Toxic Anteror Segment Syndrome

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TASS

DR.PUSHPANJALI


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Introduction :

Initially referred to as sterile endophthalmitisor postoperative uveitis of unknown cause.

Accurately termed TOXIC ANTERIORSEGMENT SYNDROME(TASS)by Monson etal in 1992.

Toxic endothelial cell destruction (TECD)syndrome : a variant of TASS with localizedendothelial damage.


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Definition :

TOXIC ANTERIOR SEGMENT SYNDROME

Sterile, acute postoperative inflammatoryreaction in which a noninfectious substanceenters the anterior segment and induces toxic

damage to the intraocular tissues that mayoccur following any anterior segment surgery.


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Outbreak of toxic anterior segment syndrome

after vitreous surgery

Arch Soc Esp Oftalmol. 2009 Aug;84(8):403-5. Andonegui J, Jimnez-Lasanta L, Aliseda D, Lameiro F. Servicio de Oftalmologa, Hospital de Navarra, 31008 Pamplona,

Espaa.( [email protected]) CASE REPORT: An outbreak of Toxic Anterior Segment Syndrome

after vitreoretinal surgery is reported. Two patients underwent exclusively vitrectomy while the other

three patients were operated of vitrectomy and some otheranterior segment procedure.

DISCUSSION: Toxic Anterior Segment Syndrome is a sterilepostoperative inflammation due to any non infectious substancethat reaches the anterior segment during surgery. It occurs inoutbreaks and while most of the cases have been reported afteranterior segment procedures, this case demonstrates thatdevelopment after vitreoretinal surgery is also a possibility.


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Severe Intraocular Inflammation after Intravitreal

Injection of Bevacizumab.

Ophthalmology. 2010 Mar;117(3):512-516.e2. Epub 2010 Jan 19.

Sato T, Emi K, Ikeda T, Bando H, Sato S, Morita SI, Oyagi T, Sawada K.

Department of Ophthalmology, Osaka Rosai Hospital, Sakai, Japan.

PURPOSE: To report 5 cases of severe intraocular inflammation that developed after an intravitrealinjection of the same lot of bevacizumab.

PARTICIPANTS: Patients treated with an intravitreal injection of bevacizumab (lot B3003B01). METHODS: The clinical charts of 35 eyes of 35 consecutive patients who were treated with intravitreal

injection of lot B3003B01 bevacizumab from December 18, 2008, through January 20, 2009, werereviewed.

MAIN OUTCOME MEASURES: Incidence of intraocular inflammation, results of bacterial cultures, best-corrected visual acuity (BCVA), and endothelial cell density.

RESULTS: Five (14.3%) of the 35 cases had severe intraocular inflammation, and the inflammation hadsome characteristics of toxic anterior segment syndrome (TASS). Five of the 5 cases had a predominantly

anterior chamber reaction, and 4 of the 5 cases were accompanied by hypopyon. Undiluted samplescollected from both the aqueous and vitreous of the 5 cases were culture negative. The BCVA was 0.66+/-0.29 (mean+/-standard deviations) logarithm of the minimum angle resolution (logMAR) units, and theendothelial cell density was 2683.6+/-97.3/mm(2) before the intravitreal bevacizumab. At the final visit,the BCVA was 0.44+/-0.36 logMAR units, and the cell density was 2679.0+/-217.5/mm(2). Thesedifferences were not significant (P = 0.171 and 0.964).

CONCLUSIONS: These observations indicate that an intravitreal injection of bevacizumab can induce sterileendophthalmitis that has characteristics of TASS.


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Pathophysiology :

TASS results from the inadvertent entry of toxicsubstances into the anterior chamber.

The histopathologic hallmark of TASS is toxic

anterior segment damage. Cellular necrosis and/or apoptosis and

extracellular damage occur, resulting in thesevere acute inflammatory response.

The corneal endothelium is often the mostdamaged structure because of its inability toregenerate and replace dead cells.

Trabecular meshwork damage - IOP


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Presentation :

The hallmark of TASS is an inflammatory reaction in theanterior segment of the eye that starts within 12 to 48 hoursafter surgery.

