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Toxic anterior segment syndrome

Article  in  Journal of Cataract and Refractive Surgery · March 2006

DOI: 10.1016/j.jcrs.2006.01.065 · Source: PubMed

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 Toxic Anterior Segment
Syndrome
Nick Mamalis, MD
CONTENTS
• Clinical Signs and Symptoms
• Etiology of Toxic Anterior Segment Syndrome
• Cleaning and Sterilization of Ophthalmic Instruments
• Treatment of Toxic Anterior Segment Syndrome
• Analysis of Toxic Anterior Segment Syndrome Outbreaks
• Prevention of Toxic Anterior Segment Syndrome
CHAPTER HIGHLIGHTS
>> Clinical recognition of toxic anterior segment syndrome
(TASS)
>> Causes
>> Treatment
>> Protocol for managing a TASS outbreak
Toxic anterior segment syndrome (TASS) is an acute, sterile postop-
erative anterior segment inflammation following any anterior seg-
ment surgery. This entity is by definition sterile or noninfectious.
This condition was initially described as sterile postoperative
endophthalmitis, but in 1992, Monson et al.1 coined the term toxic
anterior segment syndrome (TASS). In addition, cases of TASS
which are characterized by localized corneal endothelial damage
have been termed toxic endothelial cell destruction syndrome
(TECDS).2–6 A recent review/update on TASS as well as its accom-
panying editorial has provided a detailed, in-depth discussion of this
entity.7,8
TASS occurs most commonly following cataract surgery, but
may occur following anterior-segment surgeries of any kind
including glaucoma or cornea transplant surgeries. While TASS
is most commonly noted to occur acutely following anterior seg-
ment surgery, in rare instances it can have a delayed onset. This
postoperative inflammation is sterile or noninfectious and is felt
to be caused by a substance that enters the anterior segment
either during or immediately after surgery, resulting in toxic
damage to intraocular tissues.
48
CLINICAL SIGNS AND SYMPTOMS
▪ CLINICAL SIGNS AND SYMPTOMS
The most common complaint that patients with TASS have is
▪
blurred vision. Pain is usually absent which is distinct from cases
of postoperative infectious endophthalmitis. The patients may have
signs of ocular inflammation and injection. The clinical hallmark
of TASS is the fact that the inflammation presents with a relatively
immediate onset, usually within 12–48 h of surgery. This inflam-
mation is sterile and Gram-stain and cultures are negative.
The most common clinical finding in TASS is diffuse corneal
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
edema which has been described as “limbus-to-limbus” corneal
edema (Figure 48-1). This diffuse corneal edema is due to wide-
spread damage of the corneal endothelial cells. This finding is
very different from the focal areas of corneal edema which may
occur after routine cataract surgery. A second common finding
associated with this entity is marked anterior segment inflam-
mation. This is characterized by diffuse breakdown of blood–
aqueous barrier with a marked increase in inflammatory cells
in the anterior chamber. These cells may settle to the lower part
of the anterior chamber forming a hypopyon (Figure 48-2). In
addition, significant breakdown of the blood–aqueous barrier
may lead to fibrin formation in the anterior chamber which
may extend across the pupil from the iris onto the surface of
the intraocular lens and toward the incisions. Finally, TASS
may result in damage to the iris which can cause a permanently
dilated or irregular pupil with thinning of the iris stroma
(Figure 48-3). There may be associated trabecular meshwork
damage which can lead to secondary glaucoma which may be
difficult to control.
It is important to differentiate the sterile inflammation seen in
TASS from an infectious postoperative endophthalmitis. One of
the signs that are most helpful in differentiating these two entities
is the fact that TASS occurs acutely in the vast majority of cases
with signs appearing within the first 12–48 h. In bacterial
endophthalmitis, the typical signs do not often appear until 4–7
days postoperatively. The symptoms in these entities are different
in that greater than 75% of patients who have an infectious
endophthalmitis will have pain. The majority of cases of TASS
are pain free. The anterior segment inflammatory changes in both
of these entities are often very similar with significant inflamma-
tion and hypopyon formation. However, the diffuse corneal edema
589
vii Management of Complications
ETIOLOGY OF TOXIC ANTERIOR SEGMENT SYNDROME
Figure 48-1 Diffuse limbus-to-limbus corneal edema. (From Mamalis N,
Edelhauser HF, Dawson DG, Chew J, LeBoyer RM, Werner L: Toxic anterior
segment syndrome, J Cataract Refract Surg 32:324–333, 2006 (review/update).
