If not treated quickly, endophthalmitis can damage the retina and result in poor vision, so it’s safer to assume the patient has endophthalmitis and treat it first as an infection, he said. The primary differential diagnosis is infectious endophthalmitis. © 2021 Bryn Mawr Communications, LLC.All Rights Reserved | Privacy Policy, Recurrent Epithelial Ingrowth and Regression, TASS: What Every Anterior Segment Surgeon Needs to Know. Be aware that iris damage associated with TASS only occurs in some cases, however. TASS Treatment 1. rule out endophthalmitis first 2. suppress inflammation - intense steroid eg. Even corneal edema caused by complicated and difficult cataract surgery (eg, with Fuchs' corneal dystrophy) is generally sectorial and often most noticeable near the wound or centrally and opposite the wound where most of our surgery is performed. Although endophthalmitis can manifest 1 day postoperatively, the Endophthalmitis Vitrectomy Study 1 has shown that most cases of endophthalmitis do not show up until later. Endophthalmitis Vitrectomy Study Group. If you sense that the patient's condition is worsening despite steroid treatment, then endophthalmitis is the likely diagnosis, and the patient should be treated promptly. Our advertisers are important supporters of this site, and content cannot be accessed if ad-blocking software is activated. Contact information When you realize that, of your eight postoperative patients, all have unusual inflammation and three cases are severe, you wonder if you ever want to practice medicine again. Residual debris or viscoelastic on surgical instruments can cause an inflammatory reaction which can resemble endophthalmitis. Differential diagnosis between experimental endophthalmitis and uveitis in vitreous with Raman spectroscopy and principal components analysis December 2011 Journal of … If doubt exists as to whether the patient has endophthalmitis or TASS, vitreous biopsy and intravitreal antibiotics are warranted. Despite the severity of the outcome for the patient, endophthalmitis settlements have ranged from $9,000 to $735,000 compared to a low of $500 and a high of $1.8 million for all settlements. Therefore, unusual changes on the day after surgery may indicate TASS, but alone this finding is not definitive. Distinguishing between the two conditions is therefore an important factor in dealing with either disease determining a diagnosis is not an academic exercise as more ophthalmologists encounter TASS. Steve Charles, MD, Charles Retina Institute, Germantown, Tennessee, advised using disposable cannulas rather than reusable ones. The hallmark of TASS is its rapid onset, usually within 12-24 hours. If physicians are worried about cost, it seems counterintuitive but sterilizing and reusing cannulas actually costs more than using disposable ones because of the labor costs associated with cleanup, Dr. Charles said. It is not intended to constitute legal advice and should not be relied upon as … All rights reserved. The appearance of fibrin on a hydrophilic IOL—especially after an IOP spike and the development of posterior synechiae—is not rare. 3.1) . Three sight-threatening complications of TASS are intractable glaucoma, cystoid macular edema, and corneal decompensation (Fig. Pupillary ... TASS vs Endophthalmitis Nawat Watanachai. 58 In tropical countries, such as India, fungal endophthalmitis is a significant problem. TASS is a form of sterile, noninfectious endophthalmitis with or without pain, marked decrease in vision, diffuse corneal edema that extends limbus to limbus, photophobia and severe anterior chamber reaction, occasionally with hypopyon. Dr. Olsen has financial interests with iMacular Regeneration (Rochester, Minnesota). TASS presents within 12-24 hours after surgery … Endophthalmitis is a rare condition that affects your eyes. Apply topical prednisolone acetate 1% every 1–2 hours and monitor the patient closely, even a few hours after starting treatment, to ensure the inflammation and corneal edema are not worsening, he said. The typical hallmark of TASS is an inflammatory process that starts within 24 hours of cataract surgery. Recent retrospective case series have reported post-injection endophthalmitis rates between 0.022 percent and 0.16 percent. Intraocular solutions like balanced