toxic anterior segment syndrome, TASS, endophthalmitis, purulent endophthalmitis, infection after cataract surgery, inflammation after cataract surgery, cataract extraction, phaco, phacoemulsification, eyepain, complication of cataract surgery,

1. Toxic Anterior Segment Syndrome
VS
Endophthalmitis
Nawat Watanachai
Chiangmai University
APGC & RCOPT 2016

2. • why these 2 are so important?
• why we need to know what are the differences?
Toxic Anterior Segment Syndrome
VS
Endophthalmitis

3. an ordinary day of an eye surgeon

4. and on the next day

5. and this is what you feel,
as always

6. but it may not always be like that

7. THIS may be what you see
on the next day(s)

8. THIS may be what you feel
on the next day(s)

10. what really happens?
• major questions
• what is it : infection or not?
• why this happens?

11. what really happens?
• DDX :
• endophthalmitis
• TASS
• lens-induced uveitis
• masquerade syndrome (eg lymphoma)
• VH

12. TASS or Endophthalmitis
• can appear almost/ exactly the same
• but treatment are NOT the same
• so do the prognosis
• needs early diagnosis/ treatment
• distinguishing between the 2 conditions is an important
factor.

13. Endophthalmitis
• incidence after cataract Sx 0.08-0.3% (1/1,250 -1/300)
• Aaberg Jr TM et al, Ophthalmology 1998
• Taban M et al, Arch Ophthalmol 2005
• risks :
• blepharitis
• temporal sutureless CCI, poor wound construction
• topical anes.
• Cooper BA, Am J Ophthalmol 2003
• Nagaki Y et al, J Cataract Refract Surg 2003.
• Germs
• 94% of cultured confirmed cases = Gram Positive
• 70% = coagulase-negative Staph
• Endophthalmitis Vitrectomy Study Group

14. Endophthalmitis :
Classic symptoms
• pain, blurred, floaters, light sensitive
• usually start on 4th-7th day after Sx
• some can start on 1st-2nd day after
Sx
• note : 25% do not report pain on early
days

15. Endophthalmitis :
Classic signs
• lid swelling
• conj injection/ chemosis
• purulent/ watery discharge
• corneal edema
• AC cell/ hypopyon
• vit cell, retina inflam./ vasculitis

16. Endophthalmitis prevention
• treat pre-existing blepharitis
• peri-/ intra-operative antibiotics
• eyelid & eye preparation with 5% povidone iodine
• careful wound construction/ closing
• discharge instructions on wound care, signs and
symptoms to report, contact information

17. endophthalmitis treatment
• identify causative organism
• stain/ culture aqueous and vitreous
• intravitreal and topical ABO
• vitrectomy

18. TASS :
Toxic Anterior Segment Syndrome
• non-infectious acute post op. AS inflam.
• cause : non-infectious substance(s) enters
the AS
• result : toxic damage to intra-ocular tissue
• mostly corneal endothelium
• no racial/ age/ sex predilection

19. TASS :
Toxic Anterior Segment Syndrome
• names
• TASS
• Sterile postoperative endophthalmitis
• toxic endothelial cell destruction
syndrome (TECDS)

20. TASS :
Toxic Anterior Segment Syndrome
• TASS’ problems
• mimic endophthalmitis
• scary outbreaks
• 2005-6 North America
• 2014-5 Thailand

21. TASS : classic symptoms
• blurred vision
• mild ocular pain
• redness
• onset 12-24 hrs after surgery
• note : endophthalmitis onset 4-7d after Sx 1
1. Mamalis N, J Cataract Refract Surg 2006.