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Figure 48-3 Atrophic iris with dilated, slightly irregular pupil.
(From Mamalis N,
Edelhauser HF, Dawson DG, Chew J, LeBoyer RM, Werner L: Toxic anterior
segment syndrome, J Cataract Refract Surg 32:324–333, 2006 (review/update).
seen in TASS is often not noted in infectious endophthalmitis. It is
important if there is any question of an infectious etiology that ante-
rior chamber and vitreous samples be taken for staining and culture.
▪
ETIOLOGY OF TOXIC ANTERIOR
▪
SEGMENT SYNDROME
Any substance that is used during or immediately after cataract
surgery which can access the anterior segment of the eye can
cause TASS. The corneal endothelium is especially sensitive
to any form of toxic insult as are many of the structures in the
anterior segment of the eye in general. The etiology of TASS
is relatively broad and may include problems involving irrigating
solutions such as balanced saline solution (BSS) and any additives
included.9–13 In addition, any other ophthalmic solutions used
during surgery, especially those which contain preservatives or
590
Figure 48-2 Anterior segment inflammation with hypopyon formation. (From
Mamalis N, Edelhauser HF, Dawson DG, Chew J, LeBoyer RM, Werner L:
Toxic anterior segment syndrome, J Cataract Refract Surg 32:324–333, 2006
(review/update).
stabilizing agents may cause toxicity to corneal endothelium
and precipitate TASS.13–15 Medications such as antibiotics
and anesthetics which are injected into the eye may also be
associated with TASS. Additionally, residues of ophthalmic
viscosurgical devices (OVDs) may cause significant postoperative
inflammation.16 Lastly, it is important to remember that any
enzymes or detergents that are used in the cleaning of instru-
ments used in anterior-segment surgery may leave behind a
residue which could cause TASS.17–19
INTRAOCULAR IRRIGATING SOLUTIONS
Intraocular irrigating solutions such as BSS have the potential
for causing problems with TASS if there are problems with the
composition of the BSS such as incorrect ionic composition,
osmolarity, or pH.9–13
It is also important to remember that any medication or solu-
tions that are added to the BSS may be associated with potential
problems with inflammation. Examples of these include agents to
dilate the pupil, such as epinephrine, and antibiotics which are
placed into the irrigating solution.
Furthermore, it is important to ensure that there is no contam-
ination in the BSS secondary to materials such as endotoxin.
There was an outbreak of TASS in the fall of 2005 which was
found to be secondary to endotoxin contamination of BSS. Mul-
tiple patients throughout the United States were found to have
signs and symptoms of TASS, but cultures of the anterior cham-
ber and vitreous showed no signs of infectious endophthalmitis.
These patients tended to occur in clusters and responded well
to intense topical corticosteroid treatments. This outbreak was
evaluated by investigators from the Intermountain Ocular
Research Center at the University of Utah, as well as investigators
from the United States Centers for Disease Control (CDC). A
thorough investigation of 112 cases from this outbreak by the
CDC found that the vast majority of patients were exposed to
one particular brand of BSS that was used during cataract surgery.
Samples were taken from many different lots of BSS and tested
for endotoxin. Several lots of BSS were found to have levels of

endotoxin exceeding the allowable limit of 0.5 EU/mL. It was
found that this BSS was manufactured by Cytosol Laboratories
and distributed by AMO as Endosol. This BSS was withdrawn
from the market which resulted in termination of the outbreak
(U.S. Food and Drug Administration FDA – Reported Recall –
Cytosol Laboratories, Inc. Product Contains Dangerous Levels
of Endotoxin. February 13, 2006).
PRESERVATIVES
Ophthalmic solutions which contain preservatives or stabilizing
agents may be toxic to the corneal endothelium and result in
TASS.13–15 The corneal endothelium is exquisitely sensitive to pre-
servatives which are used in many topical ophthalmic drops or solu-
tions. One of the most commonly used preservatives is
benzalkonium chloride (BAK). There have been multiple reports
of patients with significant corneal edema or endothelial cell damage
resulting from solutions which are preserved with BAK.5 In addi-
tion, BAK has been found to cause significant corneal edema when
used as a preservative with an OVD.6 Low levels of BAK are safe
to use on the surface of the eye, but should be avoided in medications
which gain access to the eye during anterior segment surgery.
