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
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
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?
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