Fungal Keratitis Outbreak Linked to Laser Eye Surgery in NYC

Laser eye surgery, while generally safe and effective, carries a small but serious risk of infection. Recent reports highlight the importance of meticulous infection control practices to prevent rare but potentially vision-threatening fungal keratitis caused by Purpureocillium lilacinum. A cluster of cases in New York City in late 2024 prompted a review of protocols at a local clinic and a public health alert, underscoring the need for continued vigilance among ophthalmologists.

Fungal Keratitis Following LASIK: What Happened?

In December 2024, three patients who underwent laser eye surgery at a New York City clinic developed symptoms of fungal keratitis – inflammation of the cornea – within days of their procedures. The symptoms included eye pain and vision loss. Laboratory analysis of corneal specimens revealed the presence of Purpureocillium lilacinum, a filamentous fungus, in two of the three cases. The New York City Health Department was notified, initiating an investigation into potential sources and contributing factors. One patient ultimately required a corneal transplant due to the severity of the infection.

The clinic temporarily halted surgeries while an assessment of its infection prevention and control (IPC) practices was conducted. The investigation, detailed in a report by Morbidity and Mortality Weekly Report, identified several areas for improvement.

Infection Control Lapses and the Role of P. Lilacinum

The health department’s review revealed several lapses in the clinic’s IPC protocols. These included incomplete sterilization logs for surgical instruments, the use of a disinfectant not approved for use in the procedure room and the presence of expired topical ocular medications. Perhaps most concerning was the identification of potential exposure to nonsterile water during the procedures.

Purpureocillium lilacinum, while not a common cause of keratitis, is an emerging fungal pathogen known to cause drug-resistant infections. It has been increasingly identified in cases of ocular infections, particularly in individuals with pre-existing corneal conditions or those who have undergone corneal surgery. The fungus can thrive in moist environments, raising concerns about potential contamination of surgical equipment or water sources. The investigation detected P. Lilacinum DNA in the epikeratome suction tubing, though a definitive link to the infections could not be established due to possible environmental contamination and the way the tubing was used.

What Does This Mean for Patients and Surgeons?

This cluster of cases serves as a critical reminder of the importance of stringent infection control measures in all surgical settings, but particularly in ophthalmology. While the risk of fungal keratitis following laser eye surgery remains low, the potential for severe complications, including vision loss, necessitates a proactive approach to prevention.

Fungal keratitis can be difficult to diagnose and treat, often requiring prolonged antifungal therapy and, in some cases, surgical intervention. Early recognition of symptoms – such as eye pain, redness, blurred vision, and sensitivity to light – is crucial for prompt diagnosis and treatment. Patients who have undergone laser eye surgery and experience any of these symptoms should seek immediate medical attention from an ophthalmologist.

Beyond the Clinic: Broader Implications for Ocular Surgery

The New York City outbreak prompted a review of IPC practices not only at the affected clinic but also at other ophthalmology facilities in the region. The Centers for Disease Control and Prevention (CDC) offers comprehensive guidelines for infection control in healthcare settings, including specific recommendations for ophthalmic surgery. These guidelines emphasize the importance of proper sterilization of instruments, use of approved disinfectants, and adherence to aseptic techniques.

The case also highlights the need for ongoing surveillance of fungal pathogens in healthcare settings. Increased detection rates of P. Lilacinum and other emerging fungal species underscore the importance of accurate identification and susceptibility testing to guide appropriate antifungal therapy. The CDC’s National Healthcare Safety Network (NHSN) provides a platform for healthcare facilities to track and report healthcare-associated infections, including fungal keratitis, contributing to a better understanding of the epidemiology and prevention of these infections.

What Comes Next: Refining Protocols and Enhancing Surveillance

Following the investigation, the New York City clinic implemented several corrective actions, including replacing the epikeratome, switching from cool-mist to steam humidifiers, and reinforcing adherence to established IPC protocols. The health department continues to monitor the situation and provide guidance to ophthalmology facilities in the area.

Looking ahead, several steps are crucial to minimize the risk of fungal keratitis following laser eye surgery. These include:

• Enhanced Sterilization Protocols: Ensuring thorough sterilization of all surgical instruments and equipment.
• Water Quality Monitoring: Regularly monitoring the quality of water used during procedures to prevent contamination.
• Antimicrobial Stewardship: Judicious use of antimicrobial agents to minimize the development of drug resistance.
• Staff Training: Providing comprehensive training to all staff members on proper infection control techniques.
• Proactive Surveillance: Continued surveillance for emerging fungal pathogens and monitoring of infection rates.

The authors of the MMWR report emphasize that adherence to published IPC guidance during all procedures in ambulatory settings can reduce the risk of healthcare-associated infections and related complications. Given the increasing prevalence of drug-resistant keratitis caused by fungi like P. Lilacinum, clinicians should consider fungal infection as a potential cause of post-operative eye pain and vision loss, even before definitive culture identification is available. Further research is needed to better understand the risk factors for fungal keratitis and to develop more effective prevention and treatment strategies.