Lecture: Toxic Anterior Segment Syndrome: Etiology and Prevention

[Lori] Thank you for joining me this beautiful Monday. Good morning, good afternoon, good evening to all our partners and friends around the world. I’m happy you joined me today. My name is Lori, I am a nurse. I do have a special interest in infection control. I certainly have seen my share of TASS.

We’re going to be sitting here for the next hour and just discussing toxic anterior segment syndrome. We’re going to talk about the factors that attribute to TASS. We’re going to talk a little bit about TASS versus endophthalmitis, give you a good understanding of the difference. The strategies in the prevention of TASS, and methods for investigating an outbreak, doing a quality insurance study.

From the beginning, TASS, what is TASS? TASS is an acute, severe, intraocular inflammation of the anterior segment after intraocular surgery. We used to, years ago, call it sterile endophthalmitis, I’m not sure if that’s the best term to be using. But it is a sterile, post operative inflammatory reaction. It’s non-infectious. And the reaction is caused by a non-infectious substance that enters the anterior segment of the eye.

The onset of TASS is very important. The onset and the involvement of vitreous this can help differentiate TASS from infectious endophthalmitis. TASS typically starts within 24 hours after surgery, usually you can see 24-48 hours. But it can vary, that can vary from hours to days and can go even further so you really can’t use that as written in stone, but it just gives you a good indication how you can differentiate between TASS and then endophthalmitis. In cases of TASS related to IOL contamination you can see an onset of over a month. But typically TASS involves post operatively, you’re going to see it between 24 to 48 hours after surgery.

These are your symptoms. These are usually standard, classic symptoms. You could have pain, you could have absence of pain, you could certainly have TASS without any pain at all. Marked decrease in vision, you can get photophobia, acute severe inflammatory reaction, as I mentioned, in the AC within 12-48 hours after surgery. Typically you’re going to see corneal edema, it’s going to go from limbus to limbus. You could see a dilated or an irregular pupil. Your IOP’s going to be increased, you’re going to get hypopyon, you’re going to get lack of bacterial or fungal growth. This is really important to note, your lack of bacterial or fungal growth in cultures of your taps. And typically TASS responds very well to topical steroids and drops.

The etiology, how do we get TASS? Where does TASS come from? There are so very many ways and I know many of us are used to hearing and we’re going to go into that about contamination of your instruments and flushing and making sure you’re getting all of your debris off your instruments, but there’s also other means for getting TASS. Contaminated BSS, endotoxins that can be in the BSS. And we’re going to go into how to do a study to determine if it was the BSS, but that can certainly be an indication. Any kind of intraocular irrigating solutions that may have an abnormal pH, osmolarity, or ionic composition. Very important, your viscoelastic agents, intraocular medications when you’re putting antibiotics in the irrigation solution. I know years ago we used to put vancomycin in all of our bottles with epi. I’m not sure if some of you are still doing that practice, but we did stop that practice because of the risk of TASS. But antibiotics in irrigation solution, or intracameral antibiotics as well. You also have your topical ointments and preservatives. Remember, you have an incision basically while you’re doing cataract surgery. There is the chance that your topical ointments or any type of medication that has preservatives in it can get inside of that wound and can get in the AC. Your topical ointments and your preservatives are important.

Your metallic precipitates, glove powder, when you’re touching the tips of instruments, or your IOLs. If your scrubs, as they’re loading that IOL for you, are they using gloves with powder in them? Are they holding the IOL and then trying to load it that way, are they somehow getting the tips of those instruments that are going to go into the AC and you possibly could get that glove powder onto your instrument. Water quality is a big one, I know it can be difficult in some areas with your water quality. Water quality is a very big topic when it comes to cleaning instruments. When it comes to rinsing instruments you want to be sure of the right water quality. And we’re going to get into that as well. Ultrasonic baths, we’re going to talk about. Reuse of single-use devices, there are devices that are not meant to be resterilized. This is very important. And then, of course, you breakdown in the standard sterilization practices.

Inadequate sterilization of surgical instruments and tubing. I think this is what most of us are used to seeing when it comes to TASS. Inadequate flushing of instruments between cases resulting in that build-up of viscoelastic. Irritants on the surface of ophthalmic instruments that can accumulate from inadequate or inappropriate instrument cleaning. The inappropriate use or incomplete rinsing of detergent absolutely has been associated with TASS. And that’s what we’re going to discuss mostly because I think this is where many of us have seen our cases of TASS.

