TOXIC POSTERIOR SEGMENT SYNDROME AFTER DROPLESS CATARACT SURGERY WITH COMPOUNDED TRIAMCINOLONE-MOXIFLOXACIN

The Preventive Effect of Gentamicin in the Irrigating Solution on Endophthalmitis Caused by Methicillin-Resistant Staphylococcus epidermidis After Phacoemulsification with Intraocular Lens Implantation in Rabbits

OBJECTIVE

To analyze the effect of gentamicin in the irrigating solution on endophthalmitis caused by methicillin-resistant Staphylococcus epidermidis after phacoemulsification with intraocular lens implantation.

METHODS

Fifteen rabbits were randomly assigned into three groups. During surgery, group A was irrigated with gentamicin-free solution and injected with 100 μL of normal saline postoperatively, group B was irrigated with 80 μg/mL gentamicin and injected with 100 μl of MRSE suspension, group C was irrigated with gentamicin-free solution and injected with 100 μl of MRSE suspension. At different times, corneal endothelial cell count (CEC), inflammation grading，B-scan ultrasonography and histological examination were analyzed.

RESULTS

No endophthalmitis occurred in groups A and B. Group C developed severe endophthalmitis, with massive inflammatory exudation in the vitreous cavity.

CONCLUSION

Irrigating solution containing gentamicin is favorable to reduce the incidence of MRSE endophthalmitis after phacoemulsification with IOL in rabbits.

Silicone oil tamponade induced vasculitis- a rare manifestation of toxic posterior segment syndrome

AIM

To report silicone oil tamponade induced vasculitis in the early post operative period - a rare manifestation of 'Toxic Posterior Segment Syndrome' after pars plana vitrectomy for rhegmatogenous retinal detachment.

CASE DESCRIPTION

A 50-year-old gentleman presented with vasculitis after a pars plana vitrectomy with silicone oil tamponade on the first post-operative day. He was started on oral steroids (1 mg/ kg) tapered sequentially every week. All signs of vasculitis resolved over a period of one month after which the silicone oil was removed. The patient maintained a visual acuity of 20/90 even after 3 months. There was no recurrence of vasculitis observed thereafter.

CONCLUSION

Silicone oil induced vasculitis is a rarely described entity, especially as a manifestation of toxic posterior segment syndrome. This differential must be kept in mind even on the first post-operative day in cases where silicone oil has been used for tamponade.

Toxic posterior segment syndrome with retinal vasculitis likely caused by intraocular cotton fiber after vitreoretinal surgery - a case report

BACKGROUND

Intraocular inflammation is common after anterior or posterior segment surgery. They typically manifest either as non-infectious inflammation of the anterior or posterior segment, known as toxic anterior or posterior segment syndrome (TPSS), or as sterile or infective endophthalmitis. In this report, we describe a rare case of TPSS following vitreoretinal surgery, presenting as hemorrhagic retinal vasculitis.

CASE PRESENTATION

A 58-year-old male diagnosed with a left eye acute rhegmatogenous retinal detachment underwent an uneventful primary pars plana vitrectomy with silicone oil endotamponade on the same day of presentation. At presentation, there were no signs of intraocular inflammation, and his visual acuity in the affected eye was 20/200.

RESULTS

The retina was well-attached with silicone oil in place on the first post-operative day. Along the inferior retinal periphery, a hemorrhagic occlusive vasculitis was observed. Clinical examination revealed retained intraocular cotton fiber along the inferotemporal quadrant over the retinal surface. In addition to the standard post-operative medications, a course of systemic steroids (40 mg per day of Prednisolone tablets) was started. At the end of the first post-operative week, clinical signs of hemorrhagic retinal vasculitis were beginning to resolve, and by the end of the fourth post-operative week, they had completely resolved.

CONCLUSION

This report describes an unusual diagnosis of TPSS after vitreoretinal surgery, most likely due to the presence of an intraocular cotton fiber. This excessive inflammation of the posterior segment usually responds to a course of topical and systemic steroids.

