Lecture: Toxic Anterior Segment Syndrome (TASS): Causes, Prevention, and Updates

DR. HOLLAND: Well, thank you all for being here. I am Simon Holland. I’m deeply honored to be able to give this talk. I have been involved in Orbis since the beginning, and in 1982. A former graduate of the University of Zimbabwe. And now live in Canada and doing corneal surgery at the University of British Columbia. So, excited to tell you something about an intriguing subject. It’s TASS. I would like to acknowledge my co-authors and all those now putting this talk together. Next. There are no financial disclosures. Next. Now, this is an example of what TASS can look like on the first day. Very faint inflammatory membranes and a fairly quiet eye. Next. So, what is TASS? TASS is sterile inflammation. It’s not infectious. Often confused with infection, but it’s very different. Usually occurs after anterior segment surgery, particularly cataract surgery. There’s also a variant to which is a real corneal endothelial toxicity, which is — differs in several ways. The condition is multi-factorial. And it is often very difficult to detect the cause. It’s estimated that about half the cases are related to the medical device reprocessing, or the SPD. And it’s — the culprits are usually toxins, enzymatic cleaners, dried viscoelastic, and residue on gloves. The most important aspect of this condition is that one has to rule out endophthalmitis with which it can be easily confused. Next. Looking at the instance of TASS, one of the best indicators we have is from India with studies showing that overall one can expect an instance of .22%. Doesn’t sound like a love, but given the volume of surgeries we do now, it’s a considerable amount. Due to the issues that occurred with TASS, there was an incentive to produce some sort of help for practitioners across the world who have been affected by this condition. This was as the ASCRS TASS Task Force, formed in the 2000s. Recently there’s been success with a decrease from 472 per annum down to in the period up until 2011, down to 49%. So, a ten times reduction in TASS due to multiple efforts across the world. Yeah. The Canadian story is we have formed our TASS task force to try and deal with the problem. So far we have dealt with 38 outbreaks and 12 hospital closures. TASS occurs predominantly as two forms. One is sporadic, which is, for want of a better way to express it, is isolated cases separated by more than two weeks. Normally caused a cluster or an outbreak if it’s two or more in less than two weeks. Next. So, again as I mentioned earlier, there’s been a ten fold decrease in TASS since the origination of the task force. And this is proven to be very useful as you can see how the numbers have decreased over the years. But are still are considerable problem. Next. We have seen in the last 15 years an increase in the use of intracameral, that’s injecting inside the eye. After the end of surgery. About a hundred times. The cleaning of the ultrasonic bath has also increased. Practices that are almost dying out are those related to the use of tap water to flush the handpieces. It’s not sterile. Adding antibiotics to the BSS has not been found to be useful. And using the higher concentrations of lidocaine intracamerally are also can be a problem and the causation of TASS. So, next. So, what are the features? TASS is generally asymptomatic. The patient may have some blurred vision. But pain is rare. That’s an important sort of early clue as to what you’re looking at, TASS or endophthalmitis. The corneal edema is characteristic to and can extend limbus-to-limbus. Previously, more issues with what’s called toxic endothelial destruction syndrome. Thought to be toxins accessing the anterior chamber. Fibrin is very characteristic. And inflammatory membranes are just about always seen with TASS. It does respond rapidly to topical steroids that can cause late glaucoma due to the membranes sort of on the inside of the trabecular mesh. Next. This is an example of TASS. The inflammatory membrane. Next. To put in a table, we can see that with TASS is more likely to have an immediate onset and minimal pain and blurred vision. Whereas infectious endophthalmitis, IE, usually presents a bit later, usually with much more pain and blurred vision. The appearance of TASS and its features are similar to endophthalmitis, but differ in some important ways. The more inflammation there is likely to be. And if there’s a vitreous involvement and pain, it’s more likely to be endophthalmitis, for which you would consider doing a tap and inject. Whereas if the patient is relatively comfortable and has a lot of cells and presbyopia, that’s more likely to be TASS. I realize this is not a hard stop and go rule, but it’s something to think about when you’re trying to differentiate the two. So, rapid response to steroids with TASS and no response with most — in most cases of endophthalmitis. Next. Here is another example of an early TASS. The symptoms can be absent as you can see. It’s a quiet eye. Next. So, what the outcome, however, is usually excellent. That’s the saving grace of this condition. Best corrected vision is usually better than 20 over 40, and it’s rare to have poor outcomes. This can happen, though, if they