best practice in TASS versus endophthalmitis infection control

1. ENDOPHTHALMITIS versus TASS
Mohamed ELShafie
MD, HMD
Vitreoretinal Consultant

2. Debate Debate Debate

3. b
C
c
TASS

4. 0
1
0
2
0
3
0
3
Acute, severe,
intraocular inflammation of the
anterior segment after
intraocular
Surgery
Sterile
postoperative inflammatory reaction
by non infectious substance enters
anterior segment.

5. 5 COVID19 IN CHILDREN
Typically starts within
24 hours after surgery.
IOL Contamination: onset of
over a month
Onset

6. 1
4
5
3
2
Good response to topical steroid
drops
Lack of bacterial or fungal growth
from cultures of intraocular taps
Pain or absence of pain
Marked decrease in vision
Photophobia
Acute severe inflammatory reaction
of AC within 12 - 48 hours postop
Corneal edema limbus to limbus
Dilated or irregular pupil
Increased IOP
Hypopyon
Clinical
picture

7. 0
1
0
2
Aetiology
Contaminated BSS, Intraocular irrigating
solutions, Viscoelastic agents.
Intraocular medications (antibiotics in
irrigation solutions or intracameral antibiotics)
0
3
0
4
Glove powder touching tips of instruments,
IOL’s
Reuse of single use devices
Breakdown in standard sterilization practices
Topical ointments
0
5

8. 01
Mild / early cases
Frequent 4-8 x per day steroid
1% prednisolone acetate or
0.1% dexamethasone
02
Moderate cases
take 3-6 weeks
to clear up
03
Severe cases (dense
fibrin and hypopyon)
oral prednisolone
Treatment
considerations
Surgery: if inflammation persists
AC washout
Vitrectomy
IOL removal
04

10. Massive
X
presentation
to
DesignBall
team
10
b
C
c
Endophthalmitis

11. • A Purulent inflammation of the intraocular fluids (vitreous and aqueous) due to infection
• Progressive vitritis is the hallmark of any form of endophthalmitis
Types:
• Acute or Chronic
• Develop very rapidly or slowly
• Persist for long periods of time
Exogenous Endogenous
Occurs from “outside’ the eye
• Postoperative (phaco- trab – IV)
• Traumatic
• Extension of Corneal ulcer
Originates from sources in the body
• Immunocompromised
• Hematogenous spread

12. Acute Postoperative Endophthalmitis
• Infectious endophthalmitis shortly after ocular surgery (3-5 days)
Symptoms Signs
• 94.3% reported blurred vision
• 82.1% red eye
• 74% pain:
25% of patients did not have pain.
• 34.5% swollen lid
• Epiphora
• Photophobia
• 85% hypopyon:
15% of patients may not have a hypopyon.
• 79% hazy media (Poor fundus visualization)
• Vitreous inflammation
• 26% light perception (LP) vision only

13. 70% were gram positive, coagulase-negative staphylococci
(Staphyloccus epidermidis= exotoxins + biofilm)

14. Preoperative
• Bacteria from patient’s own periocular flora.
• Introduced during procedure or early post-op period.
• Blepharitis
• +ve regurge = NLDO
• DM , Immunosuppression
• TED (exophthalmos)

15. Prevention: Intraoperative
• Good selection of cases (ECCE and SICS will never die)
• Personnel
• Eye should be prepped with 5% povidone-iodine.
• Lashes may be draped.
• Strict removal of viscoelastic
• Contaminated sol. or implants
• Long operation time

16. • Upon PCR avoid fishing and excessive manipulations
• Wound leak or dehiscence- especially a leaking SICS wound
• Suture abscess
• Vitreous incarceration in the wound
• Eroding scleral sutures used to fixate IOLs

17. Prevention:
Postoperative
Newer 4th generation fluoroquinolones (moxifloxacin) penetrate
blood ocular barrier efficiently
Patient education
DD

23. Ultrasound Evaluation
if significant vitritis or media opacity prevents
adequate view of fundus
Dispersed vitreous opacities with vitritis
Chorioretinal thickening
Assess for : retinal or choroidal detachment, retained
lens material
Retinal or choroidal detachment are poor prognostic
factors

24. INTERVENTION

25. Suspect: Denial
• Doubt between post-operative inflammation
and endophthalmitis with severe haze in the
ocular media or vitreous opacities clinically
• Possibility of an infection should be given
priority given the potentially rapid and
devastating consequences of delayed
treatment.

27. • Results :
1. No role of systemic AB
2. Acuity at presentation is important prognostic factor for vitrectomy
No role of immediate PPV for HM or better VA
Immediate PPV for PL only
3. Vitreous is the best source for culture

28. Re-consider EVS
Although intravitreal vancomycin remains a standard
choice for gram-positive organisms, intravitreal
ceftazidime is now favored over amikacin, the drug
used in the EVS, due to safety concerns about
amikacin's retinal toxicity
The availability of moxifloxacin with excellent intraocular
penetration has led some to treat systemically in spite of
the EVS findings
A subgroup analysis in the EVS identified a trend
suggesting that diabetic patients might benefit from
vitrectomy regardless of their presenting visual acuity

29. EVS: Intravitreal
• You have to inject within 1 hour
( staph epidermides is doubled every 25 minutes)
• Proper dosage and aseptic technique are critical:
Inadequate doses can cause treatment failure
Excess dose can cause toxic effects on the retina
Mixing has potential for poor technique
Only 1 from 8 needed re injection

30. Intravitreal corticosteroids
IV (dexamethasone) is controversial
Modulate the host inflammatory response to the infection and
minimize ocular damage from this response.
Avoid when fungal infection is suspected.

31. Re-inject 36-48 hours
• A minority of patients will require further treatment.
• In many cases, eyes look somewhat worse 1 day after treatment before improving subsequently.
• It requires > 24 hours to observe an improvement in clinical appearance after initial treatment.
• Often, 36 hours after treatment, culture are available.
• Decision to reinject antibiotics should not be taken lightly, since repeat injection may increase risk
of retinal toxicity
• 100% retinal toxicity rates with 3 IVI doses of 1mg vanco combined with 400 μg amikacin or 200
μg gentamicin.
Vision Pain
AC
reaction
RR :
vitreous
haze

32. PPV
24-48 not improving after IVI
Cornea
Vitrectomy is done when the vitreous is gone
Proportional to vision

33. EVS: PPV
• Break equal end of the game
• PVD
• Periphery
• SO is bacteriostatic
Conclusions: Silicone oil reduces the risk of postoperative retinal detachment,
especially in case of undetected retinal breaks, produces compartmentalization of
the eye, may lead to early visual recovery, allows laser photocoagulation, prevents
severe postoperative hypotony and has antimicrobic activity due to an inhibitory
effect for several species of pathogens.

35. You have a case or cases of infection….now what?
Data Collection
Important: gather
data one at a time
1. Patients 2. Surgical Day(s)
3. Surgeons 4. Operating Room
5. Staff (scrub,
circulator)
6. Instrument sets
–sterilizer(s)
7. Instrument
cleaning products
(have they
changed? new?)
8. Sterile
processing staff
9. Interview staff.
Explain the process
for cleaning
instruments

36. Take Home
Message
Endo is ocular surgeon responsibility
Protect yourself (medicolegal safe)
If you suspect > you inject
PPV > less is more
Determine protocol and everyone follows it.
Be always on the side of caution.