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Updated: Mar 25, 2026
Corneal Donor Tissue Preparation for Descemet's Membrane Endothelial Keratoplasty
Published on: September 17, 2014
Candida Interface Infections After Descemet Stripping Automated Endothelial Keratoplasty
Edmund Tsui1, Erin Fogel, Katrina Hansen
1*Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; †Department of Ophthalmology, New York University School of Medicine, New York, NY; ‡Concord Eye Center, Concord, NH; §Division of Public Health Services, New Hampshire Department of Health and Human Services, Concord, NH; ¶Geisel School of Medicine at Dartmouth, Hanover, NH; ‖Dartmouth College, Hanover, NH; **Concord Hospital, Concord, NH; and ††Section of Ophthalmology, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Purpose:
To describe 2 Candida interface keratitis infections occurring in the setting of positive donor rim cultures from precut corneal tissue used for Descemet stripping automated endothelial keratoplasty (DSAEK) and the ensuing public health investigation.
Methods:
Following 2 clinical Candida interface keratitis infections, patients from 2012 to 2014 in the same surgical center were evaluated for bacterial and fungal rim cultures and subsequent infection. All cases of fungal infections occurring post-DSAEK were analyzed. Data included patient demographics, surgical technique, donor rim cultures, donor mate outcomes, clinical courses, and outcomes. A review of the relevant literature was also undertaken.
Results:
From 2012 to 2014, among 99 DSAEK procedures performed, 7 (7.1%) donor rim cultures were positive for fungi. Use of this tissue with positive donor rim cultures resulted in 2 (28.6%) episodes of confirmed fungal interface keratitis, both Candida species, and presumptive treatment in an additional 2 patients. An investigation did not identify any breach in sterile technique or procedures by the surgeon or surgery center. Our literature review identified 15 reports of postoperative fungal infection associated with DSAEK, of which 11 involved Candida spp.
Conclusions:
While postoperative infection remains rare, our 2 additional cases along with those previously reported suggest that DSAEK may be susceptible to infection with Candida spp. Furthermore, this report of correlated rim cultures and clinical infection suggests a need for reevaluation of the utility of obtaining routine corneoscleral donor rim fungal culture.
Insights
Two cases of Candida interface keratitis after Descemet stripping automated endothelial keratoplasty (DSAEK) were linked to positive donor rim cultures. This suggests DSAEK may be susceptible to Candida infections, prompting a reevaluation of fungal cultures.
Area of Science:
- Ophthalmology
- Microbiology
- Public Health
Background:
- Descemet stripping automated endothelial keratoplasty (DSAEK) is an advanced surgical procedure for corneal transplantation.
- Donor tissue quality is critical for successful outcomes in endothelial keratoplasty.
- Fungal infections following DSAEK are rare but can lead to severe visual impairment.
Observation:
- Two patients developed Candida interface keratitis following DSAEK procedures.
- Positive fungal donor rim cultures were identified in 7.1% of DSAEK procedures during the study period.
- The infections were linked to precut corneal tissue with positive fungal rim cultures, specifically Candida species.
Findings:
- The use of donor tissue with positive rim cultures resulted in confirmed fungal keratitis in 28.6% of cases.
- No breaches in sterile technique were identified, suggesting the source was the donor tissue.
- A literature review revealed 15 prior reports of fungal infections post-DSAEK, with Candida spp. being the most common pathogen.
Implications:
- DSAEK procedures may carry a risk of Candida spp. infection, particularly when using tissue with positive rim cultures.
- The findings question the routine utility of corneoscleral donor rim fungal cultures.
- Further investigation into donor tissue screening and management protocols for DSAEK is warranted to prevent postoperative fungal keratitis.