have delayed diagnosis and management. In one of the outbreaks that I was responsible for trying to fix, two of the 17 TASS cases lost all vision. That’s because there was at the time there was a practice of seeing post operative patients the day after surgery and not again until after 6 weeks. Two of the patients lost vision permanently due to glaucoma from inflammatory membranes. Next. So, the presentation is — as mentioned — it can be sporadic versus outbreak. Obviously, outbreak is a lot more serious in terms of how to resolve. Okay. And just about always, there are many factors involved in the etiology. The first response of clinics is used to make multiple changes before seeking help. So, re-creating the situation which developed the TASS is difficult. The most important places to look are the MDR or SPD as it’s called in many places. Because sterilization issues are almost always involved in the process of developing TASS. The FDA did a study and showing that the leading causes are endotoxin, which is widespread in our operating rooms, can be a leading cause. Often related to fibrin accumulating. Edema can occur from endothelial toxicity, detergents, preservatives, and gloves, as you will see later. Next. Looking at the leading causes. Endotoxins on surgical equipment is one of the most common causes of TASS from inadequate flushing of the handpieces. Occluded tips. Reused phacoemulsification tubing and cannulas. And also inappropriate use of certain products. Enzymatic cleaners are important in finding the place to be used appropriately. Since if they access the anterior chamber, they can cause TASS, which can be quite severe. Generally, we have a move away from the widespread use of enzymatic cleaners. But if they are used, it is important to ensure that they are kept clean. Antibiotics added to BSS is not been found to be useful. And there have been problems with the inappropriate dosages of intraocular anesthetics and antibiotics. And other possible problems, ultrasonic baths. Insufficient cleaning. Preserved epinephrine. Inappropriate agents for skin prep, the anterior segment. Powdered gloves have been shown to be a problem. I can show you examples later. More rarely, there can be contaminated IOLs and ophthalmic viscoelastic devices. Next. The key aspects of management are use of intense topical corticosteroids. For the first two or three days. And there’s usually a rapid improvement in TASS. If there’s not, then you might have to reconsider the diagnosis as endophthalmitis. Possibly systemic steroids that can be used in severe cases. And also, anterior chamber washouts can be a helpful method to wash out the severe cases. Intravitreal antibiotics, though reason are not necessary. But again, it follows the mantra that when in doubt, it’s important to tap and inject and not let endophthalmitis escape from your attempts to keep an intact anterior segment. And again, endothelial loss or glaucoma can be a consequence of TASS. In terms of the best practices, and I’m thankful to Adam of the Canadian task force for these — some of these slides. Certainly have strict adherence to the sterilization protocols that we all have in our operating rooms. When responsible, avoid reusing disposal items. If they are used, they should be thoroughly cleaned. For the sake of safety, we’ll usually avoid detergents if we’re committed to operate by our regular — without them. Certainly, it’s important to maintain the traceability of the surgical supplies and if you have changes in surgical supply, then this can also lead to that sort of TASS in another form. It’s important to review all the possible causes and as you’ll see later in the presentation, sometimes you have to search hard over several weeks and sometimes months to find a cause which is never found which you can improve a process. So, you have a general uplifting of the quality of sterilization that you perform. And with the internal audits and protocol reviews can be extremely useful. We have one of the clinics can be affected by TASS in Canada which now have monthly audits and to ensure that they are — that they know where their supplies are coming from and they know how to deal with it if problems occur. Next. Again, the most important person in the operating room is sadly not the surgeon, but it’s your staff, and they’re critical to the safety of your unit. So, it’s important to acknowledge — that they put in for us and never leave the operating room without thanking your staff who will still be there cleaning up. Next, please. Again, looking back at the history of this — our understanding has evolved. There was a country wide outbreak affecting the states in 2006. This affected 113 clinics and was found to be due to a contaminated balanced salt solution. And it took months before this was detected. And multiple clinics experienced this, including our own. Next. The culprit at that time was endosol BSS. Again, it was what I call outsourced or contracted out and not verified at usual. Even more recently, despite all of our knowledge of this condition, just two months ago there was an outbreak of TASS related to contact lenses and enVista IOL, and the lens was reintroduced. Next. Here is a description of some of the outbreaks we’ve experienced. The