1. Toxic AnteriorSegment SyndromeDR NSD RajuPast President All India Ophthalmological SocietyChairman International Relations Wing AIOS

2. Introduction It is a specific severe anterior segmentinflammation previously termed as sterileEndophthalmitis Now termed Toxic Anterior Segment Syndrome TASS 3. Introduction Anterior segment surgery Toxic insult to tissues Typically within 12-48 hrs Limbus to Limbus edema Breakdown of blood aqueous barrier Damage to iris and trabecular meshwork Response to intensive topical steroids 4. Pathogenesis Toxic insult to endothelium by either an endotoxinor other toxic phenomenon Breakdown of blood aqueous barrier intense flarecellular reaction and hypopyon Toxic damage to iris , damage to trabecularmeshwork and consequent secondary glau coma 5. TASS CausesMultifactorial Instrument cleaning and sterilisation Inadequate flushing occluded port Enzymatic cleaners Ultrasonic bath Preservatives and stabilisers in medication Inappropriate chemical composition solutions 6. Causes of TASS contaminants on surgical instruments irrigating solutions or ophthalmic medications Topical ointments and talc during or after surgery Enzymatic cleaner in ultrasonic bath 7. TASS Task Force Larege outbreak of Tass throughout NorthAmerica in 2006 Establishment of American Society of Cataractand Refractive Society TASS Task Force 8. Recent Developments Increasing incidence in the last Decade Is a specific non infectious condition Responds well to local intensive steroid therapy That it occurs within days of surgery Major causes are endotoxin contamination andinadequate instrument sterilisation/preparationCurrent Opinion in Ophthalmology:February 2007 - Volume 18 - Issue 1 - p 48 9. Clinical Presentation Within 12 - 48 hrs post op Limbus to limbus c. edema Blood aqueous barrier breakdown Intense A C reaction Hypopyon 10. Severe TASS Damage to iris and trabecularmeshwork Secondary Glaucoma Moderate to severe TASSrespond well to intensivetopical steroids 11. Very Severe Cases Persistent corneal edema Iris thinning Permanently dilated orirregular pupil Peripheral anterior synechiae Refractory glaucoma 12. Updated Causes Endotoxins, denatured OVD Preservative and stabilising agents Residue after cleaning and sterilisation Incorrect pH osmolarity ionic composition Retained cortical material Inadequate flushing 13. use of eye ointments postoperative or at the end ofsurgery 14. TASS Acute non infectiousinflammation Cataract Surgery Anterior segment procedures Multifactorial Solutions medicationsOphthalmic devicesCleaning and sterilisation ofinstruments 15. Differential Diagnosis 16. TASS Entry of a non infectiousmaterial in the anteriorsegment 12 to 48 hours after surgery Limited to anterior segment Gram stain and culturenegative 17. Differential DiagnosisOnsetVisionPainCorneal edemaCulture negative 18. DifferentialDiagnosisPosterior segmentinvolvement 19. Incidence Increased incidence in the last decade Large outbreaks in early 2006 in North America Establishment of ASCRS TASS Task Force Many potential causes detected and detailedanalysis of data done 20. Prevention of TASS Appropriate protocols for cleaning and sterilisingsurgical equipment Paying careful attention to all solutions, medications,and ophthalmic devices used during anterior segmentsurgery Recommended Practices for Cleaning and SterilisingIntra ocular Surgical Instruments www.eyeworld.org/ewsupplementarticle.php?id=200 21. Onset Signs and symptoms Inflammation in A C Culture Negative Response to intensive Corticalsteroid 22. Malignant Glaucoma 23. BCVA 6/6p 24. Malignant Glaucoma 25. 25 G PPVIntracameral air 26. Pearls in the diagnosis andManagement Relatively early occurrence Typical Limbus to limbus corneal edema Culture negative Dramatic response to cortico steroids Possibility of Endophthalmitis 27. Management of very severeTASS Severe Endothelial Damage and decomposition Corneal transplantation Refratory glaucoma Filtering shunt surgery 28. Out break of TASS An environmental and toxic control issue Analysis of all medications and fluids Complete review of operating room Review of cleaning of instruments andsterilisation process 29. Prophylaxis May occur in cluster Need thorough evaluation and preventivemeasures the operation theatre processes andcleaning protocols and instrument cleaningprocedures 30. Conclusion Commonest cause Inadequate cleaning andsterilisation process Inadequate flushing of cannulas and hand pieces Denatured residues of OVDs Medications and solutions with Contact with IOL intra ocular surface of instrumentswith gloved hands