The most common clinical findings in patients are

(1) diffuse, limbus-to-limbus corneal edema,

(2) increased inflammation in the anterior chamber withhypopyon formation, and the deposition of fibrin.

(3) a dilated pupil with an irregularity of the iris and(4) potential damage to the trabecular meshwork with

subsequent secondary glaucoma.

(5) Cystoid macular edema in few cases.

(6) rapidly improves after topical steroids.


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Clinical course :

Mild presentation : rapid clearing of the cornealedema with no long-term corneal or trabeculardamage and normal or near normal visual acuity.

Moderate presentation : persistent corneal edemathat will take several weeks to clear, intraocularpressure that is difficult to control, and a moderateeffect on visual acuity.

Severe presentation of TASS: marked corneal edema

that does not clear, iris and trabecular meshworkdamage with resultant glaucoma, and possible cystoidmacular edema. Visual outcome is usually poordespite medical or surgical intervention.


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TASS VERSUS ENDOPHTHALMITIS


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TASS Vs ENDOPHTHALMITIS

1. TIMING OF THE DISEASE 2. PAIN


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3. CONJUCTIVAL & LID REACTION 4. CORNEAL EDEMA


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5.IRIS FINDINGS 6. IOP


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7. THERAPEUTIC RESPONSE


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TASS ENDOPHTHALMITISCAUSE Noninfectious reaction to toxic

agent present in:BSS solution

Antibiotic injectionEndotoxinResidue

Bacterial, fungal, or viralInfection

ONSET 12-24 hours 4-7 days

SIGNS/SYMPTOMS

*distinguishingfeature

Blurry visionPain: none, or mild to moderateCorneal edema: diffuse, limbus to

limbus*Pupil: dilated, irregular, nonreactive*

Increased IOP*

Anterior chamber: mild to severereaction with cells, flare,hypopyon, fibrinSigns and symptoms are limited to

anterior chamber*

Gram stain and culture negative

Decreased VA

Pain (25% have no pain)Lid swelling with edema

Conjunctival injectionHyperemiaAnterior chamber: markedinflammatory response withhypopyonVitreous involvement

Inflammation in entire

ocular cavity*

TREATMENT Rule out infectionCulture anterior chamberIntensive corticosteroids

Monitor IOP closely for signs ofdamage to trabecular meshworkand side effects of steroidsWatch closely over next few hours

for signs of bacterial infection

Culture anterior chamberand vitreousIntravitreal and topical

antibiotics

Vitrectomy


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Causes :

1. Substances that accidentally enter the eye during or after

surgery:

Topical antiseptic

Topical lidocaine jelly, anesthetic agents

Powder from gloves

Particles from tray, lint from drapes

Air contaminants

Plain water on instruments

Preservatives in solutions/ medications used

Topical ointment (an eye patch that is too tight may cause the wound tosuck the antibiotic back inside the eye)


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Causes :

2. Substances that are introduced as part of the OR procedure: Improper irrigation solutions (BSS) Inappropriate pH (< 6.5 - > 8.5), chemical composition or osmolality Addition of medications/ antibiotics (the use of vancomycin is still controversial)

Toxic preservatives in BSS (benzalkonium chloride - 1000 corneas damaged inIndia)

Contaminated BSS: During manufacturing process During addition of epinephrine (e.g. sulfites) or antibiotics Out-dated BSS (contamination with glue that leeches inside the bag)

Mitomycin-C

Contaminants on IOL Manufacturer debris Residual polishing compounds (e.g. Memorylens ) During manipulation: powder from gloves


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Causes :

3. Irritants from surgical instruments due to improper

cleaning/sterilization: Dry blood and debris left on instruments

Tissue and dry visco-elastics found in re-used phaco tips, irrigation/aspiration tips andcannulated instruments - flushed into the next patients eye

Irritants from deterioration of instruments due to re-processing: re-usable equipment and re-used single use device (SUD)

Residue of detergent on instruments not properly rinsed

Coliforms and metals left on/in instruments (tap water used instead of distilled, sterile water)

Endotoxins: gram-negative bacteria lodged inside the improperly irrigated cannulated

instruments die during sterilization but release endotoxins that are flushed into the nextpatients eye (e.g. contaminated ultrasonic cleaning solution with Klebsiella pneumoniaebacteria )

Oxidized metal deposits/residues on instruments from Plasma Gas Sterilization System

Ethylene oxide gas residue on instruments from using E.O. Sterilization Method


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Postoperative sterile endophthalmitis

(TASS) associated with the memorylens.