salt solution are a common cause; any abnormality in pH, osmolarity, ionic composition, or additives such as epinephrine or antibiotics can cause a reaction. Enrollment complete for Phase 3 studies of investigational dry eye drug, Study: Remote monitoring with implantable IOP sensor affects clinical decision making. However, postoperative endophthalmitis and toxic anterior segment syndrome (TASS) remain important challenges. TASS is a sterile inflammatory response usually occurring in the first 48 hours following cataract surgery. He is a consultant to Allergan, Inc. Dr. Olson may be reached at (801) 585-6522; randall.olson@hsc.utah.edu. However, physicians can use some criteria to help them make a diagnosis. Toxic Anterior Syndrome (TASS) is a rare sequela of uncomplicated anterior segment surgery. The bottom line is if you’re at all suspicious that the patient’s symptoms are endophthalmitis, do not delay treatment, Dr. Adelman said. If the patient is no worse by the end of the day, however, you can assume TASS is the problem. The list is long when one wants to identify the cause of TASS but it is invariably associated with a substance Surgeons may encounter many cases with profound corneal edema and a largely unresponsive pupil without damage to the trabecular meshwork. RISK FACTORS FOR POSTOPERATIVE ENDOPHTHALMITIS IDENTIFIED IN THE ESCRS STUDY 15 10. TASS diagnosis is clinical, and the clinical differentiating features are shown in Table 3.2. That way at least we have covered the one that can cause significant damage to the retina and intraocular tissues.”. Endophthalmitis is a complex condition with a potentially serious outcome for your vision. The review showed high-certainty evidence that antibiotic injections in the eye with cefuroxime at the end of surgery lowers the chance of endophthalmitis. Endophthalmitis or Non-infectious Endophthalmitis, Toxic Endothelium Corneal Diseases (TECD), Toxic Endothelium Cell Destruction Syndrome (TECDS) and Postoperative Anterior Segment Inflammation. Using disposable cannulas ensures there will be no residual OVD and will cost less overall, he said. Physicians can also assess the appearance of the cornea; with TASS, limbus to limbus corneal edema is common, but with endophthalmitis, the edema usually doesn’t extend that far. PCR. TASS can improve in time without a special treat- ment, whereas a diagnosis of endophthalmitis must be made as soon as possible in order to potentially achieve a good result. Or post uveitis Endophthalmitis Panophthalmitis 3. PREOPERATIVE ANTISEPSIS 16 11. Toxic anterior segment syndrome (TASS) and endophthalmitis are serious complications of cataract surgery that can damage intraocular structures and lead to vision loss if not treated properly. 1% Pred q 1 hr - NSAIDS - Nepafenac (Nevanac) - Diclofenac (Voltaren) - Ketorolac (Acular) - close FU - reconsider infection - degree of inflammation - corneal status - IOP. Thanks for visiting CRSToday. chambers Ant. These patients should receive frequent (every 30 to 40 minutes) drops of topical steroids and remain in the office to be monitored during the day. Conjunctival and Lid ReactionBecause TASS represents a localized chemical or toxic reaction in the intraocular anterior segment, it is often surprising how little conjunctival or scleral injection is seen at presentation. OPERATING THEATRE 17 12. Endophthalmitis/TASS Recommendations and AAO/ASCRS Reports. Limbus-to-limbus edema is thus a very important differentiating finding. The trabecular meshwork is one of the less sensitive structures. Treat the patient with antibiotics and move on to steroid treatment if symptoms don’t resolve. Even topical drops can be a culprit; preservatives or stabilizing agents that may be toxic to the endothelium can cause TASS if given access to the anterior chamber. With TASS, all of the endothelium functions poorly. ... the technique of differentiating LP vs. HM vision is most important ... (TASS) Rapid onset (w/I 12-24 hours, limbus to limbus corneal edema) One percent methylparaben-free lidocaine is now the most commonly used topical numbing agent and not associated with TASS, he added. “Wounds that are poorly constructed and not watertight may allow ingress of topical solutions into the anterior segment, leading to toxic damage,” he