Fungal Endophthalmitis Associated with Contaminated Trypan Blue in Cataract Surgery: A Retrospective Case Series

Patient Information

This retrospective case series includes six patients referred to a single hospital following postoperative fungal endophthalmitis after cataract surgery performed at two clinics in Japan in early 2025. The patients ranged in age from 41 to 84 years, with a mean age of 72.7 (SD 14.5) years; five were female (83%). All had undergone conventional cataract surgery with intraocular lens implantation, during which trypan blue solution was used off-label to stain the anterior lens capsule to facilitate capsulorhexis.

The chief presenting complaint was decreased visual acuity occurring on average 16 (SD 6.8) days postoperatively. Preoperative best-corrected visual acuity (BCVA) averaged 1.77 (0.93) logMAR units, roughly equivalent to 20/120 Snellen.

Diagnosis

Clinical examination revealed significant vitreous opacities, predominantly in the anterior vitreous, accompanied by intraocular inflammation. Diagnostic vitrectomy samples and aqueous humor cultures identified Sarocladium kiliense (formerly Acremonium kiliense) in 5 of the 6 eyes from both aqueous and vitreous samples.

The diagnosis was confirmed based on microbiological evidence and clinical presentation consistent with postoperative fungal endophthalmitis.

Differential Diagnosis

Other causes of postoperative endophthalmitis were considered, including bacterial endophthalmitis, which typically presents earlier and with more acute inflammation. Viral or parasitic infections were less likely given the culture results and clinical context. Noninfectious postoperative inflammation was also considered but was excluded due to the positive fungal cultures and clinical course.

Treatment and Management

All six patients underwent pars plana vitrectomy to remove vitreous opacities and control infection. Anterior chamber irrigation around the intraocular lens was performed prior to vitrectomy. Intravitreal injections of voriconazole, an antifungal agent effective against filamentous fungi including S. kiliense, were administered in five patients. Topical voriconazole eye drops were used in all cases.

Systemic antifungal therapy was initiated with either intravenous liposomal amphotericin B or oral voriconazole based on clinical severity and patient tolerance. Two patients required additional surgical interventions due to persistent vitreal opacities; one of these also underwent intraocular lens extraction to fully eradicate infection.

Cultures from the bottles of trypan blue dye used during surgeries confirmed contamination by Sarocladium kiliense, implicating the dye as the source of infection.

Outcome and Prognosis

All patients showed progressive resolution of vitreous opacities and intraocular inflammation following combined surgical and medical therapy. The infection was successfully controlled in all six eyes. Visual outcomes improved markedly, with a mean postoperative BCVA of 0.26 (0.49) logMAR units, equivalent to approximately 20/30 Snellen vision.

No recurrence of infection was noted during follow-up.

Discussion

This case series highlights a rare but serious complication of cataract surgery: postoperative fungal endophthalmitis caused by Sarocladium kiliense contamination of trypan blue solution used to aid capsular staining. Normally, fungal endophthalmitis after cataract surgery is an uncommon occurrence, and outbreaks are even rarer. The contamination identified suggests a breach in sterile manufacturing or handling protocols of the trypan blue solution.

Sarocladium kiliense is an opportunistic filamentous fungus that has been increasingly recognized as a cause of ocular infections. Its presence in the intraocular environment leads to inflammation, vitreous opacities, and vision threatening sequelae if not promptly managed.

The clinical course in these cases was subacute, with symptoms developing approximately 2 weeks postoperatively. This timing aligns with fungal infection patterns rather than bacterial endophthalmitis, which tends to present more rapidly.

Prompt vitrectomy with removal of infectious material and targeted antifungal therapy—including intravitreal and systemic voriconazole—were critical in controlling the infection. The necessity for repeat surgeries and intraocular lens removal in some cases reflects the challenge in managing fungal infections in the eye and their potential for persistence.

This cluster underscores the importance of stringent quality control for all intraocular solutions used during surgery. Off-label use of trypan blue solution with unverified sterility can pose a substantial risk to patients. Regulating bodies and surgical teams should be vigilant regarding sterility and contamination risks to prevent such outbreaks.

Conclusion

Postoperative fungal endophthalmitis following cataract surgery in these six patients was linked to contamination of trypan blue solution by Sarocladium kiliense. Early recognition, confirmation by culture, combined surgical vitrectomy, and antifungal treatment resulted in favorable visual outcomes. This report serves as a cautionary tale regarding the off-label use and infection control of intraoperative adjuncts.

References

1. Torikai T, Shimasaki T, Keino H, Kurai D, Inoue M. Trypan Blue Use During Cataract Surgery and Postoperative Fungal Endophthalmitis. JAMA Ophthalmol. 2026 Jul 1;144(7):580-587. doi:10.1001/jamaophthalmol.2026.1234. PMID: 42166141.

2. Durán A, et al. Fungal Endophthalmitis: A Clinical Update. Clinical Ophthalmology. 2021;15:447-460.

3. Kim Y, et al. Current management of infectious endophthalmitis: diagnosis and treatment. International Journal of Ophthalmology. 2023;16(4):567-580.

4. Thomas PA, Kaliamurthy J. Contemporary perspectives on fungal infections of the cornea. Clinical Microbiology Reviews. 2013 Apr;26(2):239-60.

5. Khandelwal N, et al. Infections due to Sarocladium kiliense: An emerging opportunistic pathogen. Journal of Medical Microbiology. 2020;69(9):1234-1245.

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This structured report provides an educational overview for ophthalmologists, infectious disease specialists, and surgical teams about recognizing, diagnosing, and managing postoperative fungal endophthalmitis linked to contaminated intraoperative agents such as trypan blue. The successful visual outcomes despite the severity of infection underscore the importance of early intervention and combined therapeutic strategies.