Acute bilateral blindness due to diffuse outer retinopathy following clear lens exchange: a case report

BACKGROUND

As the trend of refractive lens exchange for presbyopia continues to grow, our case report shows the first occurrence of an acute bilateral outer retinopathy following uncomplicated sequential clear lens extraction in an otherwise healthy individual.

CASE PRESENTATION

A 54-year-old male without significant medical history benefited from a sequential bilateral lens exchange for presbyopia. He then experienced a rapid vision loss in both eyes, accompanied by photopsias and myodesopsias, with symptoms appearing respectively 4 and 3 weeks after the surgeries. Multimodal imaging revealed a fulminant outer retinopathy, leading to a total loss of light perception within a few days. Immediate intravenous corticosteroid therapy was administered, permitting to recover a small area of central visual function in both eyes, enabling shape and color distinction. The primary diagnostic hypothesis is a presumed autoimmune retinopathy, triggered by the cataract extraction, while an alternative diagnosis could be a toxic reaction secondary to the use of intracameral cefuroxime and lidocaine during the surgery.

CONCLUSION

In this report, the authors describe the first recorded instance of outer retinopathy following cataract surgery. This occurrence raises the possibility of auto-immunization leading to retinal atrophy and vision loss as a potential outcome after undergoing cataract surgery.

Exogenous Endophthalmitis

PURPOSE

Exogenous endophthalmitis (ExE) results from microbial infection as a complication of ocular surgery, penetrating ocular trauma, and intraocular foreign bodies. We herein review the classification of ExE, etiological agents, differential diagnosis and therapeutic challenges.

METHODS

Narrative Literature Review.

RESULTS

Identification of the causative agent through ocular fluid analysis is central in the diagnostic work-up of ExE. Prompt intravitreal antimicrobial therapy is key to successful management of ExE and vitrectomy is essential in severe cases. In culture-negative cases, and in the presence of specific features, a diagnosis of sterile intraocular inflammation or toxic syndrome should be suspected.

CONCLUSION

Strict adherence to treatment guidelines may improve outcomes of ExE, however the ultimate prognosis, especially in severe cases, may depend more on the virulence of the causative organism and associated ocular complications. Accurate differential diagnosis and effective treatment are crucial elements in the management and prognosis of non-infectious masquerades of ExE.

Management of inflammation after the cataract surgery

PURPOSE OF REVIEW

To review most recent studies and clinical trials regarding pathogenesis, treatment, and prevention of inflammation after the cataract surgery.

RECENT FINDINGS

FLACS gave opportunity to evaluate inflammatory cytokines in the aqueous humour right after the laser procedure, which led to acknowledging the inflammation pathogenesis during the phacoemulsification. Although there is still a lack of evidence, which would prove the long-term benefit of NSAIDs, they are indicated and effective when risk factors for PCME are present. PREMED studies showed that combination of NSAID and steroids after the surgery for healthy subjects is cost-effective. The triamcinolone injection together with topical steroids and NSAIDs for diabetic patients after the cataract surgery was the most cost-effective in preventing PCME according to the PREMED. Dropless cataract surgery is another emerging topic: dexamethasone implants and suspensions look promising as we await more clinical trials with drug-loaded IOLs.

SUMMARY

Inflammation after the cataract surgery can be prevented, and these methods are one of the most essential topics with growing phacoemulsification rate. Topical NSAIDs are cost-effective not only for patients with risk factors for PCME but also for healthy subjects. New dropless techniques are being successfully introduced in the clinical practice.

Hemorrhagic Occlusive Retinal Vasculitis Associated With Triamcinolone-Moxifloxacin Use During Uncomplicated Cataract Surgery

This case series describes the outcomes of cataract extraction with intraocular lens placement in 2 patients.

Unusual Inflammatory Clinical Presentation After Cataract Surgery and that Thought-provoking Question: Is this Infection or Toxic Anterior Segment Syndrome?

PURPOSE

Toxic anterior segment syndrome (TASS) is a noninfectious anterior chamber reaction caused by ocular surgeries. It usually develops within the first 12-48 h after surgery. In case of clinical suspicion of TASS, endophthalmitis as a devastating disease should always be excluded. However, the fact that TASS and endophthalmitis can look the same, but the treatment for each is different. Therefore, distinguishing between the two conditions is an important factor in coping with both diseases. It was aimed to describe the features and clinical management that are considered when distinguishing the cause of unexpected inflammatory response after cataract surgery.