All right. Let’s start with your autoclave. I know many of you have tabletop autoclaves. Bacterial biofilm that’s a contamination in the autoclave reservoir. If your autoclaves work by, you have your reservoir and you’re filling that reservoir with water. Those reservoirs can produce heat-stable bacterial toxins that can contaminate your instruments during the autoclaving process. Let’s talk a little bit about this. How are you cleaning your reservoirs? Oh my goodness, I remember many years ago, we had tabletop sterilizers that we used to use for minor procedures. We could also use them in the OR as well and they weren’t very easy to clean. And you have your little tubing and we’d unlock the lock on it and the water would flow out. But you always had that film on the bottom of that reservoir. How are you cleaning that? We couldn’t get anything in there to clean it and I can remember people attempting to tip these things upside down to try to rinse out and clean these sterilizers. It was very difficult.

How are you cleaning your reservoirs? Is it easily accessible and cleanable? Can you get in there, can you clean them? Are you just let go into the flow of water to flow out and that’s it? Are you cleaning them once a day, are you cleaning them at the end of every day? Are you starting off each day with an empty reservoir stocked fresh with new water, are you using the same water from yesterday?

And then the water quality. What are you using? We’re going to talk about IFUs, instructions for use, manufacturer’s instructions. What does the manufacturer say you have to use in your reservoirs for that sterilizer? Is it, we call it critical water, is it treated, is it sterile water? Typically it’s not tap water, but what is the water quality that you’re putting in there, what is it saying that you need to use for that reservoir. But more importantly how does it tell you to clean it? What does it tell you to use? Is it asking you to use alcohol? Okay. I have seen some that tell you to rinse with alcohol but then after you do that you have got to be sure that you are running loads and rinsing and rinsing and rinsing and getting rid of whatever cleaner it’s telling you to use.

These are all important things. You need to follow your IFUs, your manufacturer’s instructions and be using what it’s telling you to use. But being sure that you’re thorough, really take a good look at how you’re cleaning your reservoirs. Is it easily cleanable? And if it’s not, you really take a good look at your sterilization processes and what you could be using to assure that whatever you’re using to sterilize your equipment is easily cleanable.

Your ultrasonic machines, this is a big one. Just like your sterilizers, heat stable endotoxins from this overgrowth of gram-negative bacilli in the water of ultrasonic cleaners. This is another cause of TASS. How are you emptying the water chamber in your sonic machines? This is one example, I just threw this in here. But you can have small ones, little ones, large ones. Either way they have to be emptied out. Same thing. Most of them have a tubing that you let go of and the water just flows out. Okay, you’re still left with that film of water on the bottom. How are you rinsing that out? How often are you rinsing that out? Not only how are you emptying it, but how are you cleaning it? Are you doing it in between patients, are you doing it once a day? What does your IFU tell you? Most of them tell you you should be doing it after every use. You’re cleaning it completely, you’re disinfecting it, washing it down and then you’re starting fresh again. I know some facilities do that once a day.

You need to look at your IFUs and you need to decide policies and procedures. You need to have a protocol. Have it written right there in front on the wall of somewhere, in the sterile processing area, this is how we clean our sonic machines. But most importantly make sure everyone is doing it the same way. Consistency. No deviation in your protocol, everyone should be doing it the exact same way. And this is one of the things we’ll discuss when we talk about quality insurance studies because typically when you see TASS, you’re going to see somewhere along the line somebody deviated from protocol. They thought, “Oh, I think it’s cleaned better this way. I think if I do it this way, we’re going to have a much better result.” And now you’ve deviated away from protocol and this is often how you can see TASS come about.

Really take a good look at your procedures for cleaning your sonic machines and making sure that you’re emptying that water chamber as well as you can. Make sure you follow your IFUs, make sure you have a good protocol for cleaning it, how often you’re cleaning it and that every person is trained correctly on it and that you have consistency, everybody is doing it the same way.

Viscoelastic. These are your ophthalmic viscosurgical devices, your OVDs. Contamination or denaturation. Really what that is is that the process of modifying the molecular structure of a protein. Basically what denaturation means is it involves the breaking of many of the bonds within a protein, within that protein molecule which is responsible for the structure of the protein in its natural state. Basically it means you’re taking away its natural quality. Contamination of the viscoelastic can certainly be a potential cause of TASS. Often it can cause clusters of cases. And when it does, this is where you’re going to look at your specific batches. This is where you’re going to go back and look at your lot numbers and see if there is a correlation. Ope, I have three, four, five cases of TASS and they all have the same lot number of viscoelastic. This is a good chance to go back and see. And if it does, this is where you’ve got to get rid of those lots.

