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Initially referred to as sterile endophthalmitis or postoperative uveitis of unknown cause. Accurately termed TOXIC ANTERIOR SEGMENT SYNDROME (TASS)by Monson et al in 1992. Toxic endothelial cell destruction (TECD) syndrome : a variant of TASS with localized endothelial damage.
TOXIC ANTERIOR SEGMENT SYNDROME Sterile, acute postoperative inflammatory reaction in which a noninfectious substance enters the anterior segment and induces toxic damage to the intraocular tissues that may occur following any anterior segment surgery.
Outbreak of toxic anterior segment syndrome after vitreous surgery
Arch Soc Esp Oftalmol. 2009 Aug;84(8):403-5. Andonegui J, Jiménez-Lasanta L, Aliseda D, Lameiro F. Servicio de Oftalmología, Hospital de Navarra, 31008 Pamplona, España.( email@example.com) 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 other anterior segment procedure. DISCUSSION: Toxic Anterior Segment Syndrome is a sterile postoperative inflammation due to any non infectious substance that reaches the anterior segment during surgery. It occurs in outbreaks and while most of the cases have been reported after anterior segment procedures, this case demonstrates that development after vitreoretinal surgery is also a possibility.
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 intravitreal injection 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, were reviewed. MAIN OUTCOME MEASURES: Incidence of intraocular inflammation, results of bacterial cultures, bestcorrected visual acuity (BCVA), and endothelial cell density. RESULTS: Five (14.3%) of the 35 cases had severe intraocular inflammation, and the inflammation had some 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 samples collected 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 the endothelial 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). These differences were not significant (P = 0.171 and 0.964). CONCLUSIONS: These observations indicate that an intravitreal injection of bevacizumab can induce sterile endophthalmitis that has characteristics of TASS.
TASS results from the inadvertent entry of toxic substances 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 the severe acute inflammatory response. The corneal endothelium is often the most damaged structure because of its inability to regenerate and replace dead cells. Trabecular meshwork damage - IOP
The hallmark of TASS is an inflammatory reaction in the anterior segment of the eye that starts within 12 to 48 hours after surgery. The most common clinical findings in patients are (1) diffuse, limbus-to-limbus corneal edema, (2) increased inflammation in the anterior chamber with hypopyon 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.
Clinical course :
± Mild presentation : rapid clearing of the corneal edema with no long-term corneal or trabecular damage and normal or near normal visual acuity. ± Moderate presentation : persistent corneal edema that will take several weeks to clear, intraocular pressure that is difficult to control, and a moderate effect on visual acuity. ± Severe presentation of TASS : marked corneal edema that does not clear, iris and trabecular meshwork damage with resultant glaucoma, and possible cystoid macular edema. Visual outcome is usually poor despite medical or surgical intervention.
TASS VERSUS ENDOPHTHALMITIS
TASS Vs ENDOPHTHALMITIS
1. TIMING OF THE DISEASE 2. PAIN
TASS Vs ENDOPHTHALMITIS
3. CONJUCTIVAL & LID REACTION 4. CORNEAL EDEMA
TASS Vs ENDOPHTHALMITIS
5.IRIS FINDINGS 6. IOP
TASS Vs ENDOPHTHALMITIS
7. THERAPEUTIC RESPONSE
Noninfectious reaction to toxic agent present in: BSS solution Antibiotic injection Endotoxin Residue 12-24 hours Blurry vision Pain: none, or mild to moderate Corneal edema: diffuse, limbus to limbus* Pupil: dilated, irregular, nonreactive* Increased IOP* Anterior chamber: mild to severe reaction with cells, flare, hypopyon, fibrin Signs and symptoms are limited to anterior chamber* Gram stain and culture negative Rule out infection Culture anterior chamber Intensive corticosteroids Monitor IOP closely for signs of damage to trabecular meshwork and side effects of steroids Watch closely over next few hours for signs of bacterial infection
Bacterial, fungal, or viral Infection
ONSET SIGNS/SYMPTO MS *distinguishing feature
4-7 days Decreased VA Pain (25% have no pain) Lid swelling with edema Conjunctival injection Hyperemia Anterior chamber: marked inflammatory response with hypopyon Vitreous involvement Inflammation in entire ocular cavity* Culture anterior chamber and vitreous Intravitreal and topical antibiotics Vitrectomy
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 to suck the antibiotic back inside the eye)
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 in India) 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
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 and cannulated instruments - flushed into the next patient s eye Irritants from deterioration of instruments due to re-processing: re-usable equipment and reused 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 next patient s eye (e.g. contaminated ultrasonic cleaning solution with Klebsiella pneumoniae bacteria ) Oxidized metal deposits/residues on instruments from Plasma Gas Sterilization System Ethylene oxide gas residue on instruments from using E.O. Sterilization Method
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 extraction and posterior chamber implantation of the MemoryLens® intraocular lens (IOL). Methods : This retrospective study evaluated 10 cases of postoperative inflammation that occurred after cataract extraction with placement of the posterior chamber MemoryLens IOL. Protocols of the Intermountain Ocular Research Center used to analyze outbreaks of unexplained postoperative inflammation as well as medical records were reviewed. Results : Nine patients had uneventful cataract extraction and 1 had a small anterior capsule tear with placement of the MemoryLens IOL. All 10 patients presented with increased anterior segment inflammation a mean of 7.8 days (range 1 to 21 days) after surgery. Three cases were tapped and were culture 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 the inflammation has not revealed an obvious etiology; however, the MemoryLens was associated with all the cases. Conclusions : We postulate that these cases of noninfectious postoperative endophthalmitis may be associated with the MemoryLens.