In addition to preservatives, agents which are used to stabilize
intraocular medications have been found to be associated with
TASS. The most commonly used stabilizing agents are bisul-
phites or metabisulphites, which are often used as a stabilizing
agent for epinephrine (to maintain the epinephrine in the reduced
state) which is added to the BSS to help maintain pupil dilation
during cataract surgery. While these stabilizing agents are not
considered to be traditional preservatives, they can be toxic to
the corneal endothelium, as well as other cells within the anterior
segment of the eye and can lead to TASS.20 It is imperative that
any medications placed into the eye during surgery are not only
preservative free but free of stabilizing agents.21
INTRAOCULAR ANESTHETICS
Intracameral anesthetics are often used in routine cataract surgery to
help supplement topical anesthetics. Preservative-free anesthetics
which are in a relatively low concentration have not been found to
be toxic to the endothelium. However, doses of lidocaine which is
preservative free (methylparaben free-MPF) at a level of 2% or higher
have been known to cause significant corneal thickening and opacifi-
cation postoperatively.22 Although these agents are preservative free,
intracameral use of anesthetics can potentially cause corneal endothe-
lial cell damage at a high enough dose.22–24 Therefore, it is very
important that any anesthetics used in anterior-segment surgery are
not only of the proper dose but are free of preservatives.
INTRAOCULAR ANTIBIOTICS
Antibiotic agents are an additional source of toxicity when either
they are used in irrigating solutions or are injected into the anterior
segment of the eye at the conclusion of surgery. These agents are
often used to help prevent endophthalmitis. Surgeons had initially
advocated the use of either gentamicin sulfate or vancomycin in the
irrigating solution (BSS) to help prevent endophthalmitis.25 How-
ever, concerns were raised about the possibility of toxicity, espe-
cially with intraocular gentamicin, which has a relatively narrow
Toxic Anterior Segment Syndrome 48
range of therapeutic versus toxic doses and has been found to cause
macular toxicity.26,27 These agents have been mostly discontinued
for use in the BSS for prevention of infection.
There has been recent work done mainly in Europe on the use
of intracameral antibiotics which are injected at the conclusion of
the surgery to help prevent endophthalmitis. Initial studies in Swe-
den regarding the use of intracameral cefuroxime for endophthal-
mitis prophylaxis showed no signs of toxicity with a 1 mg/0.1 cc
dose of intracameral cefuroxime.28 The European endophthalmitis
study which has recently been published showed a significant
reduction of endophthalmitis following the intracameral injection
of cefuroxime at the conclusion of the case.29 The issue of the
use of intracameral antibiotics to prevent endophthalmitis is an
important topic that will need to be addressed by surgeons in the
United States in the near future. The American Society of Cataract
ETIOLOGY OF TOXIC ANTERIOR SEGMENT SYNDROME
and Refractive Surgery (ASCRS) has established a subcommittee
to evaluate the various treatments of endophthalmitis, including
intracameral antibiotics. Careful measures need to be taken to
ensure that the proper mixing and dosing of the antibiotic is done
in the pharmacy in order to prevent the possibility of TASS out-
breaks due to improperly dosed or mixed intracameral antibiotics.
In addition to topical drops which may gain access to the eye during
cataract surgery, there have been recent reports regarding a relatively
delayed-onset TASS secondary to topical ophthalmic ointments
gaining access to the anterior chamber of the eye following surgery
and causing inflammation.30 A series of patients were found to have
delayed-onset TASS-like symptoms with film or oil-like substance
in the anterior chamber, coating the endothelium or on the intraocu-
lar lens (IOL). Analysis of this material using chromatography – mass
spectral analysis revealed that this material contained a mixed chain
hydrocarbon which was also found in the analysis of the steroid-anti-
biotic ointment that was placed on the patient's eyes following the
conclusion of the surgery. Such cases raised the possibility that oint-
ment placed on the surface of the patient's eye at the conclusion of
the case followed by tight patching in the setting of a clear cornea
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
wound may lead to ointment gaining access into the anterior chamber
of the eye and causing inflammation.
