Relationship Between Postphaco Relationship Between Postphaco TASS TASS

and U/S Tip and Sleeve Lumen and U/S Tip and Sleeve Lumen

Soaked in Ortho-PhthalaldehydeSoaked in Ortho-Phthalaldehyde

Guadalupe Cervantes-Coste MDGuadalupe Cervantes-Coste MDVictoria Mercado-Banegas MDVictoria Mercado-Banegas MD

Authors have no financial interestAuthors have no financial interest

Asociación Para Evitar la Ceguera en México, Hospital “Dr. Luis Sánchez- Asociación Para Evitar la Ceguera en México, Hospital “Dr. Luis Sánchez-

Bulnes”Bulnes”

Toxic Anterior Segment SyndromeToxic Anterior Segment Syndrome

SterileSterile post-op inflammatory reaction caused post-op inflammatory reaction caused

non-infectious non-infectious substancesubstance

TOXIC TOXIC damage to intraocular tissuesdamage to intraocular tissues

ACUTE…ACUTE…

… …afterafter anterior segmentanterior segment

SSurgeryurgery

12- 4812- 48 hours hours post-oppost-op

Etiologies:Etiologies:• Ocular medications Antiseptics Ocular medications Antiseptics • Preservatives Preservatives Sterilizing agentsSterilizing agents • Cleaning agentsCleaning agents Talc IOLs Talc IOLs • Viscosurgical devices EndotoxinsViscosurgical devices Endotoxins

Clinical Findings:Clinical Findings:• Descemet´s membrane Descemet´s membrane foldsfolds

• Anterior segment Anterior segment inflammationinflammation

• Diffuse, Diffuse, limbus-to-limbus,limbus-to-limbus, corneal edema corneal edema

• Widespread Widespread endothelial damageendothelial damage

• Fibrin Fibrin depositsdeposits

• Irregular and Irregular and unreactive pupilunreactive pupil

• Ocular Ocular hypertension hypertension & trabecular trabecular

damagedamage

Clinical Case:Clinical Case: Uneventful Uneventful phacoemulsification cataract surgery phacoemulsification cataract surgery ++

acrylic acrylic IOLIOL Infinity Alcon, 2.8 mm incision , continuous OZilInfinity Alcon, 2.8 mm incision , continuous OZil

CDE:CDE: 9 9 trans-op medication: trans-op medication:

Intracameral Intracameral vacomycinvacomycin

Phaco Phaco tip tip andand sleevesleeve cleaned cleaned

Ortho-Phthalaldehyde 2%Ortho-Phthalaldehyde 2% solutionsolution

TASSTASS Medical History:Medical History:

48 yr48 yr woman with metabolic cataracts OU woman with metabolic cataracts OU DM II treated with insulin DM II treated with insulin BCVA: OU: Count fingers 2 BCVA: OU: Count fingers 2 mm

Anterior segment:Anterior segment: OU: Cataracts : NOU: Cataracts : N++++++ posterior sub capsular opacity posterior sub capsular opacity ++ (LOCS III) (LOCS III)

IOL calculation IOL calculation (immersion ultrasound)(immersion ultrasound) SRK-T formulaSRK-T formula powerpower:: +24.00 D +24.00 D

1st day post-phaco:post-phaco: moderate ocular painpain

conjunctival injection

limbus-to-limbus corneal edemacorneal edema

+++ , irregular endotheliumirregular endothelium

cellscells +++

fibrinfibrin bands in 4 quadrants

mydriatic and a-reflective a-reflective pupil

IOP 10 mmHg

Treatment:Treatment: Transeptal , topical and oral Transeptal , topical and oral

steroidssteroids

Topical antibioticTopical antibiotic

3er day post-phacopost-phaco:: Ultrasound:Ultrasound: normalnormal Pain decreased, blurringPain decreased, blurring Anterior segment: no changesAnterior segment: no changes

Adding treatment:Adding treatment: Hypotensors , Hypotensors , NaCl 0.5% NaCl 0.5%

& vitamin C& vitamin C

13 days post-phacopost-phaco:: NoNo pain but blurringpain but blurring Corneal edemaCorneal edema in 3 quadrants in 3 quadrants FibrinFibrin bands at 360° bands at 360° CCells ells ++++++

Iridocorneal Iridocorneal synechiaes synechiaes

20 days post-phaco:post-phaco:

Decreased painDecreased pain

BCVA: BCVA: 1/10 1/10

Corneal Corneal edemaedema in 3 in 3

quadrantsquadrants

CellsCells ++++

FibrinFibrin bands extending to bands extending to

irido-corneal angleirido-corneal angle

IOP 18IOP 18 mmHg mmHg

Same treatmentSame treatment

Anterior capsulotomy Anterior capsulotomy (YAG)(YAG) 22 days post-phaco:post-phaco:

intense ocular pain, headache intense ocular pain, headache

and and blurringblurring conjunctival injectionconjunctival injection epithelial epithelial corneal edemacorneal edema cells ++cells ++ IOP: IOP: 3838 mmHgmmHg

360° 360° angle closureangle closure

Unresponsive Unresponsive to treatment Charbonic anhidrase inhibitors Charbonic anhidrase inhibitors Beta- blockerBeta- blocker Adrenergic agonistAdrenergic agonist

Amhed ValveAmhed Valve implantimplant 1st day post-Valve:post-Valve:

clear cornea, Valve tube clear cornea, Valve tube in-in-

situsitu AC: cells AC: cells ++ ++ IOP: IOP: 44 mmHgmmHg optic nerve cup: optic nerve cup: 7/107/10

Treatment:Treatment: Topical steroids & antibioticsTopical steroids & antibiotics LubricantsLubricants

8–15 days post-Valve:post-Valve:

vision “subjectively” improvedvision “subjectively” improved clear clear corneacornea IOP IOP 7 -127 -12 mmHgmmHg

fibrinfibrin membranemembrane without without changeschanges

22 daysdays post-Valvepost-Valve::

intense intense painpain and blurringblurring ciliary injection ciliary injection ++++

epithelial epithelial corneal edemacorneal edema AC: cellsAC: cells++ ++ IOP: IOP: 3838 mmHgmmHg

360°360° angle closureangle closure

UnresponsiveUnresponsive to treatment: to treatment:

1 month post-Valvepost-Valve:: ““blurring” , VA: CF blurring” , VA: CF 10 10 cmcm diffuse corneal edemadiffuse corneal edema in in

44 quadrants quadrants IOP IOP 14 14 mmHgmmHg

Final diagnosis:Final diagnosis:

““Corneal decompensation”Corneal decompensation”

Differential DiagnosisDifferential Diagnosis signs of infectious signs of infectious absentabsent ultrasound ultrasound NONO disturbance of vitreous disturbance of vitreous NONO response response topical prednisolone and non-steroidal topical prednisolone and non-steroidal final Visual Acuity final Visual Acuity NONO improvement during follow-up improvement during follow-up irregular pupil irregular pupil NOTNOT reactive reactive to light or medicationto light or medication

ConclusionsConclusions

• colorlesscolorless liquid & liquid & bestbest disinfectant cold sterilization disinfectant cold sterilization• enzymes of detergents enzymes of detergents deactivated deactivated to to 140° C140° C or or • most autoclaves reach 120 to 130° C most autoclaves reach 120 to 130° C • small lumen instruments…small lumen instruments…

… … possibly possibly reservoirsreservoirs sterilizing solution residue sterilizing solution residue

TASSTASS from sterilizing solutions residue from sterilizing solutions residue PREVENTABLEPREVENTABLE

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