22. TASS : classic signs
• early postop inflammation, limited to AS
• typically quite severe
• +/- hypopyon formation
• +/- fibrin in AC/ iris surface/ IOL
• IOP : low-normal
• diffuse limbus-to-limbus corneal edema
• (widespread endothelial damage)
• no/ few reaction in anterior vitreous
• gram stain and culture negative

23. TASS vs Endophthalmitis
TASS ENDOPHTHALMITIS
timing
the day after Sx
, 12-48 hrs
usually >2d after Sx
commonly 4-7 days
pain
none-mild-moderate
(unless v. high IOP)
more
(25% no pain)
discharge watery purulent
conj and lid reaction less more
corneal edema limbus-to-limbus edema localized/ segmental
David B et al. Advanced Ocular Care 2011
Mamalis N. J Cataract Refract Surg 2006
David C et al. Eyeworld 2014

24. TASS vs Endophthalmitis
TASS ENDOPHTHALMITIS
AC
fibrin,
occasional hypopyon
hypopyon
iris +/-
fixed dilated, often c spotty or
diffuse areas of atrophy
SRTL
IOP
normal,
high is more suggestive
low-normal
vitreous clear vitritis, VH
David B et al. Advanced Ocular Care 2011
Mamalis N. J Cataract Refract Surg 2006
David C et al. Eyeworld 2014

25. TASS Treatment 1. rule out endophthalmitis first
2. suppress inflammation
- intense steroid eg. 1% Pred q 1 hr
- NSAIDS
- Nepafenac (Nevanac)
- Diclofenac (Voltaren)
- Ketorolac (Acular)
- close FU
- reconsider infection
- degree of inflammation
- corneal status
- IOP

26. TASS progression
• mild cases
• improve in few days
• no residual damage
• moderate cases
• prolonged clearing (3-6 wks)
• possible corneal edema/ damage
• severe cases?

27. TASS progression
• severe cases
• PBK, corneal scar
• permanent iris damage
• dilated pupil
• irregular pupil that react poorly
• potential TM damage —> OHT, glaucoma
• PCO/ capsule fibrosis —> decenterd IOL
• PVD/ VH/ RB/ RD

28. • if it is NOT JUST ONLY ONE CASE?

29. TASS :
Potential Causes
• 1. issues with cleaning and sterilization
• 2. intraocular medication/ solution
• 3. drops and ointments
• Cutler Peck CM et al. J Cataract Refract Surg 2010
• Mamalis N et al. J Cataract Refract Surg 2010
• David C et al. Eyeworld 2014

30. TASS :
Potential Causes and prevention
• 1. issues with cleaning and sterilization
• retained blood/ lens fragment/ tissue
• enzymes/ detergents/ preservatives
• endotoxin contamination
• 2. intraocular medication/ solution
• 3. drops and ointments

31. TASS :
Potential Causes and prevention
• 1. issues with cleaning and sterilization
• retained blood/ lens fragment/ tissue
• even small amount of tissue/ blood may cause serious inflammation
• cause : inadequate cleaning of tubalar instruments
• residual lens materials/ OVD in phaco/ I&A handpiece (1)
• enzymes/ detergents/ preservatives
• endotoxin contamination
• 2. intraocular medication/ solution
• 3. drops and ointments
Kim JH. J Catarct Refract Surg. 1987

32. TASS :
Potential Causes and prevention
• 1. issues with cleaning and sterilization
• retained blood/ lens fragment/ tissue
• even small amount of tissue/ blood may cause serious inflammation
• inadequate : residual lens materials/ OVD in phaco/ I&A handpiece
• keep reusable instruments at minimum esp tube/ cannula instruments
• adequate flushing/ cleaning instruments in between cases with sterile de-ionized or
distilled water
• not allow instruments to dried before cleaning
• enzymes/ detergents/ preservatives
• endotoxin contamination
• 2. intraocular medication/ solution
• 3. drops and ointments