OPHTHALMIC VISCOSURGICAL DEVICES
An additional potential source of TASS are commonly used
OVDs (previously referred to as viscoelastics). A large amount
of remnant OVD in the anterior chamber of the eye can cause
an increase in intraocular pressure (IOP) as well as increased
inflammation postoperatively.
An additional problem is the possibility of denatured residual
OVD left in either reusable cannulas, tips or handpieces which
have not been properly flushed following surgery. This residual
OVD may be broken down during sterilization and can cause
toxic inflammation following flushing of this material into the
eye in subsequent cases.16 In addition, this OVD may actually
retain other materials such as detergents or enzymes which are
used during cleaning and processing of instruments that could
conceivably lead to inflammation in the anterior segment of the
eye or TASS. It is critically important that any reusable cannulas
or instruments be thoroughly flushed at the conclusion of a case
in order to not allow the OVD to dry on the instruments which
can occur when cannulas are exposed to the air, making cleaning
very difficult. It is recommended that all cannulas, handpieces or
591
vii Management of Complications
phacoemulsification tips that are exposed to OVD be thoroughly
flushed using sterile, deionized, or distilled water to ensure that
there is no residue left on the instruments between cases.
▪
CLEANING AND STERILIZATION
▪
OF OPHTHALMIC INSTRUMENTS
The cleaning and sterilization of instruments for use in anterior
segment surgery has become an important factor in many recent
cases of TASS. Beginning in February of 2006, the number of
TASS cases reported to the Intermountain Ocular Research
Center of the University of Utah, as well as to the TASS center
at Emory University and to industry representatives began to
increase markedly. Multiple clusters of cases of TASS were found
TREATMENT OF TOXIC ANTERIOR SEGMENT SYNDROME
in surgical centers throughout the United States and Canada. The
Ad Hoc TASS Task Force was established with funding from the
ASCRS to help investigate this outbreak. Two questionnaires
regarding instrument reprocessing as well as the use of products
in anterior segment surgery were developed and a database was
established to investigate the causes of the TASS outbreak
Approximately 130 different centers reporting TASS were
evaluated. The Ad Hoc TASS Task Force issued its final report
on September 22, 2006 regarding the analysis of this TASS out-
break (Toxic Anterior Segment Syndrome (TASS) Outbreak:
Task Force Final Report - www.ascrs.org and www.aao.org).
There was no conclusive epidemiologic evidence to suggest any
one product was responsible for the increase in the TASS cases
reported. Also, analysis of the information did not reveal a single
cause or point source related to this particular TASS outbreak.
However, there were multiple potential etiologic factors which
were found to be related to the cases of TASS. The issue of
cleaning and sterilization of instruments for cataract surgery was
found to be the most important factor involved in many of the
cases of TASS. Specifically, the taskforce found that the short
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
time available between cases to properly clean and reprocess
instruments was an area of concern. The use of reusable cannu-
lated instruments of any kind was found to be a potential source
of TASS because they normally have small internal diameters and
openings as small as 0.3 mm. This includes ultrasound and irriga-
tion–aspiration (I–A) handpieces for use during surgery. It is
critically important that all reusable handpieces and cannulas are
flushed thoroughly at the conclusion of each case. Inadequate
flushing may allow a buildup of residual cortex and OVD which
could lead to toxic anterior segment inflammation.
Another important area when evaluating the cleaning and ster-
ilization of instruments that was also evaluated by the task force
was the use of enzymes or detergents in the cleaning of the
instruments. Enzymes or detergents that are used in the cleaning
of instruments for anterior-segment surgery may leave a residue
which could cause TASS.18,19
If any of this residual enzyme or detergent is not properly rinsed
from the instruments, it has the potential to cause TASS. Detergents
have been found to accumulate on the inner surfaces of reusable
instruments, especially when there is dried or residual OVD. It
should be noted that the enzymes and detergents are not completely
inactivated when exposed to high temperatures used in the autoclav-
ing of instruments. There is a possibility that the residue of deter-
gents and enzymes left in cannulas or phaco or I–A handpieces
592
may cause potential inflammation. There have been reports of an
increase in corneal thickness secondary to endothelial damage in
both rabbits and humans due to enzymatic detergents.13,19
Initial evaluations of the toxicity of detergents to the corneal
endothelium were referred to as the toxic endothelial cell destruc-
tion (TECD) syndrome. Reports of severe TECD following cat-
aract surgery have been found to occur from detergent residues on
reusable cannulas.2
Furthermore, the use of ultrasound baths to clean ophthalmic
instruments between cases is a potential source of TASS. The
ultrasound baths may become contaminated by Gram-negative
bacteria which can produce a heat-stable endotoxin that can sur-
vive autoclaving and cause TASS. Even though the bacteria are
incapacitated by heat from the autoclave, the endotoxin remains
viable. Deposits of the heat-stable lipopolysaccharide endotoxins
can remain attached to the instruments or cannulas and can cause
significant inflammation in the anterior segment of the eye if they
are injected into the eye.31 Endotoxin is difficult to remove from
ophthalmic instruments and may require an alcohol rinse. Con-
sideration should be given to eliminating the use of ultrasound
baths in the cleaning of ophthalmic instruments. Ultrasound
baths are often necessary to remove bulk contamination on
instruments which is important in areas such as general surgery,
but is not a factor in most anterior segment ophthalmic surgeries.