Outbreak of toxic anterior segment syndrome associated with glutaraldehyde after cataract surgery
Ünal M, Yücel 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 segment syndrome (TASS) after uneventful phacoemulsification cataract surgery. Setting: Department of Ophthalmology, Akdeniz University, Antalya, Turkey. Methods: Six eyes of 6 patients developed TASS after uneventful phacoemulsification cataract surgery with implantation of a 3-piece acrylic IOL performed by 2 ophthalmologists on the same day. Clinical findings included corneal edema, Descemet's membrane folds, anterior chamber reaction, fibrin formation, and irregular, dilated, and unreactive pupils. Results: Glutaraldehyde 2% solution was used inadvertently by the operating room staff who cleaned and sterilized reusable ocular instruments before autoclaving. None of the affected corneas improved. Additional surgical procedures were required and included penetrating keratoplasty, trabeculectomy, and glaucoma tube implantation. Conclusions: Glutaraldehyde in concentrations generally used for cold sterilization is highly toxic to the corneal endothelium. The operating room staff involved in sterilizing instruments should be well educated about and careful to follow the protocols to properly clean and sterilize reusable ocular instruments.
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, Ross MJ, 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 were reviewed, 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 steam condensates were analyzed by use of spectroscopy and ion chromatography. RESULTS: During the outbreak, 8 (38%) of 21 cataract operations were complicated by TASS, compared with 2 (0.07%) of 2,713 operations performed from January 1996 through November 2002. Results of an initial investigation suggested that cataract surgical equipment may have been contaminated by suboptimal 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 reprocessing procedures. 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 autoclave steam generator in the outpatient surgical center. When impurities in autoclave steam moisture were eliminated, 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 result from inappropriate maintenance of steam sterilization systems. Standardization of protocols for reprocessing of cataract surgical equipment may prevent outbreaks of TASS and may be of assistance during outbreak investigations.
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, Nash WA, 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 clear corneal incisions with implantation of the same 3-piece silicone IOL design. Postop medications included antibiotic/steroid ointment and pilocarpine gel; each eye was firmly patched at the end of the procedure. On 1st POD, some patients presented with diffuse corneal 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 the anterior chamber, which was later seen coating the IOL. Additional surgical procedures required included penetrating keratoplasty, IOL explantation, and trabeculectomy. 2 corneal buttons were analyzed histopathologically. 2 explanted IOLs had gross and light microscopic analyses (as well as surface analyses of 1 of them), and 4 other explanted IOLs had gas chromatography-mass spectrometry.
RESULTS: Pathological examination of the corneas showed variable thinning of the epithelium with edema. The stroma was diffusely thickened and the endothelial cell layer was absent. Evaluation of the explanted IOLs confirmed the presence of an oily substance coating large areas of their anterior and posterior optic surfaces. Gas chromatographymass spectrometry of the lens extracts identified a mixed chain hydrocarbon compound that was also found in the gas chromatographymass spectrometry analyses of the ointment used postoperatively. CONCLUSIONS: The results indicate that the ointment gained access to the eye, causing the postoperative complications described. These cases highlight the importance of appropriate wound construction and integrity, as well as the risks of tight eye patching following placement of ointment.
