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Fungal infection after endothelial keratoplasty: association with hypothermic corneal storage
  1. Nicola Lau1,
  2. Aida Hajjar Sesé2,
  3. Victor A Augustin3,4,
  4. Geert Kuit1,
  5. Mark R Wilkins1,
  6. Theofilos Tourtas3,4,
  7. Friedrich E Kruse3,4,
  8. Klavs Højgaard-Olsen2,
  9. Rohini Manuel5,
  10. W John Armitage6,7,8,
  11. Daniel F Larkin1,
  12. Stephen J Tuft1
  1. 1 Corneal Service, Moorfields Eye Hospital NHS Foundation Trust, London, UK
  2. 2 Department of Ophthalmology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
  3. 3 Department of Ophthalmology, University Hospital Erlangen, Germany, Erlangen
  4. 4 Department of Ophthalmology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
  5. 5 National Infection Service, Public Health England, London, UK
  6. 6 Tissue and Eye Services, NHS Blood and Transplant, Bristol, UK
  7. 7 Translational Health Sciences, University of Bristol, Bristol, UK
  8. 8 European Eye Bank Association, Veneto Eye Bank Foundation, Zelarino, Italy
  1. Correspondence to Professor Stephen J Tuft, Moorfields Eye Hospital NHS Foundation Trust, London EC1V 2PD, UK; S.Tuft{at}


Purpose To compare the incidence of fungal infection after endothelial keratoplasty (EK) when donor tissue had been stored in hypothermic medium or organ culture.

Methods We describe the clinical features of 10 cases of fungal infection (keratitis or endophthalmitis) following EK identified at three European centres. Case definition was the culture of fungus or a positive PCR from the host cornea or anterior chamber after EK. A survey of the incidence of infection after EK was conducted by the European Eye Bank Association. The main outcome measure was the number of cases in which donor tissue had been stored in hypothermic medium compared with organ culture.

Results The 10 cases occurred between 2014 and 2017. All donor corneas had been stored in hypothermic medium sourced from three US eye banks. Three pairs of mate corneas caused infections in six recipients. Candida spp were identified from nine cases, with one isolate of Purpureocillium lilacinum. Data on 16 862 corneas supplied for EK were available from 16 European eye banks for the 5-year period from 2012. There were 17 reported cases of infection, of which 15 (88%) were fungal infections and 14 (82%) were Candida spp. Fungal infection was reported from 3 of 14 476 (0.02%) corneas supplied in organ culture compared with 12 of 2386 (0.50%) corneas supplied in hypothermic medium (p<0.0001). The incidence of infection after hypothermic storage was similar for material sourced from Europe (0.52%) or the USA (0.61%).

Conclusions Infection after EK is strongly associated with Candida spp. The possible explanations for the higher incidence of infection when tissue is stored in hypothermic medium are discussed.

  • cornea
  • infection
  • eye (tissue) banking

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  • Contributors SJT, WJA and DFL conceived the study and wrote the manuscript. NL, MRW, AHS, VAA, TT, FEK and KHO collected the clinical data. RM, NL, GK and MRW performed the UK public health assessment. All authors read and approved the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was a retrospective review of records approved by the Moorfields Eye Hospital Clinical Research Management and Audit Department (reference: CA18/CED/02).

  • Provenance and peer review Not commissioned; externally peer reviewed.

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