"When an outbreak occurs, why do some surgeons have no TASS at all while others have multiple episodes on different surgical days?" asks Dwayne Kertanis, administrator of the Constitution Eye Surgery Center in Newington, Conn. "Thank goodness this issue does not present itself very often."

Last month, Outpatient Surgery Magazine surveyed 201 facilities that host eye cases about TASS. Sixty-two (30.8%) of those centers have had a TASS outbreak. Not too surprising, as reports of TASS today are sporadic compared to the nationwide outbreaks of 2005-06. What's noteworthy is that only 45 of those 62 (67.2%) centers that have had cases are confident that they discovered and eliminated the cause of the TASS, meaning that about one-third of affected facilities aren't exactly sure why the TASS started or stopped.

"I'm actually surprised that two-thirds know what caused TASS because we rarely have an exact smoking gun to point at," says Peter Ness, MD, an ocular pathology and research fellow at the John Moran Eye Center at the University of Utah, who reviewed the survey results at our request.

Trial and error
When TASS struck at a USPI surgical center not long ago, Clint Chain, RN, BSN, director of clinical quality and patient safety at United Surgical Partners, was quick to act. First, he ordered the facility to cease doing eye surgery until the problem was resolved. Second, he worked with industry consultants and the Intermountain Ocular Research Center at the University of Utah, which is acting as a clearinghouse to help evaluate TASS outbreaks, to identify several possible causes. They asked:

Was it that staff were unfamiliar with the new closed container system that they were trialing to sterilize instruments? Was the use of enzymatic detergent in cleaning and decontamination to blame? What about reusing single-use medication ampules between cases? Or re-sterilizing plastic sleeves that are designed for single use? And let's not forget the water study that showed high copper levels present. So many questions, so few answers.

"We never determined the reason why it occurred," says Mr. Chain, "but we did determine that these are the problematic areas that we might have an issue with."

While a root cause didn't emerge, something perhaps more valuable did. With the help of consultants, Mr. Chain developed for all USPI facilities a TASS pre- and post-op checklist, available for download at www.outpatientsurgery.net/forms.

A few cases have been published linking cause and effect, but often the inciting factor for TASS is unknown — it could be denatured viscoelastic that remains in reusable cannulas or it could be detergent trapped inside irrigating cannulas.

Maine Eye Care Associates in Waterville, Maine, had a severe TASS outbreak about 15 months ago. The ASC sent the records of 10 affected patients to the University of Utah. "We followed every one of their suggestions and the TASS outbreak disappeared," says ASC Director Barbara Mann, RN. It was a laundry list of suggestions:

• Eliminate the use of the ultrasonic cleaner.
• Purchase a flush machine.
• Use only distilled water to clean instruments.
• Use sterile water on the back table to place tips and cannulas in immediately to prevent the viscoelastic from hardening.
• Use preservative-free epinephrine.
• Use disposable 30g cannulas.
• Discontinue intraoperative vancomycin.

Ms. Mann isn't sure which step(s) worked — only that "we haven't had TASS occur since the changes were made."

"It could be any one of those things," says Dr. Ness. "If the ball is dropped in any one of those areas, it could end up causing TASS. Because it's difficult to say which factor it was, it's necessary to have very thorough procedures for your reprocessing staff."

Trial and error — that seems to be the tack most of our survey respondents take to eliminate TASS. Rather than firing a single bullet, it's best to spray several shots at the problem. "We believe it takes more than a single strategy," says Janet Johnson, RN, clinical manager at Elmwood Park (Ill.) Sameday Surgery. She shares her do's and don'ts:

• To avoid buildup in lumens, don't use detergents. She's labeled all enzymatic and detergents "not for ophthalmology use."
• Use only preservative-free meds for intraocular use.
• Flush lumens with 120cc of sterile water, then 60cc of air.
• Clean the ophthalmology-dedicated ultrasound machine in sterile water only. After every 4 uses and at day's end, clean the ultrasound with alcohol, rinse with sterile water and wipe dry.
• Use disposable cannulas only.
• Educate surgeons on avoiding use of pre-op topical anesthetic gels or jelly and post-op eye drops and ointments with preservatives that could seep into the wound.

As noted in "How Would You Rate These Factors That Could Cause TASS?" on page 44, our survey respondents were unable to zero in on 1 or 2 culprits when we asked them to rate how likely they felt that 14 factors could cause TASS.

Dr. Ness routinely recommends that facilities do 3 things when they report TASS:

1. Increase flushing. A trait most centers with TASS share is that they're not flushing adequately. "Whether that's the cause of TASS is hard to tell, but that's the most common thing that we recommend: Increase flushing to clear out the handpieces," says Dr. Ness. The official recommendation is to flush 120cc through each port. "We flush each port of the handpiece and I&A handpiece with 120cc of distilled water after the procedure and blow them out with compressed air," says Cheryl Crouse, RN, the clinical administrator of The Outpatient Eye Surgery Center in Metairie, La., which has never had an outbreak.

2. Stop using preservatives in ophthalmic solutions. From lidocaine to BSS, all of your intraocular medications and anesthetics used for blocks should be preservative-free.

3. Clean the ultrasound machine. Don't just drain the ultrasound machine after use — wash it down regularly with alcohol and use a lint-free towel to dry it. Otherwise, says Dr. Ness, the endotoxin from the bacteria can stick around in the ultrasound bath and cause TASS.

Like herding cats
If managing TASS feels a lot like herding cats, keep your eye on the strong indicators of TASS that our survey respondents and the experts we talked to uncovered. What matters is preventing and managing an outbreak even if you're not quite certain how you did so.