problem with endotoxin, which is everywhere where there’s moisture, we see this more in, again, high volume, multi-surgeon clinics. This is one we followed over a 24-month period. And it is important because of the number of cases involved. See it again, the incidence of about 2.1% of which there are in this group of over 100 cases. Two add up to be endophthalmitis. Something to keep watching out for all the time. Next, please. Didn’t put this up to intimidate everybody. But just to show how many steps one has to go through if we’re having trouble controlling an outbreak. Remembering that half of these cases you see will be associated with outbreaks. Obviously, cleaning protocol. Short cycle sterilizers, and bi-manual phaco-emulsifications have also been shown to be problems if not well-cleaned between treatments. This is a clinic that made multiple changes in cleaning protocols because they just couldn’t control the outbreak. The widespread contamination in the clinic was found on review. They changed the sterilizers, initiated the clean protocols. This was the case where the endosol was involved. Taking all these measures did result in resolving the outbreak. Next, please. We have found that the use of what we call epidemic curve can be useful for a table. And by marking along it, a linear path like that, you can see the noting the changes that are made and where they’re made and the effect of the — on the course of the outbreak can be very useful because you kind of can rapidly use sort of sites of where the cases are coming from. So, it is useful to see how you can bring — improve a protocol within it. Could be a task and resurface again. Next, please. So, this is one of the most difficult outbreaks I have been involved in. This was involved multiple cases of TASS. They led to closure, but major OR in Canada. They had to change enzymatic cleaners, and found that debris clogging the ports of the I & As and stopping using the enzymatics. The two — we experienced two closures of the clinic in this situation. Next, please. This is another outbreak from a specific cause, which, again, is less common. And this occurred in one of our hospitals. And one endophthalmitis case associated with 16 task cases. Next, please. And here again, you can see how we’ve charted the epidemic curve. So, you can relate to the different methods used to control this. We’ve finally located it to the cleaning sterilizer. Which showed the growth of biofilm on the inside. Next. And this is — the STATIM sterilizer that was previously in use. The great part is that it’s rapid, but the duration of action of heat is insufficient to kill the bacteria that may be within the sterilizer. And if not, there may be a partial cure, meaning that those remaining endotoxin can be found in the walls of the sterilizers if they’re not adequately cleaned. This we did take apart. And next. And you can see those are gram-negative rods encased in biofilm which is a protective coating. Next? And this is the free forms of Ralstonia pickettii. Gram-negative, but it’s a potent bacteria and can survive quite a significant cleaning. Next. Another outbreak of tabletop sterilizers occurred much more recently. Occurred about six years ago. Reported by Sorenson. The confirmation of the microbial biofilm on the inner reservoir walls. Affected 18 of the 23 regional Statim sterilizers. Again, this can be simply corrected by cleaning the wall of the sterilizer or using a longer cycle. Endotoxin is resistant, but it is sensitive to a longer cycle. So, that’s how we can deal with that. Next, please. We described over 25 years ago the DLK, diffuse keratitis associated with table top sterilizers. Same linkage to the biofilm from the inner walls of the reservoir sterilizer. Again, the importance of inactivating the pro-inflammatory mediators as I showed you earlier. Next, please. This is another outbreak. This was a multi-factorial causation as far as we could determine. Again, a high instance, 66 cases out of 1715. This led to a clinic closure for more than three weeks. And 24 changes had to be made to the surgical process. So, you can see the impact of TASS and why we have to try and do what we can to keep it away from our operating rooms. Next. But yes, some of the actions we had to take. There were multiple simultaneous interventions including all the aspects of surgery. And the important issues from this was prolonged, you know, cleaning and flushing of the handpieces. The discontinuation of vancomycin which was found to be incorrectly mixed and the flushing of the handpieces would be assessed, which was regarded as insufficient. Next. And here is the remaining — so, the remaining 24 cases. You’ll see there this quick rinse in the contamination process. This is a — sort of a clever idea where to take the pressure off the staff having to clean the instruments by washing sterile water through them. It can be done automatically. The problem occurred, again, in one of our institutions. Next. Was that the tubing became contaminated. Okay? We made multiple changes to the process. And to eventually resolve it. Next. Here is another outbreak curve. And you can see how different actions were taken and there is the response. Next, please. This was an interesting case