METHODS

A retrospective review of medical records of 13 patients who developed TASS in our clinic at Ege University Ophthalmology Department on three different days between July 2022 and December 2022 were included in this study. Anterior segment photographs of those 13 patients and the records of ophthalmological examinations of those patients, including best-corrected visual acuity (BCVA), ocular pressure, biomicroscopic, and fundoscopic examination, were collected. Medical data were evaluated retrospectively.

RESULTS

The mean time to onset of clinical symptoms was 27.6 h. The main complaint was pain in nine patients. The primary symptom in the remainder of the patients was blurred vision. Severe hypopyon was seen in 5 cases. Despite the presence of pain and hypopyon, patients who were treated with topical steroids were closely followed up (every 2 h) because they were consecutive patients and had relatively acute onset complaints. Inflammation was regressed after an average of 4 h. No factor causing TASS was found. The BCVA was at the minimum level of 8/10 on the 5th day of surgery.

CONCLUSION

When distinguishing TASS from endophthalmitis, severe pain, relatively late onset, hyperemia, and the presence of severe hypopyon usually lead ophthalmologists to the clinical diagnosis of endophthalmitis. However, in this study, most of the patients diagnosed with TASS had severe pain, a significant portion of them had hypopyon, and the onset of the symptoms was relatively late. Close follow-up immediately after suspicion plays a vital role in clinical diagnosis and management accordingly.

Update on Retinal Drug Toxicities

Purpose of Review

This review aims to provide an update on the clinical presentations and diagnostic findings of drug-induced retinal toxicities.

Recent Findings

Several newly FDA-approved medications have been associated with acute retinal toxicities, including brolucizumab, MEK inhibitors, ulixertinib, and FGFR inhibitors. Additionally, as previously believed-to-be well-tolerated medications, such as pentosan sulfate sodium, anti-retroviral therapies, and certain intraoperative ocular medications, are used more frequently or for longer periods of time, associated toxic retinopathies and inflammatory reactions have been reported. Finally, advances in ocular imaging have revealed novel findings in hydroxychloroquine and tamoxifen maculopathies.

Summary

Discovery of new medications, increased frequency of use, and longer-term use have led to increased reports of retinal toxicities. Advances in retinal imaging have allowed for earlier detection of subclinical changes associated with these medications, which may help prevent progression of disease. However, more research is needed to determine the point at which vision loss becomes irreversible. Risks and benefits must be assessed prior to discontinuation of the offending, but potentially lifesaving, therapy.

Toxic Posterior Segment Syndrome Presenting as Occlusive Retinal Vasculitis following Vitreoretinal Surgery

Purpose

To report a rare retinal manifestation of toxic posterior segment syndrome following vitreoretinal surgery.

Methods

In this case series, we report three cases of rhegmatogenous retinal detachment for which pars plana vitrectomy with silicone oil injection was done. All three patients developed an intense anterior chamber reaction along with occlusive vasculitis-like fundus picture.

Results

The three patients were started on topical and systemic steroids, and there was a dramatic improvement in vision and clinical signs at postoperative week 1.

Conclusion

Toxic posterior segment syndrome is a sight-threatening complication after vitreoretinal surgery, but responds well to topical and systemic steroids.

Postoperative Endophthalmitis and Toxic Anterior Segment Syndrome Prophylaxis: 2020 Update

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 peer-reviewed evidence. This review highlights the current evidence in the prevention strategies for postoperative endophthalmitis and TASS.

Unmasking of infectious retinitis and intraocular lymphoma in patients after uneventful dropless cataract surgery

In this case series, 3 unique cases of severe immune-mediated pathologies (primary ocular lymphoma, toxoplasmosis chorioretinitis, and syphilitic retinitis) after dropless cataract surgery with intraocular steroid injection are reported. Patient immune status and subsequent local immunosuppression after dropless cataract surgery played roles in the worsening of these pathologies. This report demonstrates the need for vigilance when administering immunosuppressive agents locally during cataract surgery.