▪ TREATMENT OF TOXIC ANTERIOR
SEGMENT SYNDROME ▪
Once again, it is important to ensure that an infectious etiology has
been adequately ruled out of cases of suspected TASS. Once the
toxic agent enters the eye and causes inflammation and damage
which leads to TASS, the mainstay of treatment is the suppression
of the secondary inflammatory response. The primary treatment
for patients with TASS is the use of intense topical corticosteroids
to help calm the inflammation and limit the damage not only from
the initial toxic insult but also from the secondary immune response.
Patient's should be started on topical prednisolone acetate 1% drops
every 1–2 h and be carefully followed in the first several days follow-
ing the onset of TASS. In addition, the IOP should be closely mon-
itored in patients with TASS. Although the pressure may initially be
low, recovery of aqueous production by the ciliary body may cause a
rapid increase in IOP as the inflammatory reaction decreases. The
initial toxic insult causing TASS not only may injure the cornea
and iris, but also can cause significant damage to the trabecular
meshwork. Lastly, the inflammation can lead to formation of periph-
eral anterior synechia, which may also contribute to a rise in IOP.
Patients should be followed closely to ensure that the inflamma-
tion is not worsening and that the pressure remains stable. Careful
slit-lamp examinations of the anterior segment of the eye should be
performed regularly to document the resolution of the anterior
segment inflammation and corneal edema if it is present.
CLINICAL COURSE
The clinical outcome of a patient with TASS is directly related to
the degree of toxic insult to the anterior segment of the eye occur-
ring during or immediately following the surgical procedure.
Patients who have a relatively mild case of TASS tend to undergo

Figure 48-4 Resolving toxic anterior segment syndrome with clearing
cornea, rapidly clearing anterior segment inflammation with small residual
keratic precipitates.
rapid clearing of the corneal edema over the course of several days
to weeks. In addition, the inflammation will clear relatively rap-
idly with minimal associated sequelae and no permanent damage
(Figure 48-4). Patients who have suffered a more moderate insult
causing TASS may have a more prolonged course lasting weeks
to months with eventual clearing of the cornea and possibility of
small residual corneal edema. These patients may also have
increased IOP. Patients who have a more severe initial insult often
suffer permanent damage to the anterior segment of the eye. This
can include diffuse corneal edema which is non-clearing and may
require cornea transplantation for treatment (Figure 48-5). In
addition, the patient's may suffer other inflammatory sequelae,
such as chronic cystoid macular edema. The significant damage
to the trabecular meshwork, as well as possible peripheral synechia,
Figure 48-5 Severe toxic anterior segment syndrome with permanent
damage showing marked corneal edema and residual chronic anterior segment
inflammation. Copyright 2006, with permission from Elsevier.
Toxic Anterior Segment Syndrome 48
may lead to a very difficult to control glaucoma, which is often
resistant to treatment. Damage to the iris may also lead to a fixed,
dilated pupil with significant iris thinning.
▪ ANALYSIS OF TOXIC ANTERIOR
SEGMENT SYNDROME OUTBREAKS ▪
The issue of cleaning and sterilization of instruments has been
found to be increasingly related to outbreaks of TASS. Therefore,
it is important to analyze how instruments are not only sterilized
but also, just as importantly, cleaned prior to actual sterilization.