where glove powder was found to be response for TASS. All cases occurred with one surgeon. But it was found to be the technique he was using to load the lenses. Next. You can see the touching of the tip of the inserter with the gloved hands was how he was loading it. Next. This was on the gloves, this residue from a specific glove type. Once we stopped using this glove type, we were able to resolve the outbreak. Next. It’s a condition that keep us on our toes and have to think about what the possible causes could be. Next. Here is obviously the solution. Pre-loaded IOLs which many of us use now. And the disposal I & A tips. But again, not all units are in a situation where they can go to disposable ways to control TASS. Better to try and prevent it because it will also move obviously from environmental reasons and cost. We want to reuse all we can without initiating TASS. Next. Just to go through recent outbreaks you may find of interest. We have one treated as endophthalmitis but was shown not to be. But you can see how dense. Next, please. You can see how dense the membranes can be in TASS. This all resolved with even the large pupil. We could resolve all that with just topical steroids. Next. And here is another example of using the use of the disposable I & A tips. If using disposable I & A tips, we have also found that when you handle the sheathes that can sort of negate your previous action using a disposable. So, it’s good to check to make sure one problem doesn’t go on to cause another. Next, please. This is automatic washer. You can see that brown tubing down there. This was never clean from its institution two years previously. More because it — there wasn’t a protocol for it. But you can see the danger of, you know, having that. We were able to just change out the tubing and do this every month. And we have not had any further issues. Next. Staff fatigue is an important aspect. We found that we have had a big push to try and get our cases done given the surgery and the pressure after COVID. And the volumes have gone up as has some of the cases of TASS. Often related to taking shortcuts through the cleaning processes. It’s understandable. So, if you’re — if one’s really caught up about what’s causing TASS, staff fatigue may be an aspect. Next. Of the most recent outbreaks, again, we haven’t found, you know, significant risk factors in many. That doesn’t mean to say we’ve failed. Because it invariably means that the process has been improved significantly and the proof is that you are — you can control TASS. But message is that you don’t always get the answer. But cataract surgery remains vulnerable to unpredictable outbreaks. Particularly, again, the effect of COVID has been significant. Next. Another example of TASS. And this is — you could see how easy it would be to confuse this with endophthalmitis. And again, not to go on too long, but when in doubt, it’s important to tap and inject. Next, please. This was an outbreak related to tap water, we believe. 35 cases of TASS. The unit was closed down. Multiple issues related to their SPD. They start issues again, using a very confined space, and use of the Quick Rinse that I showed you earlier. Some of the outbreaks become quite puzzling to solve. There was one in a hospital where it involved specifically one surgeon, one nurse, and one room. And when things were changed, it was corrected. Next. This is one of the most recent outbreaks. And again, remembering that the number of cases gone down ten times in sort of 16 years. We still have TASS. This is a tail of two outbreaks. They were both fairly close to each other. One was in a private institution and one in a public. And that’s in the part of British Columbia, part of Canada we live in. 34 TASS cases occurred. And we were requested to try and help. We didn’t find a specific cause initially. And we took a fair bit of time to try and resolve this outbreak. We never found the specific cause. But it’s just the proximity which had us thinking of maybe something more widespread, which would be the water source. The communities were having water shortages and there were some issues with the pipes and the process things there. So, we think that may have been the cause. Next. Here is the use of an outbreak curve, again, to track the cases happening. 300, so 19 TASS cases. Seven additional cases recorded before the intervention. And you can see how of the instance and changes over the course of the outbreak. So, we have to make multiple changes, see the effect. If there’s none, then continue and then try and resolve it and find the cause. Next. This is the — the other which showed 15 cases. And again, this temporal and proximal association. Next, please. In this situation, we suggested they go to reverse osmosis water filtration. And did a complete revamp of the both operating rooms, ensuring that all devices were reprocessed by the end of the day and not stored overnight. And we also acquired an MDR machine that does not use detergent. And to use exclusively for ophthalmic devices. When things are mixed up with the general surgical instruments, there are often issues. Next. So, our suggestion here was to switch to a dilution of intracameral Vigamox rather than the community prepared Cefuroxime. And