Postoperative Endophthalmitis and Toxic Anterior Segment Syndrome Prophylaxis: 2020 Update

Abstract

Improved surgical techniques have led to an increase in the number of outpatient ophthalmic procedures. In spite of decreased surgical times and overall improved outcomes, endophthalmitis remains one of the most severe complications of ophthalmic surgery. Although there are well known risk factors for postoperative endophthalmitis, some prophylaxis strategies remain controversial. A category of noninfectious postoperative inflammation, known as toxic anterior segment syndrome (TASS), is a rare but important complication of cataract surgery. While several worldwide outbreaks of TASS have occurred, it is challenging to identify an etiology in order to reduce the risk of further cases. Endophthalmitis and TASS cannot be prevented completely, but their rates may be decreased through risk reduction strategies supported by peerreviewed evidence. This review highlights the current evidence in the prevention strategies for postoperative endophthalmitis and TASS.

The effect of postoperative oral antibiotic therapy on the incidence of postoperative endophthalmitis after phacoemulsification surgery in dogs: 368 eyes (1997–2010)

“…The two conditions have similar clinical signs, but TASS is marked by peracute onset (usually within 24 h of surgery), whereas post-phacoemulsification endophthalmitis can be delayed up to 6 weeks or more. Other distinguishing features include the degree of ocular discomfort, flare/cell/hypopyon response, and vision loss, all of which are minimal in TASS cases but severe in endophthalmitis cases ( Sengillo et al, 2020 ).…”

“…Rates from 0–1.4% have been published in dogs ( Sigle & Nasisse, 2006 ; Johnstone & Ward, 2005 ; Azoulay et al, 2013 ; Ledbetter, Spertus & Kurtzman, 2018 ; Lacerda et al, 2018 ). The presumed sources of ocular infection in humans are the eyelids and conjunctival surface ( Speaker & Menikoff, 1991 ) and risk factors include advanced age, immunosuppressive comorbidities ( e.g ., diabetes mellitus), and intraoperative complications ( Sengillo et al, 2020 ); the same are presumed to be true for veterinary patients ( Ledbetter, Spertus & Kurtzman, 2018 ). Although variations do exist, standards of care for prevention of infection during cataract surgery among human medical institutions have been suggested ( Rosha et al, 2006 ; Rudnisky, Wan & Weis, 2014 ; Behndig et al, 2013 ).…”

“…While intracameral antibiotic administration has found widespread acceptance as bacterial endophthalmitis prophylaxis ( Haripriya, Baam & Chang, 2017 ), the most widely cited strategy, and the approach with the highest level of evidence of efficacy, is the preoperative use of 5% povidone-iodine on the periocular and ocular surfaces ( Speaker & Menikoff, 1991 ; Taylor et al, 1995 ; Liesegang, 2001 ; Ciulla, Starr & Masket, 2002 ; Mayer et al, 2003 ; Ou & Ta, 2006 ; Rosha et al, 2006 ; Sengillo et al, 2020 ). Perioperative administration of topical antibiotics is common in both human and veterinary cataract surgery, despite a lack of evidence that they reduce the incidence of post-operative bacterial endophthalmitis ( Grzybowski et al, 2016 ; ESCRS Endophthalmitis Study Group, European Society of Cataract & Refractive Surgeons, 2007 ; Huang et al, 2016 ).…”

Two Cases of Consecutive Toxic Anterior Segment Syndrome after Uneventful Trabeculectomy Surgeries in a Tertiary Center

“…Additionally, a significant number of reported cases have occurred as clusters of outbreaks [ 1 , 8 ]. The origin of this reaction seems to be noninfectious substances introduced into the eye during surgery [ 1 , 7 , 8 , 9 ], producing a breakdown of the blood–aqueous barrier [ 10 ].…”

Intracameral r-tPA for the management of severe fibrinous reactions in TASS after cataract surgery

“…In TASS prompt control of inflammation is essential to prevent any permanent damage to delicate ocular structures such as the corneal endothelium, trabecular meshwork, and macula. 3 In addition, the inflammation may result in fibrinous membrane formation with anterior or posterior synechiae which may lead to acute angle-closure due to pupillary block. 4 While topical or subconjunctival steroids may be used successfully in mild to moderates cases, intracameral recombinant tissue plasminogen activator (r-tPA) may be effective in severe fibrin reaction refractory to steroid treatment.…”