Again, quality insurance study. But typically when you have contaminated viscoelastic, or even contaminated BSS, same thing, you’re usually going to see those clusters of cases, they usually involve a specific batch or a specific lot number. You can also get contamination by an endotoxin during the manufacturing from bacterial fermentation. Traces of viscoelastic residue can attach to surgical instruments. This is that biofilm on the instruments. And they may not get completely removed during cleaning. You didn’t do thorough cleaning. And that’s when you take away from the viscoelastic natural quality and it can become toxic.

Some of the ways that viscoelastic can certainly cause TASS, one it’s contaminated, the viscoelastic itself is contaminated. Or the viscoelastic is sitting there on the instrument, sitting inside of the instruments. You’re talking about cannulas, and it’s not thoroughly clean and it stays on there and then it’s brought into the next patient and these instruments are used on the next patient. These are some of the ways you can certainly cause TASS from viscoelastic.

And of course, flushing of instruments. I know this is a hot topic. But I think we all know that inadequate flushing between cases can certainly result in that build-up of viscoelastic. Let’s go back to the basics of decontamination. Decontamination starts immediately at your back table, your scrub nurses, your assistants. Be sure that after you’re using that instrument or that cannula, that you already begin cleaning it, right then and there. Right on that back table. Don’t let things sit there and dry on your back table. You want to be sure that you’re cleaning things as thoroughly as you can but right away.

When you’re done with a procedure, are those instruments going to sit there for a little while before somebody in sterile processing can get to them. Well, they do make sprays that you can spray instruments with that will keep them moist until you can get to the decontamination process in your sterile processing department. Keep those instruments moist, clean them as soon as you can.

Flushing of all lumens. These are your small bore instruments, your cannulas, even your phaco needles. If your phaco needles are getting reprocessed, that’s your IFUs, and your manufacturer’s instructions say that you can reprocess your phaco needles. Typically they have, it will say you can reprocess it five times or 10 times. Be sure you’re flushing these things very well and according to manufacturer’s instructions.
Copious amounts of fluid. If you’re using a machine, typically they send out about 120cc of fluid followed by air. You’re using a syringe, that’s fine. Just be sure that you’re flushing good amounts of fluid through those cannulas. And then you’re following it up with air. Really important. Because if you’re flushing, flushing, flushing with a fluid like say it’s sterile water, you want to be sure that that sterile water’s not going to sit in there during the sterilization process. And that is going to be in that cannula for the next patient for that surgeon to push out right into the next patient’s eye. Air is a very, very good point to make no matter what you’re doing when you’re flushing, be sure that you’re following it with air. Some people have machines and they have compressed air, that’s great if you have it, if you don’t perfectly fine. You can use a syringe. An air syringe, just fill it up with air and push it until you see no more fluid come out.

Make sure that your final rinse is treated water and is not tap water that can have all kinds of contaminants in it. Treated water, distilled water, sterile water. This is your treated water. You always want to make sure that that last rinse is your treated water. If you can use disposable cannulas, that’s always preferred. But I know a lot of people put a lot into using disposable instruments and if you can do it, that’s wonderful. But if your practices are thorough, and you’ve got good quality protocols, good quality procedures, you’re taking your time in between cases, you’re doing things correctly, this isn’t a race, you can use cannulas that are reusable. We’ve been using reusable cannulas for 20-30 years to be honest with you. But this is with proper protocols in place, taking the time to do it right.

Yes, disposable cannulas are certainly preferred, it takes the worry out of it. But remember, if budget doesn’t allow for disposable cannulas, you can use reusable ones and still be fine if you’re using the right protocol and the right method and take your time. That’s what most important is to take your time. Again, this isn’t a race. Every person deserves clean, sterile instruments.

Be sure that when you’re working with your surgeon, when you’re handing them a cannula, you want to make sure that you’re flushing the cannula out before you give it to them. In other words, flush those cannulas with BSS just in case, just in case, you have some fluid that may still be in there, some water that may still be in there from the cleaning process. Before you’re handing that surgeon that cannula, you want to make sure that you’re flushing it really well with BSS. Surgeons out there, you can do the same before you enter the AC. Just give it a good flush. Make sure that’s patent as well, but make sure that you’re getting any solution that may still be in there out.

