Twenty-three infants contracted viral infections after eye exams in the intensive-care unit at Children's Hospital of Philadelphia, according to an article on the Inquirer website.
The August 2016 outbreak was linked to a "lack of standard cleaning practices" of equipment used in the exams.
"Observations revealed lack of standard cleaning practices of bedside ophthalmologic equipment and limited glove use," according to a report by the hospital. "Environmental sampling of two hand-held lenses and two ophthalmoscopes revealed adenovirus DNA on each device."
The 23 cases represented more than half of the 43 infants who underwent eye exams in the neonatal intensive care unit in August 2016, the authors of the hospital's case study wrote.