advent of component corneal transplant, a single tissue may even be used for multiple recipients, thereby subjecting all of them to potential disastrous adverse events. Furthermore, such contamination may also subject other patients (non-keratoplasty) being operated in the same theatre at the same time at risk. This is extremely important for high-volume hospitals in low- and medium-income countries, where using disposable inventory is not always feasible and instruments are re-used for different patients after appropriate sterilization.

Having said that, host factors and their immune status may also play a significant role in clinical translation of infection from contaminated corneas. Both corneas from the contaminated pair in the first case, used for DSAEK in diabetic patients, resulted in endophthalmitis. In the second case, however, clinical infection occurred only in the elderly patient who underwent DSAEK [Figure 1], while the adult patient who underwent PK with the similarly contaminated mate tissue had an uneventful post-operative course. In the third case scenario, only one tissue of the donor pair was contaminated (Enterobacter and aspergillus) and the same reflected in post-operative clinical infection. In the fourth case, donor rim cultures revealed only aerobic spore bearing bacilli, which do not explain the occurrence of clinical infection, let alone a fulminant one, eventually necessitating evisceration. However, clinical infection in both patients transplanted with the particular pair, growth of pseudomonas on donor culture of the contaminated mate cornea and in the host specimens, all corroborate with donor-transmitted infection.
Figure 1: Clinical photograph of the patient (case 2) showing (a) severe keratitis and endophthalmitis on POD-2 after primary surgery; (b) intra-operative picture demonstrating removal of the donor graft (white arrow) before proceeding with full thickness corneal trephination; (c) post-operative day 1 picture after therapeutic PK and pars plana vitrectomy with a large corneal graft in-situ; and (d) final clinical outcome with a shrunken distorted globe

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Although keratitis and endophthalmitis following endothelial keratoplasty have been reported in the literature, there are only a few cases with fulminant infections resulting from MDR organisms. Further, none of the cases reported growth of causative pathogens in donor rim cultures.[14],[15] To the best of our knowledge, this is the first described case series of fulminant donor-transmitted infection following DSAEK. In this case series, majority did not have favorable anatomical and functional outcomes. All four cases required surgical intervention, with two of them eventually needing an evisceration; one developing phthisis bulbi and the other an opaque graft. Two other cases developed clinical infection where similarly contaminated mate cornea was used; of these, while one showed a reasonable response to conservative management, the other required a therapeutic keratoplasty & pars plana vitrectomy.

The role of performing routine microbiological cultures after keratoplasty still remains controversial. While it has been seen that positive fungal cultures have a much higher positive predictive value as compared to bacterial cultures,[16] their role in benefitting the line of management in case of development a post keratoplasty infection still remains equivocal. This is because availability of fungal culture reports may take weeks as apposed to bacterial cultures and sensitivity testing reports that are often available in 48–72 h. In all above cases, the authors believe that donor rim cultures did help in guiding treatment and that the practice of routine microbiological cultures after keratoplasty may prove useful in cases where donor cornea has been retrieved in the setting of high-volume tertiary care hospitals and mortuaries, esp. in developing countries, where the risk of cross-contamination of tissues cannot be completely ruled out.

Infection of any kind after a routine surgical procedure is a calamity for all concerned. Cadaver sourced corneal tissue is a weak link in the aseptic chain and we all need to be forever conscious of that. Hospital-borne MDR superbugs are a lurking risk to be further catered for in appropriate clinical settings. A high level of care in all screening and decontamination protocols need to be observed with high index of suspicion and prompt action when needed. The current COVID-19 pandemic has added one more layer to current donor screening protocols to prevent donor to host transmission of pathogenic micro-organisms, and this paper brings to light the serious implications of nosocomial spread of infections emphasizing the need for a high level of alertness and vigilance for infection control.

  Conclusion Top

This article highlights an important issue of fulminant donor cornea-related infections post DSAEK and the dangers of emerging drug resistance and hyper-virulent pathogens in ophthalmic practice

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Conflicts of interest

There are no conflicts of interest.