exclusive use of disposable cytotomes. And discontinuation of nasal port incision. There are some agreements with TASS. In some clinics, one or two surgeons seem to have a disproportion number of TASS. This is probably due to the diagnostic criteria being different. If that’s an issue, it can be useful to have a third-party to assess the diagnosis as to whether it was TASS or not. Next. So, to go back to the clinic that was causing outbreaks in our area. And again, we came down to the five possible causes, again, a variation in diagnostic criteria. Offsite preparation of intracameral drugs. Poor water quality. The reuse of phaco tips and issues related to the MDR. Next, please. So, again, I thank Adam for some of the more advice about sticking to best practices. It’s important not to hide cases. This may be obvious, but most cases are going to improve with intense topical steroids. It’s a temptation just not to report cases. But it’s always best if you think you’ve got an outbreak to deal with it as soon as you can. And this — these suggestions that you will have — next, please. On the various aspects of keeping your operating room safe and best practices. Again, the cleaning of intraocular surgical instruments as seen. Next. The ultrasonic cleaning. Keep making sure your ultrasounds are well washed and cleaned. And next. The sterilization of intraocular instruments. Again, these are well-accepted and in the protocols by which we all operate under. Next. Again, to the enzymatic detergents are still remaining somewhat controversial. But the routine use, not recommended with no clear benefits is the latest advice. The — again, it’s important where possible that you stick to manufactured guidelines. Recognizing that they’re it may not always be possible for you to do in your units. Next. Yeah. Well, that’s — I think we have come to the end of this side. We have the additional information available to you which you’ll get and everything, which was on this presentation. If you want to — so, look a bit further into the issues of TASS. So, then it seems that confusing and difficult area to study, it is critical that we keep our operating rooms safe and secure. We all know this. But particularly when we come under pressure with pushing out our volumes and then we don’t allow for adequate support to keep our surgery safe. Overall excellent news. And I think the initiative of the ASCRS should be congratulated in being partially responsible for making the ten fold decrease in TASS occur over the last 15 years. I think I’ll end up there. And again, I’ll see if you have any questions that I can answer for you.
>> Perfect, thank you, Dr. Holland. We do have a few questions that came through. So, I can read you some of those questions and you can respond. The first question is: During vitreous tap and intravitreal antibiotic injection in the pediatric age group for traumatized endophthalmitis, how much of a vitreous sample is ideal for culture sensitivity that can be drawn safely? And kind of a two-part question: What gauge needle is needed for the vitreous tap?
DR. HOLLAND: A good question. I don’t have the exact answer. I think it depends what your resources are and what is the process in your own facility. Usually in our experience, you have to get at least 23-gauge needles usually are not enough. So, we usually go to a larger needle for the tap. But usually injection needs about .1ml.
>> Perfect, thank you for that. The next question is: If TASS and post op endophthalmitis and co-exist, how can the two be distinguished?
DR. HOLLAND: Sometimes that’s not possible. But generally speaking if you think of TASS as being inflammatory, but your patient is comfortable, that’s the simplest thing. Whereas that was — never occurs if you have endophthalmitis. The patient is in pain and there’s much more information. And also it would be rare to get — well, it would be unusual to get the TASS picture with endophthalmitis. Usually you’ll have vitreous involvement. Having vitreous involvement is much less common with TASS. It’s usually fairly clear. What’s confusing, I think, is that when you look at the anterior segment, the anterior segment, as some of the slides showed, can be very inflamed. And then you — that’s what I find to be the problem cases. Whereas if you do ultrasounds or you do kind of get a view of the posterior chamber in TASS, you find that it’s, you know, it seems to be — it’s quiet. Which is almost never the case in endophthalmitis. So, there are more — if you say — talk about a path involvement right across the eye, that’s the endophthalmitis. But again, your key is to, you know, if you’re not sure, just to top and inject.
>> Understood. Thank you. The next question is more of a comment, but perhaps you can also add your thoughts. So, in Afghanistan, we don’t have all of the clinical items sometimes. And nurses and doctors sometimes tend to use the same gloves. Would you have any comments on this? If not, I can move to the next question.
DR. HOLLAND: No, I mean — I think you could just do the best you can. In that situation, I think you — I mean, if you have a fairly safe water supply, then that’s the way to go. If you don’t have gloves. But that’s probably better than trying to reuse the same gloves.