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 toxic anterior segment syndrome. RECENT FINDINGS: Toxic anterior segment syndrome has emerged within the last 2 years as a complication of increasing frequency following uneventful cataract surgery. Over 100 North American clinics reported toxic anterior segment syndrome cases to a specially constituted task force over a 4-month period in 2006. Toxic anterior segment syndrome is now recognized as a specific, noninfectious condition presenting as anterior segment inflammation that occurs within days of surgery and is responsive to topical steroids. Specific causes have been identified such as endotoxin contamination of balanced salt solutions and antibiotic ointment accessing the anterior chamber, although most cases appear to result from inadequate instrument sterilization and preparation. Outcomes are usually excellent, but delayed treatment and severe cases may result in glaucoma and persisting corneal edema requiring penetrating keratoplasty. SUMMARY: Toxic anterior segment syndrome has become a significant complication of cataract surgery. Rapidly increasing knowledge made possible by ophthalmic organizations and the prompt dissemination of research findings, however, appear to have provided the information necessary to help prevent and resolve this condition.
Toxic anterior segment syndrome after cataract surgery--Maine, 2006.
MMWR (Morb Mortal Wkly 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 the anterior segment of the eye, is a complication of anterior segment eye surgery; cataract extraction 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 syndrome typically develops within 24 hours after surgery and is characterized by corneal edema and accumulation of white cells in the anterior chamber of the eye. Although most cases of TASS can be treated successfully with topical steroids, topical nonsteroidal antiinflammatory agents, or both, the inflammatory response associated with TASS can cause serious damage to intraocular tissues, resulting in vision loss. In October 2006, the Maine Department of Health 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 CDC investigated the cluster and worked with the treating ophthalmologist and the hospital to prevent additional cases. This report describes the results of that investigation and the subsequent prevention measures implemented. Although the specific cause of the outbreak was not identified, no additional cases were reported after two series of changes were made to the materials and equipment used for surgery. Prevention of TASS requires careful attention to solutions, medications, and ophthalmic devices and to cleaning and sterilization of surgical equipment because of the numerous potential causes of the condition.
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, Edelhauser HF, 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 a national TASS referral center. Information on the procedure, details of instrument reprocessing, and products used during cataract surgery were also collected. Medications used during the procedures were tested 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%), anterior segment inflammation (49%), and cell deposition (56%). Of the patients, 100 (89%) had been exposed to a single brand of balanced salt solution manufactured by Cytosol Laboratories and distributed by Advanced Medical 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 salt solution lots, 5 (35%) had levels exceeding the endotoxin limit (0.5 EU/mL). Based on these findings, the balanced 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 a product with endotoxin. Ophthalmologists and epidemiologists should be aware of TASS and its common causes. To facilitate investigations of adverse outcomes such as TASS, those performing cataract surgeries should document the type and lot numbers of products used intraoperatively.
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 phaco surgery. METHODS: We retrospectively reviewed the charts of patients who had developed toxic anterior segment syndrome (TASS) after uneventful phacoemulsification for senile cataracts between April and December of 2005. Clinical features and all possible causes were investigated including irrigating solutions or drugs, surgical instruments or intraocular lenses, sterilization techniques for instruments, or any other accompanying disease. RESULTS: The patients consisted of 2 males and 13 females with an average age of 64.7+/-10.9 years. Five different surgeons had performed their phaco surgeries. No abnormal preoperative or operative findings were reported. Nevertheless, all 15 patients developed a moderate degree of corneal edema. Ordinary treatments 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 incidents have occurred. CONCLUSIONS: Toxic anterior segment syndrome requires special attention and thorough management, including sterilization of reused surgical instruments.
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 Chapel Hill, 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 capsule at the conclusion of routine phacoemulsification to prevent an outbreak of toxic anterior segment syndrome (TASS). METHODS: After coaxial phacoemulsification in multiple patients, opaque material was present between the optic of a posterior chamber IOL and the posterior capsule. Although there was no TASS, the material was 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%-chondroitin sulfate 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 and the 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, and calcium and a higher carbon background than the unknown material. CONCLUSIONS: The material was likely ophthalmic viscosurgical device that was chemically and structurally altered by the cleaning and sterilization process. The silicone and metallic elements were probably from the Emerald Series implantation system as the disposable cartridge is coated with silicone and the reusable injector is metal.
