Solving TASS: Maximizing
Patient Safety in VA Operating
Rooms
Mary K. Daly, MD
Chief of Ophthalmology
VA Boston Healthcare System
Associate Professor of Ophthalmology
Boston University
What is TASS?
Toxic Anterior Segment Syndrome
• Acute sterile inflammatory reaction
following anterior segment surgery
What is TASS?
Toxic Anterior Segment Syndrome
• Clinical Findings:
– limbus-to-limbus corneal edema secondary to toxic
damage of endothelium
– Aggressive AC reaction, fibrin, and hypopyon
– Dilated, irregular pupil secondary to toxic damage to iris
– Initial hypotony  elevated IOP/glaucoma due to TM
damage
Photos courtesy of:
Henry F. Edelhauser, PhD
Ferst Professor of
Ophthalmology &
Director of Ophthalmic
Research
Emory University
Atlanta, GA
Treatment
• Intense topical steroids
• Lasting sequelae  corneal edema,
glaucoma, devastating visual loss
How Extensive is the Problem
• Firm data on the incidence of TASS are
lacking
• Tends to occur in clusters ranging from a
few cases to up to 20 cases per cluster
How Extensive is the Problem
2006 North American Outbreak
• 2006 -- Major Outbreak throughout much of
North America with >100 surgical centers
reporting cases
• Formation of TASS Task Force chaired by
Nick Mamalis and Henry Edelhauser and
included representation from the ASCRS,
AAO, ASORN, AORN, APIC, CDC, and
FDA
How Extensive is the Problem
2006 North American Outbreak
• Extensive Analysis did not find a single factor but rather
multiple potential factors, with most common offenders
(courtesy of Dr. Henry Edelhauser):
– Inadequate cleaning and flushing of ophthalmic instruments
and handpieces
– Use of detergents
– Shared ultrasonic water baths
– Intraocular medications with preservatives
• Resulted in special report on recommended practices for
cleaning and sterilizing intraocular surgical instruments
to prevent TASS
Case
• Togus Maine VA
– In 1865, as the Civil War was drawing to a close, President
Lincoln signed an act establishing the National Asylum (later
changed to Home) for Disabled Volunteer Soldiers. The Eastern
Branch at Togus, Maine was the first of these homes and admitted
the first Veteran in November 1866
Case
• 85 year old male referred for:
– persistent anterior uveitis
– recurrent CME despite chronic topical Pred
Forte, Acular, and two subtenons kenalog
injections
– ‘superior angle cyst’
• All following uneventful phacoemulsification
surgery more than 2 years prior
• Continued topical pred forte and acular
• Took to OR for AC washout and removal of
‘globule’
• Irrigated AC well with automated I/A
• Sent specimen to Prof Jamie McKnight
The McKnight Lab, Dept of
Physiology and Biophysics at
BUSM
NMR
Antibiotic ointment (ilotycin) dissolved in
duturated benzene
Benzene – d6 (99.95%)
Ilotycin Ointment
Unknown Specimen
VA Boston
• Intraocular ung/inflammation/CME referred
to VA Boston
• One case of fibrin, pupillary membrane
post-op day #1 routine PK for KC
• Several cases of ‘fiber’ noted intraop and/or
post-op routine phaco
What’s the potential for TASS in
VA System as a whole?
• Approximately 40,000 ophthalmology cases/year
in the VA
– Boston performs ~ 1000/year
• TASS Task Force lead by Dr. Edelhauser, Dr.
Mamalis, Sue Clouser found 909 cases of TASS
out of 50 114 cataract surgeries (reported from 77
questionnaires)
• Extrapolate to VA ~ potential for 725 cases in VA
each year
Preventative Steps Taken at VA
Boston
• Investigated procedures from the operating
room, to SPD, and back
• Interviewed nursing staff, residents,
attendings, SPD and pharmacy staff
• Observed instrument handling
• Reviewed topical and intracameral
medicines and solutions
Steps Taken at VA Boston
• Initial findings: preserved epinephrine in
carts, sterile cloth towels in kits (fibers),
reusable cannulas, ointment being used by
some at end of cases, variable
understanding of SOPs (precleaning and
sterilization) amongst staff, unclear how
long used trays were sitting around before
being sterilized
Next Steps at VA Boston
• Reviewed all ASCRS/ASORN
recommendations and modified policies and
procedures accordingly
Next Steps
• Called the TASS Detective
– Sue Clouser, RN MSN CRNO
– Works with ASCRS
– > 100 TASS investigations
TASS Detective Report
Several different areas
needing modification
Recommendations specifically targeted:
–
–
–
Cleaning and flushing of ophthalmic
instruments and handpieces
Use of detergents
Ultrasonic water baths
VA Boston
Conclusions and Solutions to Prevent
TASS
• Distributed ASCRS/ASORN Recommendations
on the prevention of TASS
• Reviewed with staff and implemented the
recommedations of TASS Detective, Sue Clouser
• Established continuing education program for OR,
Clinic, Pharmacy, SPD staff
– Joint educational lectures q6 months on policies,
procedures, recognition of TASS Promoted open
discussion, awareness, team effort
VA Boston
Solutions to Prevent TASS
• Empowered every staff member to
familiarize themselves with the OR
processes and procedures including SPD
• Reiterated to everyone importance of
double checking all solutions/meds for
themselves to ensure correct concentrations
and preservative-free
VA Boston
Solutions to Prevent TASS
• Weekly Surgical Complications Conferences
– with non-punitive reporting mechanisms and open,
collegiate discussions and case-presentations
– Formal written peer review done on every complication
– Clearly define reportable findings
•
•
•
•
Fibrin
Hypopyon
Severe corneal edema/edema inconsistent with case
Pain, reduced vision, red eye inconsistent with case
Ophthalmic Surgical Outcomes
Committee
• VA Boston is one of the five pilot sites in the
OSOD Committee under direction of Mary
Lawrence (Deputy Director of the Vision Center
of Excellence)
• Tracking ophthalmic surgery data in order to
establish a prospective outcome-based program
to enhance the quality of cataract surgery across
the VA and the country
• Instrumental in monitoring data and identifying
and preventing potential outbreaks
Important References
*Focal Points, N. Mamalis, Module 10, 2009 (AAO)
*Instrument Re-processing Product Questionnaire Survey (ASCRS)
*Mammalis N, Edelhauser HF, Dawson DG, Chew J, LeBoyer RM, Werner L. Toxic
anterior segment syndrome. J Cataract Refract Surg 2006;32:324.
*On-line www.tassforce.com
*ASCRS and ASORN Toxic anterior segment syndrome task force guidelines.
Recommended practices for cleaning and sterilizing intraocular surgical instruments,
June 15 2009, http://www.ascrs.org/TASS/upload/TASS_guidelines-CBC.pdf
*Cohen AW, Oetting TA. Toxic Anterior Segment Syndrome (TASS): A System's Based
View of a Day in the Life of a Canula. EyeRounds.org. May 7, 2008 [cited --insert
today's date here -- ]; Available from: http://www.EyeRounds.org/cases/85-ToxicAnterior-Segment-Syndrome-TASS-Systems-Based.htm.
The End