TASS Toxic solution enters the anterior chamber Produce severe intraocular inflammation as well as corneal edema Form of sterile, noninfectious endophthalmitis Endophthalmitis Present in an acute form or in a more indolent or chronic form the latter is associated with organisms of lower pathogenicity

1. TASS AND ENDOPHTALMITIS
DECEMBER 15 2020
Dr Shayri Pillai
2nd Year Ophthalmology Resident
Liberia Eye Centre
JFK Memorial Medical Center
L V Prasad Eye Institute

2. TASS
 Toxic solution enters the anterior chamber
 Produce severe intraocular inflammation as well as corneal
edema
 Form of sterile, noninfectious endophthalmitis

3. Symptoms and signs of TASS may mimic those of infectious
endophthalmitis and include:
 Pain
 Photophobia
 Severe reduction in visual acuity
 Marked anterior chamber reaction
 Occasionally with hypopyon

4.  TASS presents within 12-24 hours
 Acute infectious endophthalmitis typically develops 2-7 days
after surgery
Features of TASS include:
 Diffuse limbus-to-limbus corneal edema
 Anterior chamber opacification
 Dilated, irregular, or non-reactive pupil
 Elevated lOP
 Pathologic changes are limited to the anterior chamber

5. Risks
 Certain solutions, either used for irrigation or injection into
the AC
 Toxic to the corneal endothelium
 Cause temporary or permanent corneal edema
 Subconjunctival antibiotic injections enter the anterior chamber
through scleral tunnel incisions
 Skin cleansers containing chlorhexidine gluconate (eg,
Hibiclens)
 Cause irreversible corneal edema and opacification

6.  Preservatives present in prediluted epinephrine ( 1:10,000)
added to irrigating solutions
 Cause corneal decompensation
 Substitution of sterile water for balanced salt solution
 Intraocular use of preserved medications
 Intraocular injection of residual toxic materials
 Present in reusable cannulas or irrigation tubing
 Cause severe endothelial damage

7.  Denatured ophthalmic viscosurgical devices
 Residues left behind by items used during cleaning and
sterilization of surgical instruments
 Heavy metals
 Intraocular medications at toxic doses and ointments
 Hydrophobic acrylics might also be at higher risk
 IOL designs as well as chemicals used in polishing,
cleaning, and sterilizing of the IOLs

8. Preventive Measures
 Carefully rinsing and air-drying reusable cannulas
 Using disposable cannulas
 Avoid the intraocular use of any topical antibiotics or
anesthetics containing preservatives
 Unpreserved 1:1000 epinephrine
 Adequate cleaning and sterilization of ophthalmic surgical
instruments

10. Treatment of TASS
 Intensive topical corticosteroids until the inflammation subsides
 Brief course of systemic corticosteroids may be beneficial
 Frequent follow -up is necessary to monitor lOP, to reassess for
signs of bacterial infection

11. Endophthalmitis
Present in an acute form or in a more indolent or chronic
form the latter is associated with organisms of lower
pathogenicity

12. Symptoms of endophthalmitis
Mild to severe ocular pain, loss of vision, floaters, and
photophobia
Signs
Hallmark of endophthalmitis Vitreous inflammation
Other signs
Eyelid or periorbital edema, Ciliary injection, Chemosis,
Anterior chamber reaction, Hypopyon, Decreased
visual acuity, Corneal edema, and Retinal hemorrhages

13. Acute endophthalmitis typically develops 2~5 days
postoperatively
Decreasing vision and increasing pain and inflammation are
hallmarks
Early diagnosis is extremely important prognosis

14. Chronic endophthalmitis
Onset weeks or months after surgery
Characterized by
Chronic iritis or granulomatous uveitis
Associated with decreased visual acuity
Little or No pain
Presence of a nidus of the infectious agent within the eye

15. Risks
Risk factors have been proposed for endophthalmitis:
Include:
 Diabetes mellitus, chronic alcoholism
 Complicated surgery
 Capsule rupture
 Amount of instrumentation
 History of prior ocular surgery
 Excessive manipulation of the eye
 Vitreous loss
 Contaminated IOLs
 Certain types of IOLs

