Toxic anterior segment syndrome outbreak after vitrectomy and silicone oil injection

Outbreak of toxic anterior segment syndrome following vitreoretinal surgery - A retrospective analysis

BACKGROUND

Toxic anterior segment syndrome (TASS) is an uncommon complication of vitreoretinal surgery and is characterized by severe anterior chamber reaction, hypopyon, and limbus-to-limbus corneal edema.

METHODS

Twenty-nine vitreoretinal surgeries were performed, of which 14 developed TASS in the early postoperative period. The operative records were reviewed retrospectively.

RESULTS

The median age of patients was 49.07 ± 16.75 years and 14.28% of them were female. Also, 71.42% were operated in the left eye and 42.8% were pseudophakic. Recurrent retinal detachment, secondary scleral-fixating intraocular lens (SFIOL), and silicone oil removal (SOR) were the most common procedures. Severe anterior chamber reaction was seen in 14 patients, circumcorneal congestion in eight, corneal edema in 11 (78.6%), hypopyon in 13 (92.8%), and severe fibrin membrane in two patients.

CONCLUSION

We describe the largest series of TASS following uneventful vitreoretinal surgery. Balanced salt solution was the instigating agent in this series. A prompt and thorough investigation is critical in obviating recurrences.

Mimickers of anterior uveitis, scleritis and misdiagnoses- tips and tricks for the cornea specialist

BACKGROUND

Anterior uveitis, inflammation of the anterior chamber and related structures, is a cohort of diseases that can present to almost any general or sub-specialty Ophthalmology practice. Its features classically involve anterior chamber cell and flare. Below the surface of these two signs exist a panoply of diagnoses. BODY: The purpose of this review is to provide a general framework for diagnoses of anterior uveitis that are often missed as well as non-uveitic pathologies that often mimic anterior uveitis. Diagnostic deviation in either direction can have vision-threatening and rarely life-threatening consequences for patients. Using a comprehensive literature review we have collected a broad spectrum of etiologies of anterior uveitis that are easily missed and non-uveitic pathologies that can masquerade as anterior uveitis.

CONCLUSIONS

We present a focused review on specific misdiagnosed anterior uveitis pathologies and some of the conditions that can masquerade as anterior uveitis and scleritis.

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 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.

Acute Noninfectious Endophthalmitis after Removal of Silicone Oil and Posterior Capsulectomy in Proliferative Diabetic Retinopathy

Purpose: Here, we report a case of acute noninfectious endophthalmitis after removal of silicone oil (SO) and posterior capsulectomy in a patient with proliferative diabetic retinopathy.Case summary: SO removal and posterior capsulectomy were performed in a 61-year-old man who had undergone vitrectomy with combined cataract surgery, membrane peeling, laser photocoagulation, and SO injection to treat vitreous hemorrhage and tractional retinal detachment three months previously. The patient’s best-corrected visual acuity on the day after surgery was 20/50; it decreased to hand motion at five days after SO removal. Exudative membrane with hypopyon, anterior chamber cell (trace), and mild conjunctival injection were observed. The patient did not complain of ocular pain. Topical steroid was applied following a diagnosis of postoperative noninfectious endophthalmitis. The exudative membrane and hypopyon decreased after three days of treatment and had resolved completely after one month of treatment. The patient’s visual acuity improved to 20/50.Conclusions: Noninfectious endophthalmitis can develop after removal of SO and posterior capsulectomy. Topical steroid treatment is effective in such cases.

Toxic Anterior Segment Syndrome After an Uncomplicated Vitrectomy With Epiretinal Membrane Peeling

Infectious endophthalmitis is the most devastating complication of eye surgery and is associated with severe inflammation of ocular tissues. This study aimed to present a similar condition, a case of toxic anterior segment syndrome (TASS) after an uncomplicated vitrectomy. A 69-year-old woman presented with epiretinal membrane and underwent 25-gauge pars plana vitrectomy with membrane peeling in her left eye. Thirty hours after the procedure, the patient complained of increasing loss of visual acuity and a red left eye. The ophthalmic examination revealed moderate hyperemia, hypopyon and snowbanks in the anterior vitreous. Subconjunctival and topical steroids were administered, and the inflammatory symptoms resolved within 30 days. The visual acuity improved to 20/32, however, cystoid changes were noted in the macula by optical coherence tomography.  TASS should be considered a potential complication after vitrectomy. This report presents a case of TASS and discusses the differential diagnosis between TASS, infectious and non-infectious endophthalmitis.

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.

Toxic anterior segment syndrome: A review

Toxic anterior segment syndrome is a surgical complication characterized by a noninfectious anterior chamber inflammatory reaction having multiple etiologies. The clinical signs (prominent limbus-to-limbus corneal edema, anterior chamber inflammation) and symptoms (decreased visual acuity, discomfort) generally occur within the first 12-48 hours after intraocular surgery. Most patients achieve good clinical and visual outcomes when there is a prompt clinical diagnosis and adequate treatment. We review the literature on toxic anterior segment syndrome, emphasizing its etiology, pathophysiology, and clinical and surgical management, as well as prognosis and sequelae. Our goal is to reduce the frequency of toxic anterior segment syndrome by highlighting the importance of prevention, early recognition, and distinguishing toxic anterior segment syndrome from infectious endophthalmitis.

Toxic anterior segment syndrome-an updated review

Background

Toxic anterior segment syndrome (TASS) can be a rare complication of anterior segment surgery. Here we reviewed the most recent advances in the understanding of TASS.

Methods

English articles related to TASS were retrieved from “PubMed” using the following keywords; “toxic anterior segment syndrome” or “TASS”. The authors of this paper reviewed all the retrieved literature and critical findings were summarized.

Results

The onset of TASS can vary from hours to months. The clinical manifestations are also variable. The causes of TASS are broad and continue to expand and could not be elucidated in over half of the reported cases. Prompt and thorough investigation to explore the causes of TASS is critical. Surgeons should be fully aware and updated regarding possible etiologies and make ceaseless efforts to prevent TASS. This effort begins with establishing TASS prevention protocols and regularly training surgical staff. Proper cleaning of surgical instruments is critical and should follow the guidelines set by The American Society of Cataract and Refractive Surgery TASS Task Force. When TASS occurs, sharing information with other ophthalmologists and reporting new causes is crucial for the prevention of outbreaks.

Conclusions

Anterior segment surgeons should be reminded that TASS is mostly preventable by the establishment of TASS prevention protocols, regular surgical staff training and thorough adherence to recommendations for cleaning and sterilizing intraocular surgical instruments.