Endophthalmitis After Penetrating

Keratoplasty
Jern Yee Chen, MBBS,1 Mark N. Jones, BSc (Hons), MSc,2 Sathish Srinivasan, FRCSEd, FRCOphth,3
Timothy J. Neal, MB, FRCPath,4 W. John Armitage, PhD,5 Stephen B. Kaye, MD, FRCOphth,1 on behalf of the
NHSBT Ocular Tissue Advisory Group and Contributing Ophthalmologists (OTAG Audit Study 18)
Purpose: To determine the incidence of endophthalmitis after penetrating keratoplasty (PK) and patient and
donor risk factors.
Design: Retrospective cohort study using national transplant registry data.
Participants: All corneal transplant recipients (n 11 320) registered on the United Kingdom Transplant
Registry undergoing their rst PK between April 1999 and December 2006.
Methods: Patients who developed endophthalmitis were identied on the transplant registry. In addition,
cases where the fellow cornea from the same donor had been transplanted were included. Clinical information
regarding donor and recipient characteristics, surgical details, and postoperative outcomes were collected and
analyzed. In cases where endophthalmitis was reported, the diagnosis was veried by a follow-up supplementary
questionnaire to the surgeon. Logistic regression was used to investigate differences in the factors associated
with the development of endophthalmitis.
Main Outcome Measures: Incidence of endophthalmitis and graft survival.
Results: The overall incidence of endophthalmitis occurring after primary PK in the UK was 0.67%. The
incidence of endophthalmitis occurring within 6 weeks of surgery was 0.16%. Graft survival after endophthalmitis
was 27% (95% condence interval, 16e38) at 5 years, with a mean best-corrected visual acuity of 1.13 (logarithm
of the minimum angle of resolution) for surviving grafts. Factors associated with endophthalmitis were donor
cause of death (infection), high-risk cases, and indication for corneal transplantation.
Conclusion: Endophthalmitis remains a serious issue, with those affected having reduced graft survival and
poor visual outcomes. Management of the identied recipient and donor risk factors are important to reduce
endophthalmitis risk. In particular, the increased incidence of endophthalmitis when the donor dies of infection
requires further explanation and review of current donor eye retrieval and eye bank practices. The delayed presentation of endophthalmitis cases also raises questions regarding possible sequestration of microbes within the
corneal tissue and the effect of antimicrobials in storage media. Ophthalmology 2015;122:25-30 2015 by the
American Academy of Ophthalmology.

Endophthalmitis after penetrating keratoplasty (PK) is a

serious adverse reaction and, although rare, usually has a
poor outcome, with many cases ending up with a visual
acuity of counting ngers or worse.1 The reported incidence
of endophthalmitis after PK varies from 0.08% to 0.77%.1e6
A systematic review by Taban et al6 found that the rate of
acute endophthalmitis (dened as onset within 6 weeks)
had, however, changed during the last few decades from
0.142% during the 1970s, 0.376% in the 1980s, 0.453% in
the 1990s, to 0.2% in the 2000s.
All data on corneal transplant recipients performed under
the National Health Service (NHS) are collected in the UK
by NHS Blood and Transplant. This information is collected
at the time of surgery (transplant record) and prospectively
for 5 years postoperatively and recorded on the UK
Transplant Registry (UKTR). Additionally, severe adverse
reactions such as endophthalmitis must be reported to the
UK regulatory authority, the Human Tissue Authority, in
compliance with the European Union Tissues and Cells
 2015 by the American Academy of Ophthalmology
Published by Elsevier Inc.

Directive.7 Provision of follow-up data is a requirement of

all surgeons undertaking corneal transplantation in the UK.
Therefore, the study of endophthalmitis cases using the
UKTR remains a relatively robust means of determining the
incidence of endophthalmitis after PK as well as determining associated potential risk factors and prognostic factors. The identication of such factors may enable measures
to be put in place to reduce the development of endophthalmitis after corneal transplantation.