Faisal S. Jehan MD, Nick Mamalis MD, Terrence S. Spencer MD, Luther L. Fry MD, Richard S. Kerstine

MD and Randall J. Olson MD

John A. Moran Eye Center, Univeristy of Utah, Salt Lake City, Utah, USA

Journal of Cataract & Refractive Surgery, Volume 26, Issue 12, December 2000, Page 1777

Purpose : To report 10 cases of delayed-onset acute intraocular inflammation following cataract extractionand posterior chamber implantation of the MemoryLens intraocular lens (IOL).

Methods : This retrospective study evaluated 10 cases of postoperative inflammation that occurred aftercataract extraction with placement of the posterior chamber MemoryLens IOL. Protocols of theIntermountain Ocular Research Center used to analyze outbreaks of unexplained postoperativeinflammation as well as medical records were reviewed.

Results : Nine patients had uneventful cataract extraction and 1 had a small anterior capsule tear withplacement of the MemoryLens IOL. All 10 patients presented with increased anterior segmentinflammation a mean of 7.8 days (range 1 to 21 days) after surgery. Three cases were tapped and wereculture negative, and 7 were presumed noninfectious. The anterior segment inflammation improved in all

patients. Treatment of the 7 patients included intensive topical steroids. Careful analysis of theinflammation has not revealed an obvious etiology; however, the MemoryLens was associated with all thecases.

Conclusions :We postulate that these cases of noninfectious postoperative endophthalmitis may beassociated with the MemoryLens.


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Outbreak of toxic anterior segment syndromeassociated with glutaraldehyde after cataract surgery

nal M, Ycel I, Akar Y;J Cataract Refract Surg vol. 32, 1696 - 1701, 2006

Purpose: To present clinical findings of a cluster of cases of toxic anterior segmentsyndrome (TASS) after uneventful phacoemulsification cataract surgery.

Setting: Department of Ophthalmology, Akdeniz University, Antalya, Turkey.

Methods: Six eyes of 6 patients developed TASS after uneventfulphacoemulsification cataract surgery with implantation of a 3-piece acrylic IOLperformed by 2 ophthalmologists on the same day. Clinical findings includedcorneal edema, Descemet's membrane folds, anterior chamber reaction, fibrinformation, and irregular, dilated, and unreactive pupils.

Results: Glutaraldehyde 2% solution was used inadvertently by the operatingroom staff who cleaned and sterilized reusable ocular instruments beforeautoclaving. None of the affected corneas improved. Additional surgicalprocedures were required and included penetrating keratoplasty, trabeculectomy,and glaucoma tube implantation.

Conclusions: Glutaraldehyde in concentrations generally used for cold sterilizationis highly toxic to the corneal endothelium. The operating room staff involved insterilizing instruments should be well educated about and careful to follow the

protocols to properly clean and sterilize reusable ocular instruments.


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Outbreak of toxic anterior segment syndrome following cataract surgery

associated with impurities in autoclave steam moisture.

Infect Control Hosp Epidemiol. 2006 Mar;27(3):294-8. Epub 2006 Feb 22.

Hellinger WC, Hasan SA, Bacalis LP, Thornblom DM, Beckmann SC, Blackmore C, Forster TS, Tirey JF, RossMJ, Nilson CD, Mamalis N, Crook JE, Bendel RE, Shetty R,Stewart MW, Bolling JP, Edelhauser HF.

Division of Infectious Diseases, Mayo Clinic, Jacksonville, FL 32224, USA.

METHODS: Medical records of patients who underwent cataract surgery during the outbreak werereviewed, and surgical team members who participated in the operations were interviewed. Potential

causes of TASS were identified and eliminated. Feedwater from autoclave steam generators and steamcondensates were analyzed by use of spectroscopy and ion chromatography.