These are wonderful machines to use if you can get them. This particular one comes with a base and it’s used to flush instruments. And it also has air that flushes through, they’re wonderful. But please remember that these can also harbor microorganisms. These also can be a result of TASS. These little tubings and all those little spots that you can get, you can get biofilm in these, these actually get autoclaved. The bottle can get autoclaved, the cap, the tubing sets. That is all autoclavable. Make sure you’re following your IFUs. And understand that there is a process for cleaning these because these can be a potential cause of TASS with all these tubings that you see here, all these joints and all these places that can harbor material in them. You want to be sure you’re cleaning these out. Have protocols in place in your facility for how often. I see most facilities do it at the end of the day, they clean it out well and they throw it all into the sterilizer. But please understand that these tubings and some of the materials in this particular machine can be a cause of TASS. And that’s something that you can certainly look at if you’re doing a study and you’re trying to go back and you’re trying to figure out oh my goodness, where did TASS come from? This is a thought. Just make sure that you’re cleaning this, you’re following your IFUs. Again, you can throw these typically into a sterilizer, if you have a sterilizer that can fit it. Just make sure that you’re cleaning them and make sure that you do have in the back of your head that this could be a possible cause for TASS.

Thorough rinsing, not only your cannulas, of course, but you’re doing decontamination of your instruments. All your instruments on your back table get decontaminated regardless whether they were used or not. If that instrument gets put on your back table, then it gets cleaned, everything. Everything gets cleaned and put in. Thorough rinsing to remove that detergent. However you’re doing it. Whether you have a wonderful big machine that does cleaning, rinsing, drying, everything together or you’re just doing it in a sink. Either way, make sure you have the right protocols in place for rinsing these instruments. Rinse, rinse, rinse, get that detergent off of there.

But not just your instruments, also your instrument trays as well. Everything has an IFU and is going to tell you how to clean things. Look and see what it’s telling you and how to clean these trays. As well, these can be contaminated, look at those mats, you get those little, I have a friend who calls them little fingers, those mats. Those mats are very important, those mats can get kind of icky in there. You want to make sure you’re cleaning them well. You’ll pulling out those mats, you’re cleaning those mats according to the IFUs. That instrument tray, you’re cleaning these instrument trays according to the IFU, however it’s telling you to do it.

Just make sure that these instrument trays are not used over and over and over and over again. Or you’re taking instruments out of them, putting them back in them and they’re never getting cleaned. I have seen some facilities do that well. They take the instruments out, they put them in, these trays never get cleaned properly. Make sure those mats come out, they’re cleaned, especially underneath them. And these trays get as much love and attention as your cannulas do and as your instruments do.

Intracameral injections. This was a hot topic for quite some time and it still can be. Corneal endothelial toxicity and TASS, they can be potential concerns with intracameral injections. Certainly not telling you not to use them. That is a surgeon’s discretion. Just wanted to give you an understanding of how it can be a possible cause of TASS. The drug component itself, preservatives, any preservative. If you’re not using preservative-free intracameral injections, please be aware. Preservatives certainly can be a cause of TASS. Abnormal pH in the drug. It can be possible as well that small amounts of let’s say a subconj infection, let’s say you’re doing gentamicin, that can access the AC through a surgical incision after injection.

Intracameral injections, there’s different ways, subconj injections as well. Just keep that in the back of your head if you’re getting TASS, something to look at. I know years ago we used to do subconj injections on everyone. Some people still use them, some don’t. Honestly I see an array of different methods, different methods of intracameral injections in the sense of, I shouldn’t say methods, but some people use and some people don’t, put it that way. I can’t say that all of the sudden everybody stopped using them, I still see surgeons all the time using them. They have no problems, beautiful. I see some that have stopped for that reason of TASS. Surgeon’s discretion, just keep in the back of your head corneal endothelial toxicity and TASS with intracameral injections.

Summary on TASS. Make sure again, not a race. Adequate time taken for thorough cleaning and sterilization, adhere to protocols. Make sure everyone’s doing it the same way, everyone does it according to your policies and procedures. You don’t deviate from that. You have a sufficient inventory of instruments that meets surgical volume. This is giving you enough time for thorough processing. It’s going to be hard to keep up with surgical volume if you’ve only got a minimal amount of trays. You’ve got to process those trays as fast as you can. Make sure you have sufficient inventory to process them correctly. Make sure you’re following your IFUs. Don’t allow viscoelastic solutions to dry on instruments, make sure you’re doing decontamination at your back table as soon as possible, using decontamination at point of use. When possible to use disposable supplies, do not reuse supplies that are labeled for single-use only. Often these supplies are written that way because they shouldn’t be sterilized. They can’t be steam sterilized, they’re not supposed to be reused for a reason. Make sure you’re not reusing supplies that say single-use only.