16.  Unsutured clear corneal wounds
 Nonclear-corneal incisions had an endophthalmitis rate less than
half that of clear-corneal incisions
 Several reports suggest:
 Vast majority of the causative organisms were gram-positive
bacteria
 Minority of gram negative
 Fungal isolates in acute postoperative endophthalmitis were rare
Mix of infective agents helps dictate current empiric therapy
for this condition

17. Methods to reduce the risk of endophthalmitis
 Conditions such as blepharitis and lacrimal system
abnormalities
 Lead to high periocular bacterial colonization
 Corrected before any elective procedure
 Placing povidone-iodine 5% drops in the conjunctival sac as
part of the preoperative preparation of the eye
 Using adhesive incise drapes to isolate the lashes and lid
margins from the operative field

18.  Surgeon should carefully prepare the surgical field with an
antibacterial agent
 Adhere to sterile technique
 Maintaining appropriate intraoperative aseptic technique
Watertight incision closure is an important element of
endophthalmitis prevention, particularly when clear
corneal incisions are employed

19.  Use of preoperative intravenous antibiotics and subconjunctival
antibiotics
 Several reports suggests:
 Fivefold reduction in the risk of endophthalmitis with
intracameral cefuroxime

20. According to Endophthalmitis Vitrectomy Study (EVS) the
recommended approach for management of
postoperative endophthalmitis
Immediate 3-port pars plana vitrectomy (VTT) or a tap/biopsy
of the vitreous (TAP)
Standard Antibiotic Regimen
0.4 mg/O.l mL intravitreal amikacin and 1.0 mg/O. l mL
intravitreal vancomycin, along with subconjunctival injections
of 25 mg vancomycin, 100 mg ceftazidime, and 6 mg
dexamethasone

21. Topical antibiotics included:
 50 mg/mL vancomycin and 14 mg/mL amikacin, which were
administered frequently
 Along with topical cycloplegics and corticosteroids
 Patients assigned to intravenous antibiotics received
ceftazidime and amikacin

22. Peri-injection Risk Management
Injection volume
 An injection volume of 0.05 mL is most commonly used
 Maximum safe volume to inject without preinjection
paracentesis is believed to be 0.1 mL to 0.2 mL

23. Needle selection-
 Needle size varies according to the substance injected
 27-gauge needles often used for crystalline substances such as triam
cinolone acetonide
 30-gauge needles commonly used for the anti-VEGF agents
 Studies suggest that smaller, sharper needles require less force for
penetration and result in less drug reflux
Needle length between 0.5 and 0.62 inches (12.7 to 15.75 mm) is
recommended, as longer needles may increase risk of retinal injury if
the patient accidentally moves forward during the procedure

24. Injection site
 Patient should be instructed to direct his or her gaze
away from the site of needle entry
 Injection is placed 3 to 3.5 mm posterior to the limbus for an
aphakic or pseudophakic eye
 3.5 to 4 mm posterior to the limbus for a phakic eye
 Injection in the inferotemporal quadrant is common,
although any quadrant may be used
Sterile ophthalmic calipers or the hub of a sterile tuberculin
syringe used to mark the injection site

25. PATIENT PREP- The patient should be instructed to direct his gaze
away from the site of needle entry

26. Injection technique
 Pulling the conjunctiva over the injection site with forceps or
a sterile cotton swab to create a steplike entry path-decrease
reflux and risk of infection
After the sclera is penetrated, the needle is advanced toward the
center of the globe
 Solution is gently injected into the midvitreous cavity
Needle is removed, and a sterile cotton swab is immediately
placed over the injection site to prevent reflux

27.  Potential complications-
 Intraocular inflammation
 Retinal detachment or perforation
 Traumatic lens damage
 Intraocular hemorrhage
 Sustained ocular hypertension
 Hypotony

28.  Skuta,G.L. et.Al. American Academy of Ophthalmology
Lens and Cataract.USA
References
 Alberts & Jackobiec ‘s Principles and Practice of
Ophthalmology

29. Thank you!
Excellence Equity Efficiency
L V Prasad Eye Institute