33. TASS :
Potential Causes and prevention
• 1. issues with cleaning and sterilization
• retained blood/ lens fragment/ tissue
• enzymes/ detergents/ preservatives (1-2)
• denature at >140’C, but some autoclaves reach only 120-130’C
• should NOT use enzymes or detergents if possible
• flush with water, eg. 120cc for I/A tip
• educate cleaning team (esp in multi-subspecialty surgical centers)
• endotoxin contamination
• 2. intraocular medication/ solution
• 3. drops and ointments 1. Parikh C. Arch Ophthalmol 2002
2. Breebaart AC. Arch Ophthalmol 1990

34. TASS :
Potential Causes and prevention
• 1. issues with cleaning and sterilization
• retained blood/ lens fragment/ tissue
• enzymes/ detergents/ preservatives
• endotoxin contamination
• from any water bath, U/S, autoclave
• host GNB —> heat stable lipopolysaccharide endotoxin
• clean them throughly if possible esp water bath/ U/S bath after each use
• alcohol rinse, then clean with water
• 2. intraocular medication/ solution
• 3. drops and ointments

35. TASS :
Potential Causes and prevention
• 1. issues with cleaning and sterilization
• 2. intraocular medication/ solution
• BSS
• 2005 USA : 112 cases - specific brand of BSS
• endotoxin contamination (1-2)
• 2002 USA : 10 cases - specific IOL model
• polishing compound
• preservatives eg BAK in OVD (3)
• stabilizing agents eg bisulphites or metabisulphites in epinephrine (4, 5)
• 3. drops and ointments 1. Parikh CH, Curr Opin Ophthalmo 2003
2. Kim JH, J Cataract Refract Surg 1987
3. Eleftheriadis H, Br J Ophthalmol 2002
4. Edelhauser HF,Am J Opht 1982
5. Guzey M, Ophthalmologica 2002

36. TASS :
Potential Causes and prevention
• 1. issues with cleaning and sterilization
• 2. intraocular medication/ solution
• anesthetic/ dilating agents
• lidocaine 2% (even methylparaben free) (1) - 1% is safer
• bupivacaine 0.5%
• ABO : intracameral/ BSS
• in BSS : dosage error esp Gentamycin (2), also macular toxicity
• in AC : cefuroxime 1 mg/0.1 ml (3), cefotaxime
• not correct pH and/or osmolality
• pH 6.5-8.5 (4)
• osmolality 200-400 mOsm (5)
• 3. drops and ointments
1. Guzey M, Ophthalmologica 2002.
2. Campochiaro PA, Arch Ophthalmol 1991.
3. Barry P. J Cataract Refract Surg 2006
4. Parikh CH. Curr Opin Ophthalmol 2003.
5. Edelhauser HF. Am J Ophthalmol 1976.

37. TASS :
Potential Causes and prevention
• 1. issues with cleaning and sterilization
• 2. intraocular medication/ solution
• anesthetic/ABO : dosage error, not correct pH and/or osmolality
• needs proper concentration/ volume
• intracameral lidocaine
• antibiotics
• needs preservative-free things
• epinephrine in BSS (stabilized by bisulphate, bisulphate—> toxic)
• 3. drops and ointments

38. TASS :
Potential Causes and prevention
• 1. issues with cleaning and sterilization
• 2. intraocular medication/ solution
• 3. drops and ointments
• insecure wound
• inappropriate wound closing
• suture, if needed
• air bubble in AC
Werner I, J Cataract Refract Surg 2006

39. TASS : in conclusion
• consider if it is TASS or Endophthalmitis
• treatment : steroid/ NSAIDs
• potential causes : things enter AC and cause corneal
endothelium damage
• 1. issues with cleaning and sterilization
• 2. intraocular medication/ solution
• 3. drops and ointments

40. references
• Mamalis N, et al. J Cataract Refract Surg 2006
• Cutler Peck CM, et al. J Cataract Refract Surg 2010
• Mamalis N, et al. J Cataract Refract Surg 2010
• David C, et al. Eyeworld 2014
• Gopal L, et al. Br J Ophthalmol 2013
• Jun EJ, et al. J Cataract Refract Surg 2010