Clean ophthalmic instruments separately from non ophthalmic. For any of your centers out there that are a multi surgery center, where you’re doing other procedures besides ophthalmic procedures, if you’re doing ortho, you’re doing GI, and you’re doing ophthalmology. Make sure that you’re giving love to these ophthalmic instruments, that you’re cleaning them separately from other instruments, from all that debris that could possibly be from other large, more complex, more detailed surgeries. Make sure that you’re cleaning them separately. That you’re not doing your eye instruments and your ortho instruments in the same sonic machine.

Make sure you’re thoroughly rinsing these instruments with a copious amount of water, remove all that detergent. That water quality that last rinse really should be with critical or treated water. And make sure those ultrasonic cleaners are empty, they’re clean, they’re disinfected, they’re rinsed out of that disinfectant and dried. At least daily, preferably after each use, I understand that might be a big task for many of us. But just be sure that you’re following the IFUs, and that you have the protocols in place, and that you’re all doing it the same way.

Treatment for TASS. Most cases are very successfully treated with topical steroids. You’ve got your mild and early cases, you could have four to eight times a day of a steroid. Sometimes it’s a 1% prednisone or 0.1% of dexamethasone are usually standards. Moderate cases, it can take 3-6 weeks to clear up. Now if you get a severe case, you’ve got some dense fibrin, hypopyon, you’re going to usually use oral prednisone. Surgery is an option as well, if the inflammation persists, you may want to do an AC washout, vitrectomy, you may need to remove that IOL, these are all at the surgeon’s discretion, of course. But most cases, again, are successfully treated with topical steroids. Typically we see prednisone or dex.

Now we get into endophthalmitis. Endophthalmitis, a severe inflammatory condition resulting from an infection of the intraocular cavity, this is the aqueous and the vitreous. It can be acute, it can be chronic, it can develop very rapidly or it can develop slowly. And it could persist for a long period of time, it could be any of these.

There are two types of endophthalmitis. You have the endogenous which is rare. And this endo, outside the body, this can sometimes happen with immunocompromised individuals. Hematogenous spread, bacterial or fungal. But usually with endophthalmitis more commonly is exogenous. This occurs from outside the eye, this is your contamination in something that entered the eye. This is the most common type, it can occur after surgery, it can occur after penetrating ocular trauma, it can be an extension of a corneal infection. It can happen after intravitreal injections of VEGF. But we’re going to focus mostly on the exogenous, what you typically are going to see after surgery.

Symptoms of endophthalmitis. Poor visual acuity, you’re going to get that corneal edema, the hypopyon, the vitreous inflammation, poor fundus visualization, reduced vision. Post op endophthalmitis typically, these patients are in pain, they’re just painful, you could get swollen, red eyelids, you can get some photophobia, and ocular discharge as well. You can see some of these symptoms compared to TASS.

Etiology, it’s an infectious agent. Somehow that infectious agent got inside the eye. Bacterial most common gram-positive bacteria, now can be fungal, it can be gram-negative as well, but more commonly we see gram-positive. It can also be fungal.

Treatment. Intravitreal injections, you can get a high concentration of the drug in the vitreous cavity without the systemic side effects. You can go with vancomycin, ceftazidime, you can also go with Amikacin. I don’t see Amikacin used as often anymore because there’s a risk of macular ischemia. It doesn’t mean it’s not used anymore but I don’t see it often. It seems to be the two drugs of choice seem to be vancomycin and ceftazidime.

If you’re mixing your own, please, please be sure you’re using obviously the proper dose and aseptic technique. But these things are critical. If you don’t have the right dose, an inadequate dose can cause a treatment failure. If you have an excess dose, it can cause toxic effects on the retina and of course if you’re mixing your own drugs you have the potential for poor technique and that’s certainly not going to help, you already have an infectious eye. You certainly don’t want to add to that. If you’re mixing these drugs, please be sure that you’re following good, proper, aseptic technique and that your dosing is correct.