>> Understood. Our next question is: Can task TASS present with a dilate the pupil, 7 millimeter with fibrin?
DR. HOLLAND: Definitely, yes. There is — there was one in the presentation I showed which was — was exactly that. Again, it’s hard to imagine that’s not in ophthalmitis. But no, I have seen the pupils as large as 7 or 8 and fixed. But surprisingly, they respond well to just steroids.
>> Perfect. Our next question is: Any advice for cleaning solution to use for flush something because sometimes it’s not easy for single use.
DR. HOLLAND: No. I just think you use what you can. You know, the highest level of water you can find. And in your situation.
>> Understood. Our next question has to do with bilateral cataract surgery. Do you worry that same day bilateral cataract surgery could lead to more cases of TASS?
DR. HOLLAND: Yes. That was a major consideration when COVID led to trying to do, you know, bilateral surgery. There’s been extensive work done on that. And it’s generally regarded that there are no — I shouldn’t be too dogmatic. But as far as I know, there are no cases of bilateral endophthalmitis from same day cataract surgery. Because all the ones they’ve researched and they’ve found that that’s not an issue. Which is obviously reassuring. As I said, we won’t get cases if they haven’t been reported. They may be. But there’s no — there’s no agreed upon policy — there’s policies are generally safe in the policies we come up with to do bilateral surgery.
>> Understood. Our next question is: Is a fixed dilated pupil a feature of TASS? I’ve seen two patients with a fixed dilated pupil.
DR. HOLLAND: Yes.
>> Next question is: Does using ringer lactates affect incidence of TASS? Or increase incidence of post operative corneal edema during phacoemulsification?
DR. HOLLAND: I’m not sure, but I think the answer is yes.
I think they can be problematic.
>> Perfect. There are some questions on managing and preventing TASS. I’m to the sure if there’s anything you wanted to just re-highlight there. I know that’s a bit broad, but I just wanted to highlight those two questions.
DR. HOLLAND: I just think the way you have the greatest success is just take it slowly. You know, make the changes. Document the changes you have made. See what the outcomes were. And, you know, just — and then hopefully by doing it in segments. Thinking you will be able to get to the answer faster. Not to be disappointed if you just never find a cause. Because presumably what’s happened, you know, the response whether you get an outbreak, you know, is that everyone tries to make the changes immediately. Which is — it’s a natural tendency. Obviously, we’re trying to do that. But then it does mean that re-creating this situation so you can study it one by one. Removing the offending — potential or offending item is much more difficult. So, and I think that’s important just to go, you know, take it step-by-step if you have that luxury. Obviously, it’s difficult and you can see that the impact on TASS, you know, on, you know, all these clinics have had to close. Usually by regulatory. Some were self-closed. But it’s — it becomes a very expensive venture and not to say nothing of the problem with a patient not being able to get their surgery. But I think that’s, you know — I don’t think we can beat ourselves up that we’ve, you know, we haven’t fixed it because, again, it’s not an easy problem. And that’s why prevention is the key. And again, it to reiterate, the success that has occurred through the task forces that are set up in various countries have been significant. And they’ve changed the way we actually practice ophthalmology. It’s got a ten fold decrease in a condition like TASS is remarkable. Even if it took, you know, 15 years to get there and you can see in our story, I wanted to show the case we had, the more recent one. TASS hasn’t gone away. It’s almost always going to be there. In a way, it’s a safety measure for us to think that TASS is the warning sign that we may be pushing things too hard and maybe need to research a bit more.
>> Understood. Our next question comes from Ghana. So, they had mentioned they had a TASS outbreak over 1.5 years with over 15 cases. All delayed in presenting at day five or later. They made many changes, but it kept recurring. Finally, they substituted intracameral moxie from Aurolab from Cefuroxime dilated by us and no TASS since. Not sure if you wanted to respond to that.
DR. HOLLAND: That’s an excellent result and they should be congratulated. It’s — I have been familiar with several outbreaks that had also that experience. We saw it in our studies to how intracameral antibodies can be friend or foe. And we’ve found it in our — when we were offsite and drugs that were prepared offsite for injection can be a problem if you don’t have direct supervision yourself. But that’s an excellent result. And shows how, you know, you’re just sometimes you have to be patient. Just keep at them until you find the cause.