RESULTS: During the outbreak, 8 (38%) of 21 cataract operations were complicated by TASS, comparedwith 2 (0.07%) of 2,713 operations performed from January 1996 through November 2002. Results of aninitial investigation suggested that cataract surgical equipment may have been contaminated bysuboptimal equipment reprocessing or as a result of personnel changes. The frequency of TASS decreased(1 of 44 cataract operations) after reassignment of personnel and revision of equipment reprocessingprocedures. Further investigation identified the presence of impurities (eg, sulfates, copper, zinc, nickel,

and silica) in autoclave steam moisture, which was attributed to improper maintenance of the autoclavesteam generator in the outpatient surgical center. When impurities in autoclave steam moisture wereeliminated, no cases of TASS were observed after more than 1,000 cataract operations.

CONCLUSION: Suboptimal reprocessing of cataract surgical equipment may evolve over time in busy,multidisciplinary surgical centers. Clinically significant contamination of surgical equipment may resultfrom inappropriate maintenance of steam sterilization systems. Standardization of protocols forreprocessing of cataract surgical equipment may prevent outbreaks of TASS and may be of assistanceduring outbreak investigations.


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Toxic anterior segment syndrome and possible association with

ointment in the anterior chamber following cataract surgery.

J Cataract Refract Surg. 2006 Feb;32(2):227-35.

Werner L, Sher JH, Taylor JR, Mamalis N, NashWA, Csordas JE, Green G, Maziarz EP, Liu XM.

John A. Moran Eye Center, University of Utah, Salt Lake City, Utah 84132, USA.

PURPOSE: To report clinical and laboratory findings of 8 cases of TASS related to an oily

substance in the anterior chamber of patients foll. cataract surgery with intraocular lens (IOL)implantation.

METHODS: 8 patients had uneventful phacoemulsification by the same surgeon via clearcorneal incisions with implantation of the same 3-piece silicone IOL design. Postopmedications included antibiotic/steroid ointment and pilocarpine gel; each eye was firmlypatched at the end of the procedure. On 1st POD, some patients presented with diffusecorneal edema, increased IOP, and an oily film-like material within the anterior chamber

coating the corneal endothelium. The others presented with an oily bubble floating inside theanterior chamber, which was later seen coating the IOL. Additional surgical proceduresrequired included penetrating keratoplasty, IOL explantation, and trabeculectomy. 2 cornealbuttons were analyzed histopathologically. 2 explanted IOLs had gross and light microscopicanalyses (as well as surface analyses of 1 of them), and 4 other explanted IOLs had gaschromatography-mass spectrometry.


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RESULTS: Pathological examination of the corneas showed variablethinning of the epithelium with edema. The stroma was diffuselythickened and the endothelial cell layer was absent. Evaluation of theexplanted IOLs confirmed the presence of an oily substance coating largeareas of their anterior and posterior optic surfaces. Gas chromatography-mass spectrometry of the lens extracts identified a mixed chainhydrocarbon compound that was also found in the gas chromatography-mass spectrometry analyses of the ointment used postoperatively.

CONCLUSIONS: The results indicate that the ointment gained access to theeye, causing the postoperative complications described. These caseshighlight the importance of appropriate wound construction and integrity,as well as the risks of tight eye patching following placement of ointment.


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Update on toxic anterior segment syndrome.

Current opinion in ophthalmology Volume: 18 ISSN: 1040-8738 ISO

Publication Date: 2007 Feb

PURPOSE OF REVIEW: To review, summarize and update our present understanding of toxicanterior segment syndrome.

RECENT FINDINGS: Toxic anterior segment syndrome has emerged within the last 2 years as acomplication of increasing frequency following uneventful cataract surgery. Over 100 NorthAmerican clinics reported toxic anterior segment syndrome cases to a specially constitutedtask force over a 4-month period in 2006. Toxic anterior segment syndrome is nowrecognized as a specific, noninfectious condition presenting as anterior segmentinflammation that occurs within days of surgery and is responsive to topical steroids. Specificcauses have been identified such as endotoxin contamination of balanced salt solutions andantibiotic ointment accessing the anterior chamber, although most cases appear to resultfrom inadequate instrument sterilization and preparation. Outcomes are usually excellent,but delayed treatment and severe cases may result in glaucoma and persisting cornealedema requiring penetrating keratoplasty.