  References Top

Hajjar Sesé A, Lindegaard J, Julian HO, Højgaard-Olsen K, Møller NF, Heegaard S. A presentation of culture-positive corneal donors and the effect on clinical outcomes. Graefes Arch Clin Exp Ophthalmol 2019;257:135-41.  Back to cited text no. 1
Antonios SR, Cameron JA, Badr IA, Habash NR, Cotter JB. Contamination of donor cornea: Post penetrating kertoplasty endophthalmitis. Cornea 1991;10:217-20.  Back to cited text no. 2
Rehany U, Balut G, Lefler E, Rumelt S. The prevalence and risk factors for donor corneal button contamination and its association with ocular infection after transplantation. Cornea 2004;23:649-54.  Back to cited text no. 3
Jain R, Murthy SI, Motukupally SR. Clinical outcomes of corneal graft infections caused by multi-drug resistant Pseudomonas aeruginosa. Cornea 2014;33:22-6.  Back to cited text no. 4
Fontana L, Moramarco A, Mandaraà E, Russello G, Iovieno A. Interface infectious keratitis after anterior and posterior lamellar keratoplasty. Clinical features and treatment strategies. A review. Br J Ophthalmol 2019;103:307-14.  Back to cited text no. 5
Nahum Y, Russo C, Madi S, Busin M. Interface infection after Descemet stripping automated endothelial keratoplasty: Outcomes of therapeutic keratoplasty. Cornea 2014;33:893-8.  Back to cited text no. 6
Joint Review of Eye Bank Standards of India; 2013:17-23. Available from: www.ebai.org/Eye%20bank%20standards%20of%20India.pdf. [Last accessed on 2020 Jan 16].  Back to cited text no. 7
Kiatos E, Armstrong JJ, Hutnik CM, Tsioros SM, Malvankar-Mehta MS, Hodge WG. The value of corneoscleral rim cultures in keratoplasty: A systematic review and cost-effectiveness analysis. Clinicoecon Outcomes Res 2017;9:459-74.  Back to cited text no. 8
Everts RJ, Fowler WC, Chang DH, Reller LB. Corneoscleral rim cultures: Lack of utility and implications for clinical decision-making and infection prevention in the care of patients undergoing corneal transplantation. Cornea 2001;20:586-9.  Back to cited text no. 9
Mian SI, Aldave AJ, Tu EY, Ayres BD, Jeng BH, Macsai MS, et al. Incidence and outcomes of positive donor rim cultures and infections in the cornea preservation time study. Cornea 2018;37:1102-9.  Back to cited text no. 10
Brothers KM, Shanks RMQ, Hurlbert S, Kowalski RP, Tu EY. Association between fungal contamination and eye bank-prepared endothelial keratoplasty tissue: Temperature-dependent risk factors and antifungal supplementation of optisol-gentamicin and streptomycin. JAMA Ophthalmol 2017;135:1184-90.  Back to cited text no. 11
Hassan SS, Wilhelmus KR. Medical review subcommittee for the Eye Bank Association of America. Eye-banking risk factors for fungal endophthalmitis compared with bacterial endophthalmitis after corneal transplantation. Am J Ophthalmol 2005;139:685-90.  Back to cited text no. 12
Khan SN, Khan AU. Breaking the spell: Combating multidrug resistant 'superbugs'. Front Microbiol 2016;7:174.  Back to cited text no. 13
Basak SK, Deolekar SS, Mohanta A, Banerjee S, Saha S. Bacillus cereus infection after Descemet stripping endothelial keratoplasty. Cornea 2012;31:1068-70.  Back to cited text no. 14
Taneja M, Senthil S, Paulose R, Joseph J, Sharma S, Pravin V. Intravitreal colistin for multidrug resistant acute endophthalmitis following Descemet-stripping endothelial keratoplasty due to Klebsiella pneumoniae. JCRS Online Case Reports 2016;4:52-6.  Back to cited text no. 15
Vislisel JM, Goins KM, Wagoner MD, Schmidt GA, Aldrich BT, Skeie JM, et al. Incidence and outcomes of positive donor corneoscleral rim fungal cultures after keratoplasty. Ophthalmology 2017;124:36-42.  Back to cited text no. 16


  [Figure 1]

  [Table 1], [Table 2]


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