>> Understood. Our next question is: Four parts. So, maybe I’ll give you the first two as a start. So, can we have a local antibiotic beside steroid in TASS just in case there’s also endophthalmitis? And what better option and cost effective if we change the use of detergent?
DR. HOLLAND: The first part of that question, the — no, there’s no downside to doing the antibiotics as far as I know. It’s just that it’s a lot of medication. And it’s probably not necessary to give intense topical — or intraocular steroids if you’re suspecting TASS. But I don’t think anyone would be faulted for doing that. It’s just probably not necessary. Yeah. And so, the second part of the question was?
>> So, the second was: Is there a better option or more cost effective if they change the use of detergent?
DR. HOLLAND: Well, I mean, most cases you just use a detergent in the — as prescribed. But I think in many areas, and this spends, you’ve got it — it’s a local phenomenon. You have to see what — what agents they have been using. What is reassuring, though, is that we can do, you know, we can do the surgery without having it use enzymatics. Right? If you just flush. If you do more of the cleaning. Then you don’t have to use enzymatics. Enzymatics are only — I think are only a real problem if it’s the residual that’s left after cleaning. If that’s the issue. So, if you can clean the instruments really well, I think you can use the enzymatics. Because sometimes if it’s — contradicts with the, you know, the eye view or the instructions for use, then regulatory may not let you proceed unless you use enzymatics. So, in that case, you basically have to use them. But that’s been a long debate with the ASCRS task unit is that they’ve generally gone away from recommending the use of enzymatics. I think that’s probably true in most of the facilities in Canada. We — there is limited use of enzymatics. And they are used, but with longer, prolonged cleaning methods. And then you’re just talking about the additional cost from staff time if you do enzymatics. So, I don’t think it’s a big cost difference.
>> Understood. And just the final two parts of that question are: Can we give a cycloplegic agent for the pain? And how long would we give the steroid? Local or systemic?
DR. HOLLAND: You can give a — you can dilate the pupil. And there is a risk that they’ll be permanently dilated if it’s used for too long a period because it’s a very inflammatory mix you have in there. And that can readily form membranes, as you saw. Sorry, second part of the question was?
>> Sure. The second part was if a steroid is given local or systemic, how long should it be given for?
DR. HOLLAND: Oh, okay. That you can do by patient response. Generally speaking if you’re looking although TASS, you want to use something like prednisolone 1% at least every hour. And you can go through the night for the first two nights. So, you want to be really intensive with steroids. And then you can back off pretty quickly, though. You can see, you know, once you start getting any change at all, you can back down to four times a day. It’s a fairly quick response you should get with TASS. But don’t be afraid of using lots of steroids. Systemic, we don’t usually use as much. Usually do that as a pulse dose. Two or three pulse doses in the advanced case.
>> Perfect. Thank you for that. We have another question on flushing. So, do you recommend distilled water for flushing instead of tap water?
DR. HOLLAND: Yes. Yes. Sterile distilled, it comes in various forms. But I think the highest level of water you can get is probably worth the price. Because, you know, you can see even a case where we had — like I think the one we had was probably related to water, too. The one they had the tube clinic separated by about 100K. Ones that had the water problems. We have seen that with rusty pipes and things like that you see in the OR and say, you know, to use that to clean instruments, you can see it would be possible toxins. And certainly those do happen. So, basically, highest quality of water you can get, you know, without, you know, breaking your budget.
>> Understood. Next question: If hypopyon is present on first day anti-VEGF, does it incline more towards TASS or endophthalmitis, if patient has no pain but decreased vision, vitreous is involved after four days.
DR. HOLLAND: I don’t know that one. Could be either. That’s a difficult situation when they’re both involved. I think you just have to treat as both.
>> Understood. Next question is: How will you counsel a patient who had TASS in one eye and is due for surgery in another?
DR. HOLLAND: Well, obviously. You’re going to see whether it was just a sporadic case in one eye. Was the surgery a bit longer? Was it more inflammation? If the first eye was completely uneventful, but TASS occurred, for the patient’s other eye, this is not backed by any data that I know of. But I would use — I would double my use of steroid if that occurred with the second eye.