This is a great graph. I did get this from the internet. This is going to really go through here for you just the side-by-side endophthalmitis and TASS. Let’s take a look at this here. With endophthalmitis, 75% of patients typically get pain. Pain is certainly something you see in endophthalmitis. But with TASS, minimal, minimal pain if any at all. With endophthalmitis does it occur in clusters? It can be sporadic, you can get a case of sporadic endophthalmitis but typically TASS you’re going to see some outbreaks. You’re going to see those clusters.

Visual acuity, severe reduction with endophthalmitis. With TASS it can go anywhere from mild to severe. You have quite that range. Elevated IOP, it’s typically common with endophthalmitis. And it’s not common, you can get elevated IOP for sure but it’s not as common with TASS. Corneal reaction, typically it’s not limbus to limbus edema but you are going to see limbus to limbus corneal edema with TASS. Your AC reaction. Here’s your difference between the two, you’re going to see mostly 3+ cells in your endophthalmitis, whereas cells for TASS 1-3. Fibrin, it varies in endophthalmitis. In TASS you might see a 1-3+. Hypopyon you’re going to see typically a 3+ in endophthalmitis, it’s terrible to see. But in TASS you’re going to get 1+.

Pupil, round and reactive with endophthalmitis whereas in TASS you might get mydriatic, dysphoria, it can usually happen in later stages but you are going to see pupil reaction in TASS. Your vitreous reaction, vitritis, you’re going to see that, of course, in your endophthalmitis. You get an infection of the vitreous cavity. In TASS it’s usually clear you can have some spillover and vitritis is rare. You’re going to see that, obviously, mostly with your endophthalmitis.

Steroid response in endophthalmitis it can worsen it. Whereas in TASS it will improve. This is sometimes an indication how you know between the two because TASS typically has a very good response to steroids. Your antibiotic response. Same thing, it’s the opposite. It can improve your endophthalmitis whereas in TASS it can worsen it. You may not see any response. Your prognosis for endophthalmitis, it can generally be poor, depends on how fast you can treat it. Again, you see in typically 3-7 days after surgery for endophthalmitis, 1-3 days after surgery for TASS. As fast as you can catch it and you can treat it depends on its symptoms and depends on how hard it has affected the eye, depends, of course, your prognosis. With TASS it’s typically good with your steroids. You typically get a good response, whereas in endophthalmitis it can be tough.

Now, something to remember as well, 3-7 days after surgery with endophthalmitis and you can often see this even further out. You also got to look at your patients and how they’re caring for themselves. And I say this because I’ve seen this in the past where we have had to cancel patients because they’ve come in and we’ve noticed very sadly with poor hygiene or they may live alone, they’ve got no one to help them. They are potential risks for endophthalmitis. They have a risk of introducing infection into their eye. And it’s something to note when you’re doing your clinical evals or even in pre op when you have a patient that presents and you do see an unfortunate circumstance where these patients you just know that they’re a high risk for infection.

Really, really good patient education is what you need in these cases. The patients can come in, very poor hygiene, their hands, their nails, their clothes, you can tell these are unfortunate situations when they’re not caring well for themselves or they don’t have the ability to care for themself. You’ve got to remember that these patients are going to be caring for their eye, they’re going to be adding drops to their eye, they’re going to be cleaning their eyes after surgery. And they can certainly be a risk for a potential for infection. This is where good patient education comes along.

We have canceled patients for this and we have offered social work, we’ve offered if these are options, any type of medical care at home where maybe you can set up some type of care afterwards with these patients for someone to come in and help them with cleaning and help them with their drops. But it’s just something to think about, it’s not always something that is related to surgery. This could also be related to your patient and how well they can care for themself.

This is a great graph, this is something to just look at and see a difference for those, I did get the question how can you tell between TASS and endophthalmitis, here you go. This is something I actually got online and it really is a great graph to see side-by-side.

Now you have a case or you have cases of TASS. Now what do you do? Let’s talk about an outbreak. All of the sudden you have three, four, five cases that come in post op day one and they all have TASS. Where do you start? The first thing, of course, you need to do is you’re going to determine the cause so you can stop this, so you’re not looking at the next day. And there is a possibility that if you’ve got that big a cluster of TASS in that many patients you may need to close your OR until you find out what the cause of this TASS is. You certainly don’t want to continue on doing patient care if you don’t know what’s causing it.

One or two cases is one thing, but when you’re getting six, seven, 10 cases of TASS within a day, obviously something is wrong. And you really have to look and go back. And this is where you’re going to do a quality improvement study. Your goal is to find the common denominator. You’re going to find that one thing that every case has and here is where you are going to, hopefully, find the cause.