The first step in the proper cleaning of instruments involves
flushing or cleaning off any reusable instruments or cannulas at
the conclusion of the previous case prior to final sterilization. It
PREVENTION OF TOXIC ANTERIOR SEGMENT SYNDROME
is important that any reusable cannulas, handpieces, or tips from
phacoemulsification or I–A handpieces be thoroughly flushed at
the conclusion of each case. It is important that any residual
cortex or OVDs be removed prior to allowing them to dry on
the instruments. Many manufacturers recommend that at least
120 cc of sterile, deionized, or distilled water be used to thor-
oughly flush through all handpieces. It is also important that all
instruments which have received any other treatments prior to
sterilization undergo a thorough final rinse, once again with
sterile deionized water prior to autoclaving or final sterilization.
Processes used for the cleaning of instruments prior to sterilization
should also be carefully evaluated. The use of enzymes or detergents
for the cleaning of instruments should be re-evaluated, as the use of
these materials have the potential to cause TASS. It is unclear
whether it is necessary to use either enzymes or detergents following
routine ophthalmic surgery, as ophthalmic instruments do not nor-
mally have a large bioburden or large amounts of tissue attached to
them following surgery. If possible, consideration should be given
to the elimination of the use of enzymes or detergents for the clean-
ing of ophthalmic instruments. Similarly, the use of ultrasound water
baths may not be necessary because once again, ophthalmic instru-
----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
ments do not tend to have large bioburdens on them. If ultrasound
water baths are used, they should be drained and thoroughly cleaned
on a regular basis to prevent the buildup of Gram-negative bacteria
and possible endotoxin contamination.
Care should be taken to completely review all of the medica-
tions that are used in the cataract surgery and its aftermath. It
is important that confirmation be obtained that the anesthetics
used intracamerally are preservative free and of the proper dose.
In addition, any additives to the BSS, such as epinephrine, should
not only be preservative free but should also be bisulphite free. If
any intracameral antibiotics or antibiotics in the BSS are used, the
proper dosing and dilution of these medications should also be
confirmed. Both are off label uses in cataract surgery.
▪ PREVENTION OF TOXIC ANTERIOR
SEGMENT SYNDROME ▪
Since TASS has the possibility of causing significant ocular
morbidity, major effort should be focused on the prevention of
TASS. It is imperative that surgical centers and hospitals have
protocols in place regarding the cleaning and sterilization of
instruments and that the entire surgical staff involved in this
593
vii Management of Complications
process is aware of the protocols. It is crucial that the entire sur-
gical team including nurses, operating room technicians, physi-
cians, and pharmacists are aware of what is appropriate for use
in ophthalmic surgery and that they be educated about protocols
that are in place. The TASS task force investigations of outbreaks
of TASS at various surgical centers found that often there were
not adequately established protocols in place for the cleaning,
processing, and sterilization of instruments. The level and inten-
sity of cleaning of instruments often depended on who was doing
the cleaning of the instruments on a particular day and it was
often obvious that there were not well-established guidelines in
place for the surgical staff.
To help increase the awareness of TASS and to help guide in
the prevention of this complication, the Ad Hoc TASS Task
Force has taken several steps to create educational materials for
PREVENTION OF TOXIC ANTERIOR SEGMENT SYNDROME
surgeons and surgical staff. A video symposium discussing the
findings of TASS, etiological factors, and possible ways to pre-
vent TASS comprised of members of the Task Force, as well as
representatives from ophthalmic nurse's organizations is available
at www.TASSFacts.com.
In addition, the members of the Ad Hoc TASS Task Force were
involved in a symposium held at Emory University in the fall of 2006
with representatives from the major ophthalmic nurses associations,
as well as other personnel with expertise in the cleaning and steriliza-
tion of ophthalmic instruments. Input was also obtained from other
organizations such as the Centers for Disease Control (CDC) and
the Food and Drug Administration (FDA) regarding the develop-
ment of proper guidelines for the cleaning, sterilization, and proces-
sing of ophthalmic instruments. These guidelines are now available
to surgeons and their staff on the ASCRS website (www.ASCRS.
org), as well as the ASORN website and were disseminated with
the March 2007 issue of the Journal of Cataract and Refractive Sur-
gery. These guidelines should help the surgeons and their staff in
the critical process of cleaning and sterilization of instruments with
the goal of preventing further TASS outbreaks.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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