Surgical Instrument Care and Toxic Anterior Segment Syndrome

Key Points

All personnel involved in the handling of intraocular surgical instruments should adhere to established protocols to ensure that the instruments are safely prepared for use.
Although many general principles of cleaning and sterilization of surgical instruments apply to intraocular instruments, there are important distinctions that must be made because of the unique characteristics of the eye and intraocular surgery.
Some important considerations include the risks of routine enzymatic detergent and ultrasonic water bath use.
In cases of acute postoperative inflammation, surgeons must quickly differentiate TASS from bacterial endophthalmitis.
When a case of TASS is recognized, it is important to identify the cause to prevent more cases from occurring. The most commonly identifiable cause of TASS is inadequate cleaning and sterilization of surgical instruments.

Introduction

Toxic anterior segment syndrome (TASS) and postoperative endophthalmitis (POE) are rare, but potentially blinding, complications of cataract surgery. TASS is caused by the introduction of a toxic, noninfectious substance into the anterior chamber. POE is caused by the propagation of an infectious pathogen, most commonly bacteria, inside the eye. The risk for both conditions can be minimized with proper care of intraocular surgical instruments.

Although most general recommendations for surgical instrument care also apply to intraocular instruments, some accepted practices may be dangerous for patients undergoing cataract surgery because of unique characteristics of the eye and intraocular surgery. This issue of patient safety was recognized and addressed with the formation of the Ophthalmic Instrument Cleaning and Sterilization (OICS) Task Force. Composed of representatives from the American Society of Cataract and Refractive Surgery (ASCRS), American Academy of Ophthalmology (AAO), and Outpatient Ophthalmic Surgery Society (OOSS), the OICS Task Force collaborated on a set of specialty-specific guidelines outlining minimum standards of intraocular surgical instrument care.

Improper surgical instrument care is the most common identifiable cause of TASS, which is an acute, sterile, postoperative inflammatory response to a toxic substance in the anterior chamber.
Unlike POE, the inflammation in TASS is sterile because the toxic substance is not a microbial pathogen.
Specific inciting substances that have been identified in cases of TASS include enzymatic detergents, bacterial endotoxins, denatured ophthalmic viscoelastic devices (OVDs), ocular medications, preservatives, and intraocular solutions incompatible with eye tissue preservation.
Common exam findings include diffuse “limbus-to-limbus” corneal edema, severe anterior segment inflammation, and fibrin formation.
The goal of treatment is to suppress inflammation and prevent long-term inflammatory sequelae with intense topical corticosteroid therapy.
A thorough investigation of the source of contamination should commence once a case of TASS is discovered to prevent more cases from occurring.

This chapter reviews guidelines for surgical instrument care and clinical information on TASS.

Surgical Instrument Care

All intraocular instruments used during cataract surgery are critical items and must be cleaned and sterilized. Because of the small size of the eye, intraocular instruments rank as some of the smallest surgical instruments. Because of the nature of surgery, used cataract surgical instruments carry a low tissue and bacterial burden compared with procedures on other body parts. The eye’s small size and sensitivity to toxins make it especially susceptible to both iatrogenic and infectious contaminants. Even trace amounts of toxins that might be well tolerated in other body cavities can cause TASS in the eye. As a result, some accepted instrument care practices should be avoided or used with caution for cataract surgeries. Lastly, cataract surgery can be performed quickly and at high volumes relative to most other surgical procedures. Consequently, efficient instrument turnover must be accomplished while maintaining the integrity of the sterilization process. This chapter focuses on recommendations intended to maximize the sterility of intraocular surgical instruments while minimizing the risk for introducing toxic substances to the eye which can cause TASS.

General Principles

There are many steps that must be taken before the actual processing of instruments to prevent future surgical complications.

All surgical facilities should establish a set of clearly written protocols for instrument cleaning and sterilization.
During the creation of these “policies and procedures,” input from all groups of personnel involved in the handling of surgical instruments should be considered.
Written protocols should be derived from current industry standards and manufacturer’s instructions for use (IFU).
Given the diversity of ophthalmic surgical products and instruments, physicians and nursing staff should be able to adjust written protocols with guidance from the best available clinical evidence.
Upon completion, the written protocols should be approved by the facility’s governing body.
Updated facility protocols and equipment IFUs should be made readily available to all operating room (OR) and instrument processing staff.
The policies and procedures should be reviewed annually and when any new instruments or equipment is acquired.

After cleaning and sterilization protocols are established, all personnel involved in the handling of surgical instruments should be educated on the general principles of asepsis and trained on the proper mechanics of intraocular instrument processing.

This training should cover cleaning, inspection, preparation, packaging, sterilization, storage, and distribution of relevant instruments or machines.
Appropriate personnel should also undergo any other training needed to do their job, such as the operation and maintenance of machines.
Continued competency should be checked with performance evaluations completed annually and whenever any new instruments or equipment are acquired. The results of the competency evaluations should be recorded and saved for future reference.

TASS and POE are rare, but significant, postoperative complications of cataract surgery that may be attributed to improper instrument processing. OR staff should understand the causes and precautionary measures that can be taken against both conditions. A facility’s incidence of TASS and POE should be tracked to judge the effectiveness of the written protocols and the successful completion of the described procedures. An increase in frequency of either condition necessitates an early and thorough investigation to find the cause to prevent a larger outbreak. The investigation should include a review of medication, instrument, and equipment use, as well as maintenance and inspection records. Hence, accurate documentation consistent with facility policies can help prevent more cases of TASS and POE.

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