The problem with toxic anterior segment syndrome is that there are more questions than answers when it comes to understanding the hows and whys. Here's what's known: TASS is a non-sterile, post-op inflammation occurring predominantly in cataract patients, typically within 24 hours of surgery. Here's what's not known: the exact cause.

In March, an ad hoc task force of representatives from the American Society of Cataract and Refractive Surgery and the American Society of Ophthalmic Registered Nurses attempted to provide some answers to administrators who want to keep their facilities TASS-free. Their long-awaited "Recommended Practices for Cleaning and Sterilizing Intraocular Surgical Instruments" focuses on preventing outbreaks by eliminating contaminated instrumentation from OR rotations.

That goal requires due diligence, according to the guidelines, which state that "preventing TASS by appropriate management of intraocular surgical instruments is a challenge that must be repeated with each cycle of cleaning and sterilization of cataract surgical instruments at every cataract surgical facility."

Take your time
As surgeons demand quicker room turnovers between cataract cases, your reprocessing techs may be pressured to cut corners in instrument reprocessing. "Working with one instrument tray per room is impossible," says Linda Timmons, director of surgical services at the University of Miami School of Medicine's Bascom Palmer Eye Institute and a member of the ASCRS-ASORN task force.

Ms. Timmons says proper cleaning and sterilization of the tools used in cataract cases takes time, and longer than the mere minutes some surgeons expect to wait between cases. Rotating two or three trays will let your staff maintain efficient room turnovers without jeopardizing patient care, she says.

One of the biggest barriers to instituting proper preventative measures is the perceived extra time it will tack on to instrument reprocessing and, ultimately, room turnovers. The perception is just that, according to Monica Ziegler, MSN, administer of the Physicians Surgical Center in Lebanon, Pa. Her facility endured a TASS outbreak in September 2006 and sporadic occurrences a month later. After instituting procedures to reduce the incidence of TASS, "we were able to keep a high volume going," she says. "We've lost seconds, not minutes, and that's a small sacrifice to pay to combat the threat of this problem."

Manufacturers' directions for use are printed for a reason: Follow cleaning and sterilization instructions to the letter. Note that instructions for disposable devices don't include cleaning directives. These single-use devices should be used whenever possible and discarded immediately.

Ms. Timmons has fielded calls from administrators reporting TASS outbreaks and discovered that many did not check the cleaning and sterilization guidelines from the device and instrument manufacturers. "If you don't know or simply don't follow the recommendations from the manufacturer, how do you know if your instruments are properly cleaned and sterilized?" she asks.

Clean and rinse
Cleaning of instruments should begin immediately after use, with ophthalmic separated from nonophthalmic instruments. The recommended practices suggest the phaco handpiece, irrigator/aspirator, irrigator/aspirator tips and inserters be flushed with balanced saline solution, wiped with a lint-free cloth and placed in a bath of sterile water before removal from the operative field.

"If the viscoelastic dries and isn't wiped off instruments, it leaves a sticky residue that cleaning detergent can later stick to," says Ms. Ziegler.

What about the detergents used to clean the instruments? The new guidelines state that the importance of enzymatic detergents has not been demonstrated and that the inappropriate use and incomplete rinsing of these detergents may have sparked TASS outbreaks. If you use enzymatic cleaners, the task force advises following the directions for use exactly to ensure the detergent is diluted with the correct amount of water. In other words, eyeballing the mix isn't appropriate. The brushes and syringes used for cleaning must be designed for cleaning medical instruments and should be discarded after each use.

"Enzymatic cleaners leave a residue that we can't see, residue that can irritate the eye," says Ms. Timmons, adding that the recommended practices actually instruct you to rinse instruments with "copious" amounts of water. She also says the rinse volumes recommended by device manufacturers should be considered minimum amounts. Rinsing should provide a flow of water through and over the instruments, using only debris-free water. "Rinsing requires a lot of fluid and should take about two to three minutes when done properly," she says. The final rinse, she adds, should be done with sterile distilled or sterile de-ionized water and include drying of the instruments with forced or compressed air.

When employing an ultrasonic cleaner, the recommendations state that gross soil should be removed before instruments are placed in the cleaner, and that machines should be emptied, cleaned, disinfected, rinsed and dried at least daily - and preferably after each use. They also stipulate that the cleaning should be done with an EPA-registered disinfectant followed by a sterile or tap water rinse. The task force recommends a final rinse of 70% to 90% ethyl or isopropyl alcohol if allowed by the cleaner's directions and if the rinse is not associated with risk of fire.

Scope and sterilize
Before packaging for sterilization, visually inspect the integrity and cleanliness of optical instruments under a microscope. If residue is noticed, clean and rinse instruments again. The task force's guidelines for properly sterilizing ophthalmic instruments are fairly standard. Again, reference and follow each instrument's directions for sterilization. Check the functioning of your sterilizer daily (at most) or weekly (at least).

One specific mention: Avoid using glutaraldehyde, a low-temperature sterilant, on optical instruments because of its toxic residue and potential for irritating the eye. The task force further notes that you shouldn't use other low-temperature methods of sterilization unless the manufacturers of the instrument and sterilizer sign off on the method's efficacy of sterilization and potential for ocular toxicity or damage to the instrument's functionality.

Don't ignore the quality of the water used in your steam sterilization process. The recommendations state that you should check water quality at least annually. "You have to know what kind of water goes into your sterilizer," says Ms. Timmons, who installed water softeners to combat the hard water being piped into her Florida facility.

A clear window
Ms. Timmons says it's essential to instruct staff about the potential causes of TASS and to reinforce the lessons during annual reviews, with a focus on educating the instrument reprocessing team. The recommended practices advise training staff "in cleaning and sterilization procedures as well as related tasks via a formal, standardized training program administered by qualified personnel."

Ultimately, Ms. Timmons believes ophthalmic instruments need to be treated differently than the tools used for other procedures. "The eye is a cavity with a clear window," she says, "and when we introduce elements that don't agree with it, the negative consequences are obvious.