The more we study toxic anterior segment syndrome, the more substances we come across that seem to be associated with acute inflammation of the anterior chamber after cataract surgery. Everything from the talc from surgical gloves to the preservative in antibiotics has been associated with TASS. As a result, there's no single thing you can do, buy or change in order to prevent the complication. The most effective means is to adopt a culture of best practices that you and your staff follow daily.

1. Switch to single-use cannulas. Removing reusable cannulas from your instrument trays and using single-use disposable cannulas on every case greatly decreases the risk for TASS. Due to the small bore of cannulas used in cataract surgery — 27- and 30-gauge — it's extremely difficult to remove all contaminants from reusable cannulas. Disposable cannulas may add a small cost to your sterile supplies, but it's well worth the investment to ensure that every cannula entering the patient's eye is contaminant-free.

2. Don't re-use single-use devices. Single use means "one time only." Follow the directions for use for your phaco tips. If it says a device is single-use, use it once and throw it out. This is a difficult decision to make with phaco tips that cost $50 to $75 each. But these small-bore devices are hard to clean. This becomes apparent when you look at the reprocessed tips through a microscope.

3. Use preservative-free medication. Even before the TASS outbreaks of 2006, benzalkonium chloride, a common preservative in topical ophthalmic medications and preparations, was known to cause corneal damage. Look for medications, such as lidocaine, epinephrine, intraocular medications and antibiotics that are preservative-free (often without benzakonium chloride), but also free of such stabilizing agents as bisulphites or metabisulphites.

4. Keep used instruments moist until processing. Ophthalmic instrument cleaning begins in the sterile field. However, remember the two danger elements: saline — the salt crystals damage instruments — and sterile water, which damages the corneal endothelium. Ophthalmic viscosurgical devices (OVDs) can dry within minutes. They damage instruments and are potentially harmful to patients when not adequately removed from instruments. OVDs have heat-stable endotoxins that have been associated with TASS. All instruments used on the sterile field should be immersed in sterile water on the surgical back table until the decontamination process begins. During the operative procedure, instruments should be kept clean of debris, blood and OVDs with the use of a moistened lint-free instrument wipe.

5. Inspect your instruments. Verify the cleanliness and the integrity of instruments under magnification. Inspect instruments for debris and damage immediately after cleaning and before packaging for sterilization. Additional or repeated cleaning, rinsing and irrigation may be required on a case-by-case basis to ensure the removal of all debris and OVDs.

6. Use an ultrasonic cleaner. After the initial washing and decontamination, the instruments should go into the ultrasonic cleaner. Ultrasonic energy, using high-frequency sound waves, thoroughly cleans instruments and will remove up to 90 percent of debris and contaminants. Ultrasound removes the tiniest particles of debris that are impossible to clean with other methods.

Rinsing and copiously irrigating cannulated instruments after ultrasonic cleaning will remove any detergent or lubricant used in the ultrasonic cleaner. Ultrasonic cleaners must be emptied, cleaned and disinfected, rinsed and dried at least daily. On busy days, or when particles are visible in the solution, the solution should be changed between cases. It is highly recommended that you have a dedicated ultrasonic cleaner used specifically for ophthalmic reprocessing because of the delicate nature of the specialty's instruments. Additionally, a dedicated cleaner reduces the risk of other unknown contaminants coming in contact with instruments.

7. Don't compromise when you sterilize. High surgical volume and pressure to reduce surgical times for cataract surgery can lead to inadequate cleaning, decontamination and sterilization procedures. Follow the sterilizer and instrument manufacturers' directions for use for sterilization. Intraocular instruments should be sterilized in accordance with the directions for use for the instruments and the sterilizer manufacturer.

8. Irrigate, irrigate, irrigate. Sometimes the simplest methods reap the best results. Copious rinsing and irrigation of ophthalmic instruments is necessary to remove blood, debris and OVDs. Pay particular attention to cannulated instruments, such as phaco handpieces, which need a good flushing to remove OVDs from inside cannulated areas. If you use a substilisin enzymatic cleaner, make sure you dilute it properly with distilled water and then rinse thoroughly.

9. Put fewer instruments on your trays. Today's small-incision cataract surgery requires fewer hand-held instruments. Place only the most used instruments in your surgical tray and keep the rest available in peel packs on the instrument cart. Store and sterilize the essential instruments in the same tray to reduce unnecessary handling.

10. Allow time for processing. It's important for all team members to understand that sterilization is not cleaning. All instruments must be thoroughly cleaned and decontaminated prior to sterilization. Although the basic principles of sterilization have not changed over the years, there have been significant changes in the complexity of instruments and processes.

The sterilization process consists of several steps you must perform in sequence to render instruments safe for use. These steps include: manual cleaning, decontamination, inspection under magnification, sterilization with quality control and monitoring. In many facilities, depending on volume, you may find that it will take you longer to process instruments than it does for the cataract surgeon to complete a case. Make sure that you have enough instrument sets in order to maintain your caseload and let your processing techs do their jobs correctly.

A chance to work together
With the mounting evidence we now have about the etiology of TASS, it's clearly evident that you must thoroughly educate all team members. Make TASS awareness part of everyday life at your facility. Explain the importance of TASS prevention at hiring interviews and hold regular training sessions devoted to it. I see this challenge as a great opportunity for nurses and surgeons to understand each other's realities, develop mutual respect and capitalize on the expertise we each bring to the care of ophthalmic patients. Working together, we can make a difference.