Let’s talk about that. Let’s talk about a good quality insurance study and how you can go back and see if you can find the cause. What’s very important about doing this is that you gather your data one data at a time. If you do more than one you’re not going to be able to narrow it down. In other words, if you see, oh my goodness, I see this, this, but I also see this. You’ve got to do it one data at a time. This is how you’re going to be able to bring it down to the level where you can see that one thing that all your patients have. Don’t go and do multiple things to see if you can figure it out. Start one thing at a time.

Pull your patients, look at your schedule, figure out every patient. Every patient you have, make a graph, every patient that developed TASS. Now look and see what surgical day, you could have them over two days if you have an outbreak of four or five and then day two, a different surgeon three or four. Pull the surgical days. All your patients with days they have surgery on. What surgeon? Is it one particular surgeon, multiple surgeons? Start there. You’re going to start your chart.

Now let’s start with the operating room if you have more than one OR. You have one, okay, that helped that. If you have more than one OR, let’s look and see which OR they were in. Sometimes your study could even stop there. Oh my goodness, 10 patients who got TASS and all 10 were in OR 1. Something’s going on in OR 1. Now you want to look at your graft, patient, surgical day, surgeon, operating room, work your way down.

Now you go to your staff, your scrubs and your circulator. How are your circulators prepping? It doesn’t mean that always happens at your back table. How are your circulators prepping the eye? You could stop there. Now you’ve identified the same scrub, move on. Instrument sets. Now let’s look at your sterilizers. Do you have more than one? If you do, you should be able to go back to all of your instruments and be able to see which sterilizers they were sterilized in. You’ve got to be able to track it. Somehow, some way, whatever your process is, whatever your protocol that you have in your facility, you need the ability to go back and track which instrument came from which sterilizer.

Typically it’s put in the patient’s chart and somehow in the patient’s record. Or you can have a log book. You could have a schedule sitting by the sterilizer. And every instrument tray that came out is going into room one, John Doe is in room one, room one the instrument tray came out of sterilizer A, sterilizer B. Or you could put it into the patient chart themselves. Either way you should be able to identify every patient and which sterilizer these instruments came out of, however your facility does them.

Now let’s look at your instrument cleaning procedures. First of all, has anything changed? Are you using a new detergent? Are you using any new solutions, have you changed water quality? Have you changed from distilled to something else? Has anything changed in how you’re cleaning your instruments? That’s often, this is where we may see TASS is when we start changing protocol. It’s okay to change, we always want to be up on our game and we always want to be using the best things for our patient care, best quality. It’s okay to change but just keep that change in mind, always know, hey, I’m changing to this. Because if you’re going to get TASS or even an infection, sometimes you can go back and say, oh my goodness, we just changed to this type of BSS from this company instead of this company. Oh okay, we’ve changed this detergent, we’re using this instead of this. And when you start introducing multiple changes this is where you may have problems. Let’s look at your instrument cleaning products. See if anything has changed.

Now let’s talk to your sterile processing staff. Are they all doing it the same way? Are they all following the same protocol? Does anyone deviate from it? We’re not out to shame anyone, we’re not out to pull anyone out, we’re out to learn. We’re out to learn from each other, education. Because this is where you’re going to find that, yep, you have that one person that is doing things separate from anyone else. And I’m going to give you a good example of that.

Years ago I did see an outbreak, cluster, so to speak, of TASS. Quite a few patients, I don’t remember how many in one day. But they were all in one day, they weren’t all with one surgeon. They were with multiple surgeons. We started the graph, we started with which patients developed TASS. We looked at the surgical days and they were different days, multiple days. We looked at the surgeons, multiple surgeons. We haven’t quite factored in anything yet, looking for the common denominator. Looking at the operating room, nope, they’re all different operating rooms. Looking at your staff. Bingo. They were all the same scrub. Different patients, different surgery days, different surgeons, different ORs, but they were all the same scrub. So there was our common denominator.

Let’s think now, same scrub. Do we have a sterile technique issue? I know this scrub, I’ve scrubbed with her, I’ve worked with her for years. I know she’s an excellent scrub. She’s got excellent technique. Because you never know, something certainly could be wrong. Didn’t really think that was it, but there’s our common denominator. After sitting down and interviewing the scrub we learned something. One of the blades that was used they were reprocessed, they were approved to be reprocessed. But this particular scrub was cleaning this blade different than anybody else on the back table. Dipping it into the BSS or wasn’t cleaning it the same way as everyone else. And low and behold, this biofilm was gathered on this blade and sitting there and was not getting sterilized very well. And she just changed to this technique. Recently thought, “Oh, I’m going to do it this way, I think this is a good way.”

