As a patient safety risk analyst, one of the patient safety issues I have seen is Toxic Anterior Segment Syndrome (TASS). Though TASS is a rare complication of cataract surgery performed by an ophthalmologist, it is potentially devastating to the patient who have a poor outcome and even blindness. The bigger issue is that usually, TASS occurs in clusters/as an outbreak related to a specific surgical suite, meaning more than one patient treated in that surgical unit will be exposed & incur TASS.

Toxic Anterior Segment Syndrome (TASS) is an acute, noninfectious inflammation of the anterior segment of the eye that is a complication of anterior segment eye surgery, most commonly seen in cataract extraction. It occurs when a foreign substance gets into the anterior chamber located between the lens and the cornea. Symptoms begin 12 to 48 hours after an otherwise successful surgery.

Typical causes of Toxic Anterior Segment Syndrome (TASS)

• Problems with irrigating or balanced salt solutions
• Medications injected into the eye during surgery
• Ointment or eye drops that gain access to the anterior chamber
• Enzymes or detergents used to clean instruments or cannulas between cases
• Heat-stable endotoxins from sources involved in cleaning and sterilization of instruments and hand pieces
• Residual material such as ophthalmic viscosurgical devices (OVDs), which are transparent, gel-like substances used during surgery
• Cleaning solutions left on hand pieces or cannulas

According to one of the CDC report, On October 11, 2006, an ophthalmologist at a 25-bed community hospital in Maine noted that eight of 10 patients on whom he had performed outpatient cataract surgery that day had an unusual degree of inflammation and decreased visual acuity.  Cataract surgery is one of the most common surgeries in the United States, with approximately 2 million procedures performed each year

According to the American Society of Cataract and Refractory Surgery, “While investigating the recent TASS outbreaks we determined that the causes were varied, including issues with sterilization, enzymes and detergents, preservatives, intraocular anesthetics and ointments, among other factors.
Today, as surgeons and surgical centers have become more and more efficient in performing cataract surgery, time constraints have led to a shorter time available between cases for the adequate cleaning of instruments. For example, there often is not enough time to adequately clean reusable hand pieces and reusable instruments used in phacoemulsification. Although the manufacturers recommend that these hand pieces get flushed with 120 cc of fluid, it is difficult to achieve that level of flushing in between cases. This allows the possibility of residual cortex, viscoelastic or other materials left on the hand pieces that are not adequately flushed. If any of this residual material is left on the instruments, it can be flushed into the eye during the subsequent case, causing inflammation or TASS.”

As of 2012 the Food and Drug Administration partnered with the Center for Disease Prevention & Control to develop better analysis for detection of contaminants in surgical suites and more aggressive surveillance of outbreaks geared to protect public health.

Legal Nurse Consultants and physicians who specialize in Ophthalmology related surgery are best suited to screen these types of cases and understand that where one TASS claim occurs,  more likely than not, other patients recently treated by this same doctor or other doctors in this clinic may also have TASS.

Med League Legal Nurse Consultant provides ophthalmology expert witness and Ophthalmologist experts, call us today for your next case review!

Rebekah Mead, MSN Ed., BSN, RN, FND, OHN, LNC  is a Legal Nurse Consultant with Med League Legal Nurse Consultant.