Methods
Patients
All patients registered on the UKTR who had undergone a rst PK
between April 1999 and December 2006 were included. The
described research methods and analysis plan adhered to the tenets
of the Declaration of Helsinki, and institutional review board
http://dx.doi.org/10.1016/j.ophtha.2014.07.038
ISSN 0161-6420/14

25

Ophthalmology

Volume 122, Number 1, January 2015

Table 1. Incidence of Endophthalmitis after First Penetrating Keratoplasty

Incidence of Endophthalmitis (Cases Within 6 Weeks in Parentheses)
Year of Transplant
1999/2000
2000/2001
2001/2002
2002/2003
2003/2004
2004/2005
2005/2006*
Total

Patients Receiving First PK, n

1440
1464
1316
1479
1562
1603
2456
11 320

n
9
8
9
13
9
13
15
76

(3)
(2)
(1)
(2)
(2)
(4)
(4)
(18)

(%)
0.63
0.54
0.68
0.88
0.58
0.81
0.61
0.67

(0.21)
(0.13)
(0.07)
(0.14)
(0.13)
(0.25)
(0.16)
(0.16)

PK penetrating keratoplasty.
*Typical nancial year starts in April of 1 year through March of the following year. The nancial year in 2005/2006 also included data from April 2005 to
December 2006.

approval was obtained. Data were collected by NHS Blood and

Transplant from the UK Ocular Tissue Transplant Audit transplant
record and follow-up forms at 1, 2, and 5 years after PK. The
clinical information collected included preoperative data (such as
indication, presence of inammation and ocular surface disease,
glaucoma and degree of corneal vascularization, eye laterality),
perioperative events (donor and recipient characteristics and
complications), and postoperative outcome (best-corrected visual
acuity [BCVA]), unaided visual acuity, complications, medications, refractive data, rejection episodes, graft survival, and reasons
for graft failure). Low-risk graft indications were ectasias, dystrophies, and corneal opacication. High-risk graft indications were
infection, injury, and ulcerative keratitis. All transplanted corneas
were stored by organ culture at 34 C for 4 weeks before being
issued. The denition of presumed endophthalmitis used in this
study was based on a clinical diagnosis made by the operating
surgeon. The diagnosis was veried by a follow-up supplementary
questionnaire to the surgeon. Additional information, such as
causative organism, date at which endophthalmitis was diagnosed,
and type of treatment given, was also sought by this questionnaire.
All statistical analyses were performed with SAS version 9.1
software (SAS Inc., Cary, NC). Logistic regression was used to
investigate multivariate differences in the factors associated with the
development of endophthalmitis. Fisher exact test was used to
investigate univariate differences. Only those factors with P  0.1
were entered into the forward stepwise regression procedure to
determine those factors associated with the development of
endophthalmitis. Cox proportional hazards regression was used to
determine whether graft survival was lower for endophthalmitis
cases in comparison with the fellow donor corneal transplants. Odds
ratios (ORs) and relative risks are quoted with 95% condence intervals (CIs). Two-sample t tests were used to investigate differences
in logarithm of the minimum angle of resolution (logMAR) BCVA
between endophthalmitis cases and fellow donor corneal transplants.

Results
Of 11 320 rst PKs undertaken between April 1999 and December
2006, 95 patients were reported to have developed endophthalmitis. Nineteen of these cases were misclassied, having other
diagnoses such as suture-related corneal abscess. There were,

26

therefore, 76 cases of clinical endophthalmitis in the 7-year period,

giving an annual incidence of 0.67% (standard deviation [SD]
0.12). The annual incidence of endophthalmitis for the period April
1999 to December 2006 is shown in Table 1.
Ten cases of endophthalmitis occurred within the rst week
after surgery, 8 cases between weeks 1 and 6, 14 between weeks 6
and 12, and 31 occurred after 12 weeks. There were 13 cases where
the time of onset was not available. Information regarding culture
results from intraocular sampling was obtained in only 24 cases.
Microorganisms were isolated in 13 (54%) of these cases, of which
4 were fungal (3 Candida and 1 Fusarium). The remaining organisms were Pseudomonas sp., Streptococcus sp., Staphylococcus
sp., and Mycobacterium sp. No information was available on donor
rim cultures because these procedures are not routinely performed
in the UK. No growth of microorganisms had been observed from
sampling of the organ culture storage medium before all corneas
were issued for transplantation.

