Thirteen cases of fungal endophthalmitis were caused by Paecilomyces lilacinus. In all cases an intraocular lens was inserted that had been sterilized in sodium hydroxide and neutralized in sodium bicarbonate. In 12 of the 13 cases, it was absolutely determined that a manufacturer's lot 128 was the neutralizing solution used. The same fungus that caused the endophthalmitis was cultured from several of the neutralizing solutions from lot 128. Eight of the 13 eyes eventually required enucleation. Of the remaining five eyes, one eventually recovered 20/25 vision, one recovered 20/80 vision, one had light perception, and two lost light perception (one of these became phthisical). This surgically induced epidemic of fungal endophthalmitis clearly shows the major consequences of a breakdown in quality control for any substance or material used intraocularly.