- Three patients developed fungal keratitis infections linked to laser eye surgery at a single ophthalmology clinic, and one required a corneal transplant.
- The culprit was Purpureocillium lilacinum, an environmental mold that has been increasingly detected in recent years.
- Proper infection prevention and control is crucial in laser eye surgery clinics, and ophthalmologists should be aware of the risk of this fungal infection.
Three patients undergoing laser eye surgery at a New York City ophthalmology clinic developed Purpureocillium lilacinum corneal infections as a result of poor infection prevention and control practices, health officials reported.
The patients all experienced vision loss, and one required a corneal transplant, due to fungal keratitis from P. lilacinum, an environmental mold, noted Michelle E. Chang, MD, of the CDC's Epidemic Intelligence Service and the New York City Department of Health and Mental Hygiene, and colleagues in the Morbidity and Mortality Weekly Report.
Chang and team highlighted several infection prevention and control deficiencies at the unidentified clinic, including:
- Incomplete logs tracking sterilization of surgical instruments
- Use of a disinfectant for surface cleaning that was not approved by the Environmental Protection Agency
- Intraoperative use of expired topical ocular medications
- Use of saline solution with no expiration date
- Exposure to non-sterile water via cool-mist humidifiers
Terrence O'Brien, MD, of the Miller School of Medicine at the University of Miami, who wasn't involved in the report, told MedPage Today that the cases are reminiscent of a wave of Mycobacterium infections tied to similar lapses at laser eye surgery clinics in the early to mid 2000s.
The allure of laser surgery can lead to carelessness among practitioners, he said. "Because it's a laser, they let their guard down a bit. You have to really follow very careful, strict guidelines."
The report doesn't specify whether the patients were undergoing LASIK surgery, but it does say the procedures were elective and "for the purpose of reducing or eliminating the need for corrective lenses."
Each year, hundreds of thousands of patients in the U.S. undergo LASIK surgery, the most popular kind of laser refractive surgery. A previous retrospective study found that the incidence of post-LASIK infectious keratitis was 0.035% per procedure.
Photorefractive keratectomy has a higher infection rate, O'Brien said, and the true incidence of infections following laser eye surgery is likely underestimated. "Physicians don't report the case, or they don't realize there was an infection because the patient went somewhere else," he explained.
According to Chang and colleagues, most cases of P. lilacinum keratitis have been reported in association with soft contact lens use, eye trauma, eye surgery, and immunosuppression.
Clinically, the fungal infection presents in the eye with pain, photophobia, and decreased vision, O'Brien said. "Those are the red flags, and you have to act quickly," since infections can burrow deep into the cornea and cause it to perforate.
Diagnosis is often delayed, however, since fungal infection can be mistaken for bacterial keratitis and treated with antibiotics. "Most people can't even pronounce or spell this organism right, let alone diagnose it," O'Brien noted. "Just having an awareness is the first step to having that high clinical suspicion of a possible infection."
If a clinic can't perform confocal microscopy or doesn't have the ability to get corneal scrapings and cultures, he said, "immediate referral to a facility that can be very rigorous in detection and treatment is mandatory."
The New York City clinic employed a single ophthalmologist and consisted of a single treatment room. Two patients began experiencing symptoms 2 and 3 days, respectively, after surgery, at which point the clinic paused surgeries. The third patient was identified the next day.
Based on the patient reports of eye pain and vision loss and postoperative clinical assessments, the clinic sent corneal specimens to a laboratory, which noted fungal elements on microscopy. Due to the unusual appearance of the organism, the laboratory notified the health department. Corneal cultures from two patients grew P. lilacinum.
Among materials from the clinic sent for environmental testing, a laboratory detected the fungus in the suction tubing of an epikeratome, a surgical device that separates the corneal epithelium from underlying corneal layers. Clinic staff said the tubing was never shared between patients, and it's not clear if it was used for any of the infected patients.
The epikeratome was replaced and cool-mist humidifiers were replaced with steam humidifiers. As Chang and team noted, CDC infection prevention and control guidelines recommend against the use of cool-mist humidifiers in healthcare facilities.
The three patients were first treated with topical voriconazole and natamycin, and eventually all were switched to oral posaconazole. Details about clinical outcomes, including the status of the patient who underwent corneal transplant, were not available.
Another eight patients who underwent procedures during the same time period didn't develop infections.
A recent analysis of fungal culture results from a major U.S. commercial laboratory found increasing rates of P. lilacinum from 2019 to 2025, Chang and team noted, explaining that the use of certain P. lilacinum strains as pesticides in agriculture could be increasing infections in people.
O'Brien described one particularly striking case from his own practice: A patient was carrying a poinsettia plant, scratched their cornea on the edge of a leaf, and developed a severe P. lilacinum infection. Apparently, the poinsettia had been treated with a P. lilacinum strain as a pest control agent.
Disclosures
Chang reported no disclosures.
A co-author disclosed relationships with the Infectious Diseases Society of America and the Johns Hopkins Center for Health Security.
O'Brien had no disclosures.
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