Risk Factors
A list of factors considered in the logistic regression modeling is
provided in Table 2. Donor cause of death, indication, reason for
graft, surgical procedures and complications, and suturing method
were each found to be associated (P  0.1) in univariate analyses
with the development of endophthalmitis and were included in the
logistic regression model. Death to enucleation time, days in organ
culture, and recipient risk factors (inammation, infection, glaucoma, ocular surface disease, or other) were not considered to be
associated with an increased risk of endophthalmitis (P > 0.1).
The logistic regression model of the factors that were found to
be associated with endophthalmitis is shown in Table 3. The odds
of developing endophthalmitis were >4 times greater for corneas
from donors in whom the cause of death was infection compared
with those from donors who died from other causes (P 0.001).
There was no evidence to suggest a difference for any of the other
donor causes of death. Of the 7 cases of endophthalmitis where the
donor had died from an infection, 5 cases died from septicemia and
1 from meningitis. In the 1 other case, the exact type of infection
was not recorded. For the 18 cases that developed endophthalmitis
within 6 weeks, donor cause of death was not found to be a signicant risk factor (P 0.2), although this may be owing to the
small sample size.

Chen et al

Endophthalmitis After PK

Table 2. Univariate Analyses for Factors Considered in the

Logistic Regression Model of Endophthalmitis after Penetrating
Keratoplasty

Table 3. Factors Associated with Increased Incidence of

Endophthalmitis
Factor

Factor

Donor age
Donor sex
Donor cause of death
Solid organ donor
Death to enucleation time
Enucleation to CSD excision time
Four-degree storage
Days in organ culture
Endothelial assessment
Endothelial cell density
Year of transplant
Recipient age
Recipient sex
Donorerecipient age difference
Primary graft indication (high risk/low risk)*
Reasons for grafty
Recipient risk factorsz
HLA matched
Additional surgical procedures/complications
Donorerecipient trephine difference
Suturing method
Grade of operating surgeonx

0.4
0.2
0.001
0.6
0.3
0.2
0.5
0.5
0.3
0.5
0.7
0.5
0.5
0.2
<0.0001
<0.0001
0.3
0.6
0.1
0.3
0.08
0.7

CSD corneal scleral disc; HLA human leukocyte antigen.

*High-risk indications for graft failure: infection, injury, ulcerative keratitis.
Low-risk indications for graft failure: ectasias, dystrophies, and opacication.
y
Reasons for graft: visual, cosmetic, or therapeutic (severe infection,
threatened or actual perforation).
z
Other additional risk factors not included or specic to the original graft
indication: inammation, ocular surface disease, glaucoma, corneal neovascularization, previous ocular surgery.
x
Grade of operating surgeon: trainee ophthalmologist, fellow ophthalmologist, consultant ophthalmologist.

Indication for corneal transplant, such as infection, injury, and

ulcerative keratitis, as well as a history of previous ocular surgery,
seemed to be associated with the development of endophthalmitis,
with an OR nearly 3 times greater compared with low-risk indications (P 0.0002). There were too few cases to be able to
classify the risk according to the type of previous ocular surgery.
Recipients who received a transplant for reasons such as impending
or actual perforation were also more likely to have developed
postoperative endophthalmitis, with an OR nearly 2 times greater
compared with those undergoing a transplant solely for visual
reasons (P 0.007). There were 1000 cases where perforation
(incipient or actual) was the indication for PK. Of these, 24
developed endophthalmitis. Although perforation was a signicant
risk factor for the development of endophthalmitis (2.4%; P <
0.0001), there was no signicant difference in the risk of
endophthalmitis between those cases where infection was (n 8)
or was not (n 16) present (P 0.99). Cases where there was
preexisting endophthalmitis were excluded from the study (n 4).
In the remaining cases where microbial keratitis was the indication
for PK, infection was not found to be a signicant risk factor for
the development of endophthalmitis (P 0.11).
The indication for requiring a corneal transplant was the only
factor associated with the development of endophthalmitis within 6
weeks, with an OR of 8.3 (95% CI, 1.9e35.9) for high-risk
compared with low-risk indications (P 0.005). The majority of

Donor cause of death

Intracranial
Trauma
Cardiovascular
Respiratory
Cancer
Infection
Other
Indication for graft*
Low risk
High risk
Reason for graft
Vision only
Other reasonsy

OR

95% CI

2468
711
3169
896
2419
240
1417

1.0
1.2
0.7
0.3
1.3
4.4
0.8

0.5e3.3
0.3e1.3
0.1e1.3
0.7e2.4
1.8e10.8
0.3e1.9

0.7
0.2
0.1
0.4
0.001
0.6

5741
5579

1.0
2.8

1.6e5.0

0.0002

8733
2587

1.0
1.9

1.2e3.1

0.007

*High-risk indications for graft failure: infection, injury, and ulcerative

keratitis. Low-risk indications for graft failure: ectasias, dystrophies, and
opacication.
y
Other reasons: visual, cosmetic, or therapeutic (severe infection, threatened or actual perforation).

cases of acute endophthalmitis occurred in the high-risk group: 16

of 5579 compared with 2 of 5741 in the low-risk group.