Toxic Anterior Segment Syndrome (TASS): studying an outbreak
Farm Hosp. 2008 Nov-Dec;32(6):339-43. Sarobe Carricas M, Segrelles Bellmunt G, Jiménez Lasanta L, Iruin Sanz A. Servicio de Farmacia, Hospital de Navarra, Pamplona, España. firstname.lastname@example.org 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 process which 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 methods applied to the materials were analyzed, as well as the drugs and substances used which might have caused the outbreak. We verified the substances prepared by the Pharmacy Department, specially the 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 that the outbreak would be related to the washing process performed previously to the sterilization of the instrumentation used in the surgery, mainly because the recommendation to use distilled and sterile water for this purpose was not followed and, on the contrary, tap water continued to be used.
Toxic Anterior Segment Syndrome Following Penetrating Keratoplasty
Philip Maier, MD; Florian Birnbaum, MD; Daniel Böhringer, MD; Thomas Reinhard, MD . Arch Ophthalmol. 2008;126(12):1677-1681. Objectives To describe an outbreak of toxic anterior segment syndrome (TASS) following penetrating 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. In addition to routine microbial tests on organ culture media, we looked for specific pathogens and endotoxins in all of the materials used for organ culture or PK. Furthermore, we analyzed all of the perioperative products and instrument processing. Results Of the 94 patients who underwent PK, we observed 24 cases of postoperative sterile keratitis. Causal research revealed that the accumulation of cleaning substances or heatstable endotoxins 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 instruments may be an important cause of TASS as in this series the TASS-likesymptoms resolved after modified instrument-cleaning procedures. The standardization of protocols for processing reusable trephine systems might prevent outbreaks of TASS following PK.
Toxic anterior segment syndrome following irissupported phakic IOL implantation with viscoelastic Multivisc BD.
Eur J Ophthalmol. 2009 Nov 30. [Epub ahead of print] Kremer I, Levinger E, Levinger S. TA University, Tel Aviv; and "Enaim" Medical Center - Jerusalem and Sackler School of Medicine, Jerusalem - Israel. Purpose. To report on the association between Multivisc BD and toxic anterior segment syndrome (TASS) post phakic intraocular lens (IOL) implantation. Methods and Patients. Two patients developed severe toxic anterior chamber inflammation following implantation of phakic iris fixated IOL with Multivisc BD viscoelastic. Anterior chamber washout was performed with intracameral antibiotic injection. Local antibiotics were continued until cultures were found to be negative. Thereafter, intensive local and systemic steroids were initiated and gradually tapered down. Results. The inflammatory reaction disappeared completely and the visual acuity improved from hand motion to 6/9 without correction within 1 week. Conclusions. Any viscoelastic material may be contaminated by heat-stable bacterial endotoxic as it is prepared by gene-coded bacteria. It is suggested that Multivisc BD was the etiologic factor of TASS. Refractive surgeons should be aware of this rare complication of phakic IOL implantation whenever they use a new viscoelastic material.
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 cornea penetrating injury. Three cases were caused by residual povidone iodine on instruments, 2 cases resulted from the misuse of distilled water as intraocular irrigating liquid during cataract surgery, 2 cases were produced by the countercurrent of antibiotic solution via the cornea-scleral incision into anterior chamber during subconjunctival injection at the end of the surgery, and 1 case was induced by the injection of the distilled water into the anterior chamber at the end of the surgery. Three TASS cases occurred during operation and 5 cases occurred at 1 day after operation. All eight cases suffered from the painless blurred vision. Three cases occurred during operation presented with decrease of corneal transparence and depigmentation 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 day or one time per hour was used in all cases. Carteolol 2% eye drop, two times per day, was used for the cases with ocular hypertension. The cornea was clear in 6 cases, but corneal endothelial decompensation in 2 cases after therapy. CONCLUSION: Various toxic agents injected into anterior chamber by misuse can result in TASS. All these misuse can be avoided. Early diagnosis and proper management may be important to improve the prognosis of TASS.
Toxic anterior segment syndrome after uncomplicated cataract surgery.
