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.