Trypan Blue Use During Cataract Surgery and Postoperative Fungal Endophthalmitis

Importance: Postoperative fungal endophthalmitis following cataract surgery is rare, but 6 cases of fungal endophthalmitis associated with Sarocladium kiliense (formerly Acremonium kiliense) have occurred in a short term. All of these cases developed after conventional cataract surgery. Objective: To report the findings of an outbreak of postoperative fungal endophthalmitis after use of trypan blue solution during cataract surgery. Design, Setting, and Participants: This is a retrospective case series of 6 patients with postoperative fungal endophthalmitis who were referred to a single hospital from 2 clinics in Japan and underwent vitrectomy in 2025. The clinical findings and culture results were evaluated, and samples of the trypan blue solution were cultured. Exposure: Postoperative fungal endophthalmitis following cataract surgery. Main Outcomes and Measures: The treatment and recovery of patients from postoperative fungal endophthalmitis were evaluated based on the clinical and microbiological findings. Results: The age of the 6 patients ranged from 41 to 84 years (mean [SD], 72.7 [14.5] years), and 5 of the 6 patients (83%) were female. The mean (SD) interval from the initial surgery to examination at the hospital was 16 (6.8) days. The mean (SD) preoperative best-corrected visual acuity was 1.77 (0.93) logMAR units (Snellen equivalent, 20/120). Vitrectomy was performed on all eyes, and the vitreous opacities were most prominent in the anterior vitreous. After anterior chamber irrigation around the intraocular lens, vitrectomy with intravitreal antibiotic injection was performed. S kiliense was identified in the aqueous humor of 5 eyes and in the vitreous of 5 eyes. Five eyes were treated with intravitreal voriconazole, and topical voriconazole was administered to all eyes. Systemic treatment with intravenous liposomal amphotericin B or oral voriconazole was also used. Two eyes required reoperations for further removal of the vitreous opacities, including the extraction of the intraocular lens in 1 eye. The vitreous opacities and inflammation improved in all eyes. The infection was controlled in all cases, with a mean (SD) postoperative visual acuity of 0.26 (0.49) logMAR units (Snellen equivalent, 20/30). The same organism was also detected in the trypan blue solution. Conclusions and Relevance: Postoperative endophthalmitis was associated with the presence of S kiliense from the off-label use of contaminated trypan blue solution during cataract surgery.