Outcome and Comparison with Fellow Donor Mate

Cornea
Of the 76 cases of endophthalmitis, the fellow cornea from the
same donor had been transplanted in 62 cases (82%). None of the
62 cases where the fellow donor cornea was transplanted reported
the development of postoperative endophthalmitis. Five-year graft
survival was only 27% (95% CI, 16e38) after the development of
endophthalmitis compared with 75% (95% CI, 60e84) where the
fellow cornea had been transplanted and the recipient did not
develop endophthalmitis (P < 0.0001; Fig 1). The mean logMAR
BCVA in the surviving grafts was 1.13 (SD 1.17) for endophthalmitis cases compared with 0.78 (SD 1.24) for fellow mate
corneas, but this difference was nonsignicant (P 0.2). In the 14
donors in whom the fellow donor cornea was not used, the reasons
for discarding the fellow cornea included 6 corneas (8%) with low
endothelial cell count or stromal opacity, 5 corneas (7%) with
bacterial or fungal growth detected during organ culture, and in 3
cases (4%) the cornea was issued for transplantation but not used.
In 2 of the 5 cases of contaminated tissue, the donor cause of death
was infection (pneumonia and meningitis). The majority of the
fellow donor corneas were used for a PK (n 54) with only a
small number for other graft types: deep anterior lamellar keratoplasty (n 4), epikeratoplasty (n 2), supercial lamellar (n 1),
and not reported (n 1). There were a number of characteristics
that were distinguishable between the 2 groups. Most notably, a
greater number of patients who developed endophthalmitis
received a transplant for high-risk indications: 58 of 76 (76%)
compared with 27 of 61 (44%) who received the fellow cornea
(P 0.0001). Those patients who developed endophthalmitis were
also more likely to have had other risk factors present at the time of
surgery (inammation, glaucoma, and ocular surface disease): 43
of 76 (57%) compared with 21 of 61 recipients (34%) of the fellow
cornea (P 0.0009). A smaller number of patients who developed

27

Ophthalmology

Volume 122, Number 1, January 2015

Figure 1. Five-year graft survival.

Endophthalmitis cases
(n 76);
corneal transplants from the fellow donor eye (n
62);
overall UK primary penetrating keratoplasty survival
(n 7521).

endophthalmitis were grafted solely for visual reasons: 43 of 75

(57%) compared with 48 of 60 recipients (80%) of the fellow
corneas (P 0.005). (Note, data on forms received by the UKTR
were incomplete in 1 case of endophthalmitis and in 2 cases of
fellow donor eyes.)

Discussion
Endophthalmitis after PK remains a devastating condition
with severe visual morbidity and a 5-year graft survival of
27% based on registry data. For primary PK undertaken in the
UK within the NHS between 1999 and 2006, the incidence of
endophthalmitis was 0.67% with little change in the annual
rate over the 7-year period. Although the rate of acute
endophthalmitis of 0.16% was lower than the overall pooled
international estimate of 0.38% reported in the systematic
review by Taban et al,6 it is possible that, despite the reporting
requirements, cases may not have been reported. Although the
actual rate in our study may therefore be higher, it is also
likely that incomplete capture of cases may apply to many of
the other studies reported in the literature. It is also worth
noting that the inclusion criteria were different between our
study and the systematic review by Taban et al.6 In that study,
repeat PKs were included in addition to primary PK, whereas
our study only included primary PKs because it was felt this
would reduce confounding factors as the survival for primary
grafts is often better than repeat grafts.
One of the inherent weaknesses in studies using registry
data is that the accuracy of the data depends on the
completeness and quality of the information that is collected.