said. Endophthalmitis is an infection of the tissues or fluids inside the eyeball. Toxic anterior segment syndrome (TASS), an acute, noninfectious inflammation of the anterior segment of the eye, is a complication of anterior segment eye surgery; cataract extraction is the most common form of … (6) TASS improves with topical and/or oral corticosteroids and typically resolves within 1 to 3 weeks. It is an urgent medical emergency. Fortunately, the clues outlined herein should facilitate the differential diagnosis. Unfortunately, there is no way to differentiate between TASS and endophthalmitis 100% of the time, Dr. Adelman said. The presence of conjunctival or lid injection and swelling therefore suggest endophthalmitis. The two diseases can present with similar symptoms but their management differs dramatically, so it’s important for cataract surgeons to be able to distinguish between them, according to a retina expert who presented at the 2018 ASCRS•ASOA Annual Meeting. Toxic anterior segment syndrome (TASS) may be difficult to distinguish from infective endophthalmitis. INTRAVITREAL ANTIBIOTICS 26 14. In fact, I know my colleagues feel that this complication is dramatically underreported because many cases of unusual inflammation were probably TASS that resolved and thus remained undiagnosed.I believe it is possible to tell the difference between the two types of inflammation most of the time. That finding is unlikely in endophthalmitis. Endophthalmitis can blind you if it’s not treated quickly. When treating a patient for TASS, the primary goal is to suppress the subsequent inflammatory response to toxic insult, Dr. Adelman said. Preservatives like benzalkonium chloride (BAK) in OVDs, bisulfate stabilizing agents and methylparaben in lidocaine have all been linked to TASS outbreaks. Antibiotics and ointments placed on the eye can be toxic, so must not be allowed to gain access to the anterior segment, according to Dr. Adelman. Prevention. Reflecting the relative novelty of TASS, allegations in all but 3 of the 150 claims involve an infectious rather than an inflammatory process. TASS symptoms usually start 12–24 hours after surgery, while postoperative endophthalmitis usually presents within 2 to 7 days because it takes time for bacteria to proliferate. IOPTASS can have a profound impact on the trabecular meshwork. Olsen: tolsen@emory.edu. Although endophthalmitis can manifest 1 day postoperatively, the Endophthalmitis Vitrectomy Study1 has shown that most cases of endophthalmitis do not show up until later. In the United States, it is most common in tropical areas, such as Florida, where 6% of 278 endophthalmitis cases treated between 1996 and 2001 were due to Aspergillus and other molds. If this symptom is present on the first postoperative day, you can feel at least 95 confident that the problem is TASS. What Causes Endophthalmitis? TASS is a sterile inflammatory response usually occurring in the first 48 hours following cataract surgery. (5) TASS is always Gram stain and culture negative, and the difference between TASS and sterile endophthalmitis is vitritis. A randomized trail of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Results of the Endophthalmitis Vitrectomy Study. Randall J. Olson, MD, is the John A. Moran Presidential Professor, Chair of Ophthalmology, and CEO of the John A. Moran Eye Center at University of Utah Health Sciences in Salt Lake City. Ron Adelman, MD, director of the retina and macula service, Yale University School of Medicine, New Haven, Connecticut, discussed common causes of TASS and ways to differentiate it from endophthalmitis in his presentation during the “Retina Essentials for Cataract and Refractive Surgery” symposium. Nonetheless, endophthalmitis should never be eliminated as a diagnosis until the therapeutic response is measured! Assume TASS with any eye that exhibits an unusual amount of inflammation and limbus-to-limbus corneal edema on the first postoperative day until proven otherwise. PainAlthough both TASS and endophthalmitis can cause significant or no pain, it has been my and my colleagues' experience that pain more often indicates endophthalmitis. When you get one case of TASS, go through every detail of the operating room to try to find the source compound that’s causing a reaction, Dr. Olsen said.