Eur J Ophthalmol. 2010 Jan-Feb;20(1):106-14. Ozcelik ND, Eltutar K, Bilgin B. Ophthalmology Department, Istanbul Education and Research Hospital, Istanbul, Turkey. PURPOSE: To evaluate the anterior segment examination findings and the response to medical therapy of patients who had toxic anterior segment syndrome (TASS) after uncomplicated cataract surgery. METHODS: Fourteen eyes of 14 patients were enrolled in the study. Visual acuity, biomicroscopic anterior segment examination, intraocular pressure measurement, and fundus examination were performed to assess TASS occurring during postoperative 12-48 hours after uncomplicated phaco surgery. The visual impairment, corneal edema, tyndallization, fibrin formation, hypopyon, vitritis, and response to steroid therapy were evaluated prospectively. RESULTS: After topical steroid therapy lasting for 1 week, visual acuity improved in 11 eyes. No significant visual improvement occurred in 3 eyes. Significant corneal edema was found in 4 and mild corneal edema was observed in the other 10 eyes. Fibrin reaction occurred in 5 and tyndallization in various degrees was positive in all eyes. There was a 1-mm hypopyon in 1 patient. There was no sign of vitritis and steroid therapy was effective in all of the patients. In addition to topical treatment with steroid and antibiotic drops; systemic and subconjunctival steroids were used in 3 patients who had fibrin formation and in one patient who had hypopyon . CONCLUSIONS: After uncomplicated cataract surgery, toxic anterior segment may occur in the early postoperative period, which is treated successfully with steroids. More studies are needed to understand the multifactorial risk factors affecting the etiopathogenesis of this syndrome.
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, Associate Professor & Visiting Eye Surgeon,Dr. Mir Zaman, Senior Registrar,Dr. Mohammad Younas Khan, Consultant Ophthalmologist,Dr. Anwar Iqbal & Dr. Naz Jehangir Postgraduate Trainees Pakistan Institute of Community 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 to emphasize importance of its early diagnosis, appropriative treatment and prevention which is all the more important. PATIETS and MATERIALS: We had two outbreaks of TASS at two different occasions in 2007-08 after routine cataract extraction with posterior chamber implant. We retrieved clinical records of all patients and collected information on a specially designed performa. Details of postoperative signs and symptoms and treatment were recorded. All the patients were followed up for at least 3 months. We also looked at methods 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. All the patients were successfully treated. Final visual acuity was 6/6 in 7 patients, 6/9 in 3 patients and 6/18 in 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 of onset and sparing of posterior segment are important factors for diagnosis along with other clinical features. Early and intensive treatment with topical steroids, cycloplegics and oral anti-inflammatory drugs can resolve the condition and visual acuity can improve to preoperatively expected levels.
When reports of toxic anterior segment syndrome (TASS) in North America suddenly began to escalate to five times their normal level early in 2006, the American Society of Cataract and Refractive Surgery (ASCRS) provided support for a task force convened to investigate the reasons why and develop recommendations for reducing its incidence. Analysis of the data the task force assembled failed to reveal any single cause of the outbreak and, 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 the instruments used in cataract surgery appears to be a critical factor in reducing the risk of TASS. The team came up with this Special ASCRS/ASORN Report: Recommended Practices for Cleaning and Sterilizing Intraocular Surgical Instruments . Guidelines : Establish written protocols for instrument cleaning and reprocessing, certify competency of responsible personnel, and monitor compliance Use only medications and solutions that are free of preservatives, bisulfites, or metasulfites.
Medical Care Once TASS is confirmed, patients should be started on topical steroids. Careful assessment and treatment of elevated IOP. Nonsteroidal antiinflammatory drops. Close follow-up.
RULE OUT ENDOPHTHALMITIS
Surgical Care Intraocular lens exchange. Corneal transplantation. Trabeculectomy (seton valve procedures).
1980 1992 2000 2002 2005 2006 2006 2006
Sporadic reports of severe anterior segment inflammat ion following cataract surgery Condition termed Toxic Anterior Segment Syndrome (TASS) Monson et al. JCRS 1992 Delayedonset TASS associate d with Memory Lens softened city water that supplied the autoclave steam generator (sulphate impurity) October Increasing reports of sterile Inflammat ion linked to BSS(Endo sol) TASS at Communi ty Hospital in Maine Numerou s eye centers in North America reported an increase incidence of TASS following Outpatien t cataract surgery ASCRS created a TASS Task Force to investigat e outbreaks of TASS and identify causative agents
³Just because something is sterile, it does not mean it¶s not toxic!´
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