28

In the UK, the UKTR was established to collect data

nationwide in a standardized reporting format to reduce errors
arising from misclassication and misreporting. Despite the
inherent weakness in this system, there was a high return rate
of 97% for the transplant record and high return rates of 87%,
85%, and 82% for the 1-, 2-, and 5-year follow-up forms,
respectively (Jones M. Summary of form return rateseOTAG
(14)8. Report presented at: NHS Blood and Transplant Organ
Donation & Transplantation Directorate, 25th Meeting of the
Ocular Tissue Advisory Group, January 15, 2014; London).
Very few transplants are performed privately in the UK using
tissue externally sourced from other countries. Therefore, the
study of endophthalmitis cases using the UKTR is a fairly
robust means of determining the incidence of endophthalmitis
after corneal transplantation and for identifying potential risk
and prognostic factors.
We found a signicant association between donor cause
of death and development of endophthalmitis with infection
as a particular risk factor. It is notable that, in an earlier
report in the UK, corneas from donors who had died from
infection were more likely to be discarded because of
contamination of the medium.8 Similarly, Rehany et al9
found the highest prevalence of contaminated corneas in
cases where the donor cause of death was septicemia. In
contrast, other authors have not found sepsis in donors to be
associated with an increased risk of endophthalmitis.10e12 In
the United States and Australia, most donor corneas are
stored in hypothermic conditions and septicemia is a
contraindication if the prospective donor cornea is hypothermically stored.13e15 In contrast, in Europe and New
Zealand corneas are predominantly stored in an organ culture medium,16,17 and patients with bacterial septicemia are
not precluded as donors as long as concomitant microbiological testing is performed.15,18 In the UK, microbiological
testing involves sampling uid from the storage medium but
not the tissue itself. The signicantly increased incidence of
endophthalmitis occurring when the donor died of infection
requires further explanation and a review of the processes of
donor tissue decontamination and microbiological
screening. It is well known that donor corneas may be the
source of infectious contamination because donor corneas
contain viable cells and as such cannot undergo typical
sterilization processes.13 The current practice in the UK is
not to use a disinfectant such as chlorhexidine or povidone
iodine at the time of retrieval; instead, globes are immersed
in povidone iodine for 2 minutes before corneal scleral disc
excision. In contrast, the Eye Banking procedure manuals
from Australia and the United States advocate disinfection
at the time of enucleation or in situ excision to reduce microbial load.19,20 In the UK, the mean death to corneal
preservation time is 34 hours, which is longer than in other
parts of the world (Australia, 10.5e16 hours; United States,
9.25 hours; Australian Corneal Graft Registry, personal
communication, 21 August 2012; Eye Bank Association of
America, personal communication, December 6, 2013,
respectively). The combination of not using a disinfectant at
the time of retrieval and the long death to preservation interval may potentially lead to higher loads of microorganisms in the donor corneas. Contamination of aqueous humor
has been shown to be signicantly associated with age,

Chen et al

Endophthalmitis After PK

death-to-sample time, and premortem systemic infection.21

This distinction is important because the endothelial surface
cannot be exposed to disinfectants, unlike the epithelial
surface. It is also worth noting that the Amnitrans Eye Bank,
with a similar death-to-preservation time as in the UK, reported a reduction of donor contamination from 11.5%,
which is at least 2-fold higher than in the UK,8 to 1.4% after
the introduction of chlorhexidine in addition to povidone
iodine for globe disinfection after enucleation,22,23 suggesting that the addition of chlorhexidine to the disinfection
protocol would merit evaluation.
Presently, there is no published evidence that preprocessing microbiological testing has a predictive value. It may,
therefore, be worthwhile to evaluate the potential benet of
microbiological sampling before and/or after disinfection
before placement in storage media. In New Zealand, microbiological testing of the corneoscleral rim is performed before
storage and then of the organ culture medium before transplantation. From 1991 to 2003, Patel et al17 reported no cases
of endophthalmitis resulting from potentially contaminated
donor tissue.17 In the UK, microbiological testing is not undertaken on corneosceral rims before placement in organ
culture medium; however, samples are taken from the organ
culture medium after 7 days in organ culture and again 2 days
before issuing the donor corneas.13 It is noteworthy that blood
culture bottles have been shown to be more sensitive and
allow more rapid detection of microbial contamination than
conventional microbiological methods, enabling the earlier
release of donor corneas without compromising microbiological safety.24e26 It is unclear whether the antimicrobials
(streptomycin, penicillin, and amphotericin B13) in the organ
culture medium reduce the sensitivity of isolating a microorganism. It may, therefore, be reasonable to consider the use
of culture systems that contain antibiotic-absorbing resins that
inactivate the antibiotics in the organ culture medium, thereby
enhancing the sensitivity of microbial growth27 (Thomasen H,
Steuhl KP, Meller D. Evaluation of a new protocol for sterility
controls of corneal culture medium. ARVO poster session,
May 6, 2014).
Interestingly, most of the cases of endophthalmitis in this
study occurred after 4 weeks. Although speculative, it is
possible that the delay in presentation reects inhibition but
not eradication of microorganisms by antimicrobials in the
organ culture medium, followed by the use of topical antimicrobials in the rst few weeks after surgery. Subsequent
discontinuation of the topical antimicrobials with concomitant use of steroids may allow growth of sequestered microorganisms. It will be interesting to compare the incidence
of endophthalmitis after PK with that after endothelial keratoplasty. In endothelial keratoplasty, the layers of donor
stroma and epithelium are removed, leaving only a very thin
layer of stroma, Descemets membrane, and a single layer of
endothelial cells. This may, therefore, remove a microbiological load of sequestered organisms within the tissue.
The isolation of microorganisms from intraocular sampling in this study was low (54%) compared with other
studies, where isolation rates of 80% in cases of endophthalmitis have been reported.16,23,28e30 This limited
inferences regarding the causative microbe and the generalization of our ndings.