It was certainly an innocence enough act but after doing the study, we realized there’s our common denominator, there’s our one scrub and she was cleaning things differently than everyone else against protocol, against the IFU, innocently enough she thought it was a nice way to do it, she thought it gave it a good final rinse. But unfortunately that final rinse caused this biofilm to sit on the blade and now that blade is going into a clear corneal incision and there you go, there’s your introduction into the AC. This is how a QI study, this is how you can find that common denominator.

After you’ve done your study, let’s hope you’ve found that common denominator, don’t just stop there. This is where you need to interview your staff. This is where you get everyone together, again, not to shame everyone and you certainly don’t have to call anyone out, but this is to explain the process of cleaning instruments and explain to everyone what change in protocol can do. By this time everyone’s going to know that you have a TASS outbreak. You can certainly do your quality insurance study as a team, you can assign team members. Again, you don’t want to go, you want to do one thing at a time but you can certainly do this as a team approach. But in the end you want to make sure you have good staff communication, explain the process to cleaning instruments from the back table all the way until your sterilization area. This way you’re going to sit everybody down and you’re just going to talk through it.

And this can include your surgeons as well. Your surgeons really, how many surgeons know your process for sterilizing instruments? They know and understand the right process. They should understand the process as well. And know that you’re doing everything that you can do to be sure that you’re giving the best quality care to your patients. Involve them as well. But in the end, your quality insurance studies, you’re going to look for that common denominator. Start from the beginning one at a time. Make a graph: patient, surgical days, surgeon, operating room, staff, look at all your staff, scrub and circulator. Make sure you’re following your instrument sets from the sterilizer to the patient that you can go back, you should be able to go back and look and see patient A that had instruments that came from sterilizer A. Look at your instrument cleaning products, has anything changed, is anything new? Look at the protocol, has anyone changed anything? Talk to your sterile processing staff, make sure we’re all following the same thing. And make sure that you interview your staff and you explain the process for cleaning instruments and that you’re following the same protocol.

Staff education. Just as I mentioned. All team members. This isn’t just your scrub, if you find that it was the scrub, or it was the circulator, you’re not just going to pull them out and call them out and call it a day. You’re going to get together and include all team members. You’re not there to shame anyone, you’re just there for staff education to learn from each other. Emphasize the importance of TASS prevention.

Staff awareness. When you have new staff and you’re bringing new staff in, especially those who may not be familiar with ophthalmology. Do they know what TASS is? If you’re out in the outside world and you’re coming from med surg or you’re coming from a different world of nursing, do they understand and know what TASS is? This is where they really need to be sat down and go through some type of continuing education on what TASS is, what endophthalmitis is. And how to prevent it.

Hold regular training sessions yearly, quarterly, however you’d like to do it, just make sure that you’re holding training sessions that people keep in mind. And always have that constant education on TASS. And make sure that everyone understands the guidelines on appropriate cleaning and sterilization of your equipment.

Consistency. Determine the protocol and make sure that everyone is following it. The staff education is very important, quality insurance is very important, do your studies, sit down, do one at a time. Don’t do a whole cluster of implementing things all at once. And in the end you’ll probably find your common denominator.

And that’s it, that is my talk on TASS. I think we may have a few questions, I’m not sure. Yeah, just a few. Can I share my slides? Yeah, I’m happy to share slides with anyone. If you have any questions on the bottom of your screen, you’re going to see Cybersight.org. Please feel free to log in and ask any questions through Cybersight. I’m always happy and always available to answer any questions for you and certainly could share my slides if you’d like me to.

Systemic disease drugs, high risk of causing TASS? Again, for me it’s all about your intracameral injections. Those are the drugs I was focusing mostly on. Your intracameral injections certainly had a background in TASS. But focused mostly on those otherwise my talk mostly consisted of all ophthalmic when it comes to medications.

Thank you, everyone. Thank you for joining me today. I appreciate all the wonderful comments that are coming through. And again, if you have any questions, please feel free to reach out. Cybersight.org. And I am happy to answer any questions that you may have. Have a wonderful day and enjoy this beautiful Monday. Thank you.