SUMMARY: Toxic anterior segment syndrome has become a significant complication ofcataract surgery. Rapidly increasing knowledge made possible by ophthalmic organizationsand the prompt dissemination of research findings, however, appear to have provided theinformation necessary to help prevent and resolve this condition.


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Toxic anterior segment syndrome after cataract

surgery--Maine, 2006.

MMWR (Morb MortalWkly Rep.) 2007 Jun 29;56(25):629-30.

Centers for Disease Control and Prevention (CDC).

Toxic anterior segment syndrome (TASS), an acute, noninfectious inflammation of theanterior segment of the eye, is a complication of anterior segment eye surgery; cataractextraction is the most common form of this type of surgery. Various contaminants, usually

from surgical equipment or supplies, have been implicated as causes of TASS. The syndrometypically develops within 24 hours after surgery and is characterized by corneal edema andaccumulation of white cells in the anterior chamber of the eye. Although most cases of TASScan be treated successfully with topical steroids, topical nonsteroidal antiinflammatoryagents, or both, the inflammatory response associated with TASS can cause serious damageto intraocular tissues, resulting in vision loss. In October 2006, the Maine Department ofHealth and Human Services (MDHHS) received a report of a cluster of TASS cases among

outpatients who had undergone cataract surgery at a hospital in Maine. MDHHS and CDCinvestigated the cluster and worked with the treating ophthalmologist and the hospital toprevent additional cases. This report describes the results of that investigation and thesubsequent prevention measures implemented. Although the specific cause of the outbreakwas not identified, no additional cases were reported after two series of changes were madeto the materials and equipment used for surgery. Prevention of TASS requires carefulattention to solutions, medications, and ophthalmic devices and to cleaning and sterilization

of surgical equipment because of the numerous potential causes of the condition.


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Multistate outbreak of toxic anterior segment

syndrome, 2005.

J Cataract Refract Surg. 2008 Apr;34(4):585-90.

Kutty PK, Forster TS,Wood-Koob C, Thayer N, Nelson RB, Berke SJ, Pontacolone L, Beardsley TL, EdelhauserHF, Arduino MJ, Mamalis N, Srinivasan A.

PURPOSE: To present the findings of an outbreak of toxic anterior segment syndrome (TASS).

SETTING: Six states, 7 ophthalmology surgical centers, United States.

METHODS: Cases were identified through electronic communication networks and via reports to anational TASS referral center. Information on the procedure, details of instrument reprocessing, andproducts used during cataract surgery were also collected. Medications used during the procedures weretested for endotoxin using a kinetic assay.

RESULTS: The search identified 112 case patients (median age 74 years) from 7 centers from July 19, 2005,through November 28, 2005. Common presenting clinical features included blurred vision (60%), anteriorsegment inflammation (49%), and cell deposition (56%). Of the patients, 100 (89%) had been exposed to asingle brand of balanced salt solution manufactured by Cytosol Laboratories and distributed by AdvancedMedical Optics as AMO Endosol. Two patients continued to have residual symptoms. There were no

reports of significant breaches in sterile technique or instrument reprocessing. Of 14 balanced saltsolution lots, 5 (35%) had levels exceeding the endotoxin limit (0.5 EU/mL). Based on these findings, thebalanced salt solution product was withdrawn, resulting in a termination of the outbreak.

CONCLUSIONS: This is the first known report of an outbreak of TASS caused by intrinsic contamination of aproduct with endotoxin. Ophthalmologists and epidemiologists should be aware of TASS and its commoncauses. To facilitate investigations of adverse outcomes such as TASS, those performing cataract surgeriesshould document the type and lot numbers of products used intraoperatively.


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Development of toxic anterior segment syndrome

immediately after uneventful phaco surgery.

Korean J Ophthalmol. 2008 Dec;22(4):220-7.

Choi JS, Shyn KH.

Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea.

PURPOSE:We report on 15 cases of suspected toxic anterior segment syndrome after uneventful phacosurgery.

METHODS: We retrospectively reviewed the charts of patients who had developed toxic anterior segmentsyndrome (TASS) after uneventful phacoemulsification for senile cataracts between April and December of2005. Clinical features and all possible causes were investigated including irrigating solutions or drugs,surgical instruments or intraocular lenses, sterilization techniques for instruments, or any otheraccompanying disease.

RESULTS: The patients consisted of 2 males and 13 females with an average age of 64.7+/-10.9 years. Fivedifferent surgeons had performed their phaco surgeries. No abnormal preoperative or operative findingswere reported. Nevertheless, all 15 patients developed a moderate degree of corneal edema. Ordinarytreatments were not helpful. We suspect that lack of sterilization resulted in the development of the

syndrome, because after ethylene oxide gas sterilization was replaced with autoclaving, no such incidentshave occurred.

CONCLUSIONS: Toxic anterior segment syndrome requires special attention and thorough management,including sterilization of reused surgical instruments.


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Identification of unknown intraocular material after cataract

surgery: evaluation of a potential cause of toxic anterior

segment syndrome.

J Cataract Refract Surg. 2008 Mar;34(3):465-9.

Mathys KC, Cohen KL, Bagnell CR.

Department of Ophthalmology, Microscopy Services Laboratory, University of North Carolina at ChapelHill, School of Medicine, University of North Carolina Hospitals, Chapel Hill, North Carolina 27599-7040,USA.

PURPOSE: To describe and identify unknown opaque material between the optic of an AR40 intraocular

lens (IOL) injected with the Emerald Series implantation system (both AMO, Inc.) and the posterior capsuleat the conclusion of routine phacoemulsification to prevent an outbreak of toxic anterior segmentsyndrome (TASS).

METHODS: After coaxial phacoemulsification in multiple patients, opaque material was present betweenthe optic of a posterior chamber IOL and the posterior capsule. Although there was no TASS, the materialwas removed from 2 eyes and analyzed with scanning electron microscopy (SEM) and x-ray microanalysis(XRM). Similarly, crystalline lens, Klenzyme (Steris Corp.), Viscoat (sodium hyaluronate 3.0%-chondroitinsulfate 4.0%), and Provisc (sodium hyaluronate 1.0%) were analyzed.

RESULTS: On SEM, the material had an irregular undulating surface similar to that of Provisc. Viscoat andthe crystalline lens had smoother surfaces. On XRM, the material contained sodium, chlorine, and calcium,like Viscoat and Provisc, and phosphorous and sulfur, like Viscoat. The material also contained silicone,magnesium, aluminum, titanium, iron, and zinc. Klenzyme had smaller peaks of sodium, chlorine, andcalcium and a higher carbon background than the unknown material.

CONCLUSIONS: The material was likely ophthalmic viscosurgical device that was chemically andstructurally altered by the cleaning and sterilization process. The silicone and metallic elements wereprobably from the Emerald Series implantation system as the disposable cartridge is coated with silicone

and the reusable injector is metal.


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Toxic Anterior Segment Syndrome (TASS): studying an

outbreak

Farm Hosp. 2008 Nov-Dec;32(6):339-43. Sarobe Carricas M, Segrelles Bellmunt G, Jimnez Lasanta L, Iruin Sanz A. Servicio de Farmacia, Hospital de Navarra, Pamplona, Espaa. [email protected] INTRODUCTION: An effect associated with cataract surgery known as Toxic Anterior Segment

Syndrome (TASS) has been reported in recent years. It is an inflammatory non-infectious processwhich appears within the first few hours after surgery and generally resolves well with topical

steroids if the course of treatment is started promptly. In this paper we describe the syndrome and analyze the possible causes for the TASS outbreak that

occurred in our hospital and affected 5 patients. METHODS: As the syndrome may be due to multiple causes, the members of a research team

created at the hospital reviewed all the procedures involved. The washing and sterilization methodsapplied to the materials were analyzed, as well as the drugs and substances used which might havecaused the outbreak.We verified the substances prepared by the Pharmacy Department, speciallythe irrigating solution which was used in all the cases.

