TASS AND ENDOPH.pptx

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 2 nd 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

9. 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

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

11. 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

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

13. 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

14. 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

15. 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

16. 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

17. 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

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

19. According to Endophthalmitis Vitrectomy Study (EVS) t he recommended approach for m anagement of postoperative endophthalmitis I mmediate 3-port pars plana vitrectomy (VTT) or a tap/biopsy of the vitreous (TAP) S tandard A ntibiotic R egimen 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

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

21. 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

22. Needle selection- Needle size varies according to the substance injected 27-gauge needles often used for crystalline substances such as triamcinolone 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

23. 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

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

25. 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

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

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

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