And tell the patients the changes we’ve made. It’s a rare occurrence. And the response that you had, it’s safe to increase and we will take a measure to increase the number of Anti-inflammatories we give you. I would probably say that in a situation where the patient has that experience.
>> Understood. The next question is on the main mode of treatment. Just to confirm, is topical steroids intensive the main mode of treatment?
DR. HOLLAND: Yes.
>> Also, a question on Urrets-Zavalia syndrome and how to differentiate that in TASS if you’re familiar with that.
DR. HOLLAND: You know, I don’t have any experience there.
>> No problem. We can move to the next question, which is does oral steroids have a role in treating TASS?
DR. HOLLAND: Yes, I think so. Particularly in severe cases. Also, it’s very reassuring that the — you don’t depend on the patient or other factors to do the drops every hour or so. But no, systemic steroids can be very useful. We initially didn’t use them. But increasingly, I think they have been used as a, you know, as, you know, in short-term. More widely than they were before. I think it’s a good option.
>> Understood. Oh, sorry.
DR. HOLLAND: I think we under-use the systemic steroid a bit. A few days use is probably better than not. It covers those patients who may have questions about their ability to use, you know, Q1H steroid.
>> Thank you. The next question is that on detergent again. So, would you recommend what would be the best detergent to use in cleaning instruments to prevent TASS?
DR. HOLLAND: I’ll be controversial and say no, none. There’s no best unit. If you’re going to — yeah. If you follow the guidelines that we have in North America, then TASS use is minimized, and we only use it when we have to. And then we take additional clean — additional cleaning to compensate for it. Just that we’ve had bad experiences with detergent. And I think it’s been accepted. It’s a long-running debate which I’m more familiar with the American situation. But it’s been a long-running debate with, you know, the FDA and the industry or the — like a membership like the ASCRS. Sort of count as to whether we need to use detergents. And it’s come down to, I think, individual preference and what regulatory in your area want to do with it. Ideally, you want to use a minimum amount of detergent. And keep it well and really clean the instruments well. If you’re gonna use detergent.
>> Thank you. The next question is: Can TASS cause post-op corneal endothelial dystrophy? And how should this be managed?
DR. HOLLAND: Yes, it can. You can get endothelial damage. Particularly if it’s the sort of offending sort of incident has been, you know — it’s more likely to be a — in any experience, a toxin that’s been injected, you know, from the cleaning materials. We used the washing of the eye and things like that. But you know, again, if you can wash everything off, then you’ll be safer when it comes down to just cleaning the instruments the best you can.
>> Perfect. Thank you, Dr. Holland. We have the last two questions. So, I’ll share them with you now. So, the first question: Do you recommend AC washing in case of TASS?
DR. HOLLAND: A what washing?
>> AC wash something
DR. HOLLAND: Oh, yes. In severe cases, yes. In less severe cases, no. Because you don’t want to add anything further by making it, you know, going in and tapping it. Because it may stir up more issues. So, but if in a case that’s not resolving fast, then yes. If there’s a lot of anterior segment, you can flush it out. So, I would recommend that. But only in severe cases.
>> Yes. And then the last question: Can we inject intracameral moxifloxacin solution for prevention of endophthalmitis or intracameral use in the only way? And the second question is how much exact amount of intracameral moxifloxacin should be injected?
DR. HOLLAND: Yes, you can use intraocular injection of moxifloxacin. That’s probably the most widely used now. But I think for the exact dosage, then I would check locally and see what — what’s available to you.
DR. HOLLAND: Yeah. No, it’s just that you’re welcome to, you know, send questions through to me. I’ll try and do my best to answer them. I put it through to our team that we have, which has been so supportive in terms of TASS that we’ve dealt with. And so, you know if you direct them to Orbis on Cybersight, then we’ll do our very best to, you know, answer the questions. And a lot of it’s kind of local information. Like the dosages they’ll be using are somewhat dependent on, you know, what everybody else is doing in the community and what your community standard is. So, anyway, we do all we can. And I just found a — this experience a very valuable one and I’ve learned a lot and see how important the subject is for all of us. And, you know, it’s just nice to know we’re part of a big community that we can share all of these ideas. I really want to thank Orbis, again, for the opportunity to present and to all of you for all your patience. And I hope I got most of those questions correct for you. So, it’s been great. And a special shoutout to Orbis for this role in educating all of us. Thank you.