RESULTS: According to the results obtained in the biochemical, micro-biological, pH, osmolarity and

endotoxins assays, the solutions prepared by the Pharmacy Department were all correct. DISCUSSION: Since the results obtained in the analyses of the substances used were correct and no

adverse effect was observed after the re-administration of the substances, we may conclude thatthe outbreak would be related to the washing process performed previously to the sterilization ofthe instrumentation used in the surgery, mainly because the recommendation to use distilled andsterile water for this purpose was not followed and, on the contrary, tap water continued to beused.


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Toxic Anterior Segment Syndrome Following

Penetrating Keratoplasty

Philip Maier, MD; Florian Birnbaum, MD; Daniel Bhringer, MD; Thomas Reinhard, MD .

Arch Ophthalmol. 2008;126(12):1677-1681.

Objectives To describe an outbreak of toxic anterior segment syndrome (TASS) followingpenetrating keratoplasty (PK) and to examine its possible causes.

Methods Owing to a series of TASS following PK between June 6, 2007, and October 2, 2007,

we reviewed the records of all patients who had undergone PK during that time. Inadditionto routine microbial tests on organ culture media, we looked for specific pathogensand endotoxins in all of the materials used for organ culture or PK. Furthermore, we analyzedall of the perioperative products and instrument processing.

Results Of the 94 patients who underwent PK, we observed 24 cases of postoperative sterilekeratitis. Causal research revealed that the accumulation of cleaning substances or heat-stableendotoxins on the surface of the routinely used guided trephine system was most likely

responsible for the TASS. Conclusions To our knowledge, this is the first report on TASS following PK. Suboptimal

reprocessing of surgical instrumentsmay be an important cause of TASS as in this series theTASS-likesymptoms resolved after modified instrument-cleaning procedures. Thestandardization of protocols for processing reusable trephine systems might preventoutbreaks of TASS following PK.


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Retrospective analysis of clinical characteristics

of toxic anterior segment syndrome

Zhonghua Yan Ke Za Zhi. 2009 Mar;45(3):225-8. Yang SL, Yan XM. Department of Ophthalmology, Peking University First Hospital, Beijing 100034, China. OBJECTIVE: To investigate the etiology, clinical features, treatment and prognosis of toxic anterior segment

syndrome (TASS). METHODS: It was a retrospective series case study. The clinical data of eight definite diagnosed TASS cases

were retrospectively analyzed. RESULTS: Among eight TASS cases, seven were post cataract surgery cases and one was post corneapenetrating injury. Three cases were caused by residual povidone iodine on instruments, 2 cases resultedfrom the misuse of distilled water as intraocular irrigating liquid during cataract surgery, 2 cases wereproduced by the countercurrent of antibiotic solution via the cornea-scleral incision into anterior chamberduring subconjunctival injection at the end of the surgery, and 1 case was induced by the injection of thedistilled water into the anterior chamber at the end of the surgery. Three TASS cases occurred duringoperation and 5 cases occurred at 1 day after operation. All eight cases suffered from the painless blurredvision. Three cases occurred during operation presented with decrease of corneal transparence anddepigmentation of iris. On the first day after operation, all cases had diffuse corneal stroma edema and

severe anterior uveitis. Dexamethasone 0.1% or prednisolone acetate 1% eye drops, three times per dayor one time per hour was used in all cases. Carteolol 2% eye drop, two times per day, was used for thecases with ocular hypertension. The cornea was clear in 6 cases, but corneal endothelial decompensationin 2 cases after therapy.

CONCLUSION: Various toxic agents injected into anterior chamber by misuse can result in TASS. All thesemisuse can be avoided. Early diagnosis and proper management may be important to improve theprognosis of TASS.