In contrast with the report by the Eye Bank Association of

America, where endophthalmitis occurred after transplantation from the same donor in 24 of 121 cases of
endophthalmitis,16 none of the patients in this study who
received the fellow cornea from the same donor were reported
to have developed endophthalmitis. These corneas were,
however, predominantly transplanted into low-risk cases,
which emphasizes the importance of recipient factors. From
our results, it is apparent that recipient factors are associated
with an increased incidence of endophthalmitis. Although
previous ocular surgery was found to be an associated risk
factor, we were unable to classify this risk according to the
type of previous ocular surgery. There was a signicantly
higher rate in patients who had high-risk transplants or who
were undergoing a transplant where the primary reason was
not visual. Perhaps in these high-risk recipients, in addition to
other considerations, donor rim cultures should be performed
at the time of keratoplasty because this may help to guide
therapy should endophthalmitis ensue.30 In a systematic review, Wilhelmus and Hassan31 found that endophthalmitis
occurred 12 times more often among recipients of a culturepositive donor cornea, with positive donor rim cultures having
a sensitivity of 67% (95% CI, 47%e83%) and specicity of
85%. Because of the substantial costs of routine screening,
however, the authors questioned the value of routinely submitting all donor rims for microbiological testing.31
The development of endophthalmitis after corneal
transplantation remains a serious issue. Risk factors for the
development of endophthalmitis are both donor and recipient related. It is important, therefore, that eye retrieval and
eye bank practices be kept under review to ensure the provision of high-quality and safe tissue to recipients, in
particular, the use of disinfectants at the time of enucleation
and/or before corneoscleral disc excision in the eye bank,
the antimicrobials in the storage medium, and the testing of
culture medium and the tissue itself. In view of our ndings,
this seems to be even more pertinent in septicemic donors. It
is equally important for surgeons to be extra vigilant in highrisk cases and to consider the use of additional prophylactic
measures to reduce the risk in such cases.

References
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Volume 122, Number 1, January 2015

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Footnotes and Financial Disclosures

Originally received: March 3, 2014.
Final revision: June 23, 2014.
Accepted: July 21, 2014.
Available online: September 25, 2014.

Financial Disclosure(s):
The authors have no proprietary or commercial interest in any materials
discussed in this article.
Manuscript no. 2014-335.

St. Pauls Eye Unit, Royal Liverpool University Hospital, Liverpool,

United Kingdom.

Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, United
Kingdom.
3
Department of Ophthalmology, University Hospital Ayr, Ayr, Scotland.
4

Department of Medical Microbiology, Royal Liverpool University Hospital, Liverpool, United Kingdom.

School of Clinical Sciences, University of Bristol, Bristol, United

Kingdom.

30

Abbreviations and Acronyms:

CI condence interval; NHS National Health Service; OR odds
ratio; PK penetrating keratoplasty; SD standard deviation;
UKTR UK Transplant Registry.
Correspondence:
Jern Yee Chen, MBBS, St. Pauls Eye Unit, 8Z link, Royal Liverpool
University Hospital, Prescot Street, Liverpool, Merseyside, United
Kingdom L7 8XP. E-mail: jy_chen79@yahoo.com.au.