1 figure omitted
Endophthalmitis is a severe condition caused by inflammation of the
ocular cavity that often is associated with infection of the internal structures
of the eye. The source of infection can include bacteria disseminated through
the bloodstream and contamination of the cornea at the time of ocular surgery
or trauma. Complications include rapid, irreversible vision loss that can
progress quickly to panophthalmitis, requiring surgical removal of the eye.1Clostridium perfringens,
an anaerobic gram-positive bacillus found in soil and bowel flora, is an infrequent
cause of endophthalmitis. Although the majority of cases are caused by penetrating
injury with soil-contaminated foreign bodies, C. perfringens endophthalmitis has been reported in patients after cataract surgery.2,3 This report describes two cases
of C. perfringens endophthalmitis that occurred within
24 hours after transplant of contaminated corneas. These cases demonstrate
the potential for transmission of Clostridium infection
from donor to recipient. Clinicians should be aware of potential infection
risks associated with transplantation of corneal tissues and report any infections
to the appropriate eye bank.
In February 2003, two patients received corneal transplant of the right
eye on the same day in the same facility. The corneas used for both patients
were recovered from one donor, a woman aged 55 years who died from metastatic
The first patient, a man aged 64 years, had severe eye pain, nausea,
and vomiting within 12 hours after surgery. He had increased intraocular pressure
and decreased light perception in the eye in which the cornea was transplanted.
Eye examination was consistent with endophthalmitis without evidence of periorbital
or orbital involvement. The patient underwent a vitrectomy and was treated
with intraocular vancomycin and ceftazadime. Two days after the surgery, inflammation
of the eye persisted, but no evidence of systemic illness was found. Repeat
vitrectomy was performed, and clindamycin and gentamicin were injected for
treatment of suspected bacillus endophthalmitis; systemic penicillin G and
clindamycin were started. Cultures of fluid inside the eye yielded C. perfringens. With treatment, the patient's infection resolved; however,
he continued to have minimal light perception and retinal detachment and necrosis.
The second patient, a man aged 80 years, was determined on routine evaluation
1 day after surgery to have decreased visual acuity (20/400) and probable
early endophthalmitis in the eye in which the cornea was transplanted. Infection
progressed to severe endophthalmitis; however, he had no evidence of periorbital
or orbital extension of the infection and no signs of systemic illness (Figure
1). Intraocular vancomycin and ceftazadime were administered. Two days after
surgery, the patient's visual acuity had diminished to only light perception.
The patient underwent an additional vitrectomy and was administered intraocular
clindamycin and gentamicin with systemic clindamycin and penicillin G. Intraocular
cultures also yielded C. perfringens. On follow-up,
he recovered 20/200 vision, which was consistent with his preexisting maculopathy.
Cultures of both donor corneas, collected immediately before transplantation,
subsequently grew C. perfringens. Review of data
from the eye bank indicated that the donor body was refrigerated within 3
hours after death; eyes were recovered approximately 8 hours after death.
The corneal tissues had undergone tissue processing as recommended by the
Eye Bank Association of America (EBAA).4 The
donor tissue had been maintained in a solution of gentamicin and streptomycin,
and transplantation was completed within 48 hours of tissue recovery. The
eye bank and the surgeon had evaluated the donor tissue by slit lamp examination
and found no abnormalities. No other tissues were recovered from this donor.
Both cases were reported by the eye bank to EBAA as recommended.
KG Banull, MD, JW Janelle, MD, Div of Infectious Diseases; WT Driebe,
MD, Dept of Ophthalmology; LL Fauerbach, MS, Shands Hospital; L Archibald,
MD, Div of Epidemiology, Univ of Florida, Gainesville. A Srinivasan, MD, D
Jernigan, MD, Div of Healthcare Quality Promotion, National Center for Infectious
This report describes the first reported cases of clostridial endophthalmitis
associated with transplantation of contaminated corneal tissue. During 1991-2002,
a total of 414,648 donor corneas were distributed for keratoplasty in the
United States by EBAA-member eye banks.5 Of
230 cases of culture-positive or clinically suspected microbial endophthalmitis
among corneal transplant recipients reported during 1991-2002, no cases of
endophthalmitis were reported to be caused by clostridia (EBAA, unpublished
data, 2003). These data indicate that corneal transplantation in the United
States has a very low risk for endophthalmitis.
Clostridial infections after implantation of contaminated allografts
were first reported in 2001 among recipients of musculoskeletal tissues from
cadaveric donors.6 In that investigation,
clostridia were recovered both from tissue recipients and from the donors
of the tissues. Difficulties in detecting bacteria in postprocessing cultures
led to release of the contaminated allografts. Cultures of the corneas collected
immediately before implantation yielded C. perfringens, indicating that the tissue donor likely had disseminated C. perfringens disease. The donor's death was attributed to metastatic
colon cancer; abdominal cancer is a known risk factor for C. perfringens bloodstream infection.7 Neither
cornea recipient acquired systemic infection; however, both had serious complications
from infection, and one experienced substantial vision loss. The findings
from this investigation underscore the serious infectious complications that
can occur from transplanted allografts containing clostridia.
EBAA recommends that corneal tissue should be recovered by specially
trained personnel using sterile technique.4 Methods
used by eye banks for processing corneal grafts include treatment with antimicrobials
or bactericidal washes (e.g., povidone iodine)8;
however, these methods do not inactivate spores. Corneas used for transplant
are not sterilized because existing methods (e.g., irradiation) make the tissues
unsuitable for transplant. Food and Drug Administration (FDA) regulations
regarding corneal tissue address the medical suitability of donors and screening
for infections caused by human immunodeficiency virus types 1 and 2, hepatitis
C virus, and hepatitis B virus.9 Neither
FDA nor EBAA provide guidance specifically for detecting or inactivating clostridial
spores on corneal allograft tissues.
Cultures of corneal tissue are not performed routinely by eye banks
before a corneal transplant procedure. Eye banks may elect to perform presurgical
(e.g., corneal-scleral rim) cultures, and positive culture reports should
be reported to the receiving surgeon or recipient eye bank. Cultures may be
performed either before or at the time of surgery.4 However,
presurgical cultures might not reliably predict endophthalmitis complicating
corneal transplantation.10 For the two cases
described in this report, culture results were not available early enough
in the infection to prevent disease in recipients. If a corneal culture obtained
at surgery identifies a pathogen, clinicians should evaluate the patient's
condition promptly and consider initiation of appropriate therapy.
Metastatic colon cancer alone is not a factor that prompts deferral
of a donor; however, the medical director should evaluate information about
any potential donor with metastatic colon cancer to determine whether the
donation should proceed. The risk for clostridial disease from corneas should
be a consideration for tissue bank directors when evaluating potential donors
with metastatic colon cancer. EBAA recommends that surgeons report adverse
events, including cases of C. perfringens endophthalmitis,
to eye banks and subsequently to EBAA within 30 days of the occurrence for
review by a medical advisory board.4 State
health departments, CDC, and FDA should be notified to assist with investigations.
This report is based in part on data provided by EJ Holland, MD, KR
Wilhelmus, MD, Eye Bank Association of America, Washington, DC.
Clostridial Endophthalmitis After Cornea Transplantation—Florida, 2003. JAMA. 2004;291(3):293-295. doi:10.1001/jama.291.3.293