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Toxic Anterior Segment Syndrome - A Reality

First Independent Ophthalmic Journal Published from Islamabad, Pakistan; Vol. 7,No. 4 Oct-Dec-2009

Dr. Mahfooz Hussain Director & Senior Consultant Ophthalmologist,Dr. Tariq Farooq Babar, AssociateProfessor & Visiting Eye Surgeon,Dr. Mir Zaman, Senior Registrar,Dr. Mohammad Younas Khan, ConsultantOphthalmologist,Dr. Anwar Iqbal & Dr. Naz Jehangir Postgraduate Trainees Pakistan Institute ofCommunity Ophthalmology, Khyber Institute of Medical Sciences, Hayatabad Medical Complex,Peshawar,Dr. Patricia D. Wade, Consultant Ophthalmology JOS University Teaching Hospital, Nigeria.

PURPOSE: The purpose is to report two outbreaks of toxic anterior segment syndrome (TASS) and toemphasize importance of its early diagnosis, appropriative treatment and prevention which is all the moreimportant.

PATIETS and MATERIALS: We had two outbreaks of TASS at two different occasions in 2007-08 afterroutine cataract extraction with posterior chamber implant. We retrieved clinical records of all patientsand collected information on a specially designed performa. Details of postoperative signs and symptomsand treatment were recorded. All the patients were followed up for at least 3 months. We also looked atmethods of instrument cleaning and sterilization in detail.

RESULTS:We diagnosed 11 patients with TASS at two different occasions as two clusters. All the patients

were correctly diagnosed and no patient turned out to be infective, which is usually the main concern. Allthe patients were successfully treated. Final visual acuity was 6/6 in 7 patients, 6/9 in 3 patients and 6/18in one patient. Increased IOP in 4 patients returned to normal at 3 months.

CONCLUSIONS: It is important to differentiate TASS patients from infective endophthalmitis. Timing ofonset and sparing of posterior segment are important factors for diagnosis along with other clinicalfeatures. Early and intensive treatment with topical steroids, cycloplegics and oral anti-inflammatory drugscan resolve the condition and visual acuity can improve to preoperatively expected levels.


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PREVENTION


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Task Force

When reports of toxic anterior segment syndrome (TASS) inNorth America suddenly began to escalate to five times their normal level early in 2006, theAmerican Society of Cataract and Refractive Surgery (ASCRS)provided support for a task

force convened to investigate the reasons why and develop recommendations for reducingits incidence.

Analysis of the data the task force assembled failed to reveal any single cause of the outbreakand, instead, suggested that a number of etiologic factors could have been involved.

The analysis also provided support for the belief that the cleaning and sterilization of theinstruments used in cataract surgery appears to be a critical factor in reducing the risk ofTASS.

The team came up with this Special ASCRS/ASORN Report: Recommended Practices forCleaning and Sterilizing Intraocular Surgical Instruments.

Guidelines : Establish written protocols for instrument cleaning and reprocessing, certifycompetency of responsible personnel, and monitor compliance

Use only medications and solutions that are free of preservatives, bisulfites, or metasulfites.


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Treatment :

Medical Care

Once TASS is confirmed,

patients should be startedon topical steroids.

Careful assessment andtreatment of elevated IOP.

Nonsteroidal anti-inflammatory drops.

Close follow-up.

RULE OUT ENDOPHTHALMITIS


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Treatment :

Surgical Care

Intraocular lens exchange.

Corneal transplantation. Trabeculectomy (seton valve procedures).


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TASS TIMELINE

1980 1992 2000 2002 2005 2006 2006 2006

Sporadicreports ofsevere

anteriorsegmentinflammationfollowingcataract

surgery

ConditiontermedToxic

AnteriorSegmentSyndrome(TASS)Monsonet al. JCRS

1992

Delayed-onsetTASS

associated withMemoryLens

softenedcity waterthat

suppliedthe auto-clavesteamgenerator(sulphate

impurity)

OctoberIncreasingreports of

sterileInflammation linkedtoBSS(Endosol)

TASS atCommunity

Hospitalin Maine

Numerous eyecenters

in NorthAmericareportedanincreaseincidence

of TASSfollowingOutpatient cataractsurgery

ASCRScreated aTASS Task

Force toinvestigateoutbreaksof TASSand

identifycausativeagents


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Just because something is sterile,

it does not mean its not toxic!


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THANK YOU!

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Toxic Anteror Segment Syndrome