ARTICLE

Toxic anterior segment syndrome: Common

causes
Carolee M. Cutler Peck, MD, MPH, Jacob Brubaker, MD, Sue Clouser, RN, MSN, CRNO,
Chris Danford, Henry E. Edelhauser, PhD, Nick Mamalis, MD

PURPOSE: To identify the most common risk factors associated with toxic anterior segment
syndrome (TASS).
SETTING: Ophthalmic surgical centers in the United States, Argentina, Brazil, Italy, Mexico, Spain,
and Romania.
METHODS: A TASS questionnaire on instrument cleaning and reprocessing and extraocular and in-
traocular products used during cataract surgery was placed on the American Society of Cataract and
Refractive Surgery web site. A retrospective analysis of questionnaires submitted by surgical cen-
ters reporting cases of TASS was performed between June 1, 2007, and May 31, 2009, to identify
commonly held practices that could cause TASS. Members of the TASS Task Force made site visits
between October 1, 2005, and May 31, 2009, and the findings were evaluated.
RESULTS: Data from 77 questionnaires and 54 site visits were analyzed. The reporting centers
performed 50 114 cataract surgeries and reported 909 cases of TASS. From January 1, 2006, to
date, the 54 centers reported 367 cases in 143 919 procedures; 61% occurred in early 2006. Com-
mon practices associated with TASS included inadequate flushing of phaco and irrigation/aspiration
handpieces, use of enzymatic cleansers, detergents at the wrong concentration, ultrasonic bath,
antibiotic agents in balanced salt solution, preserved epinephrine, inappropriate agents for skin
prep, and powdered gloves. Reuse of single-use products and poor instrument maintenance and
processing were other risk factors.
CONCLUSIONS: The survey identified commonly held practices associated with TASS. Understand-
ing these findings and the safe alternatives will allow surgical center personnel to change their
practices as needed to prevent TASS.
Financial Disclosure: No author has a financial or proprietary interest in any material or method
mentioned.
J Cataract Refract Surg 2010; 36:10731080 Q 2010 ASCRS and ESCRS

Toxic anterior segment syndrome (TASS) is a sterile in-
flammatory reaction of unknown incidence that can oc-
cur after anterior segment surgery. It typically presents
within 12 to 48 hours of surgery. The most common
finding is diffuse limbus-to-limbus corneal edema
(Figure 1) secondary to damage from a toxic insult to
the endothelial cell layer. Widespread breakdown of
the bloodaqueous barrier is another hallmark of this
condition, with fibrin in the anterior chamber and hypo-
pyon present in 75% of cases (Figure 2). Damage to the
iris may cause the pupil to dilate or become slightly
irregular, and glaucoma secondary to trabecular mesh-
work damage may also occur.
Treatment with intense topical steroidal agents will
eventually lead to resolution of the inflammation;
however, in severe cases there may be lasting sequelae,
such as permanent corneal edema, glaucoma, and
other effects of chronic inflammation. Various entities
have been shown to cause TASS. These include, but
are not limited to, endotoxin; denatured ophthalmic
viscosurgical devices (OVDs); preservatives such as
benzalkonium chloride, bisulfites, and metabisulfites;
heavy-metal residue, fine-matter particulates, and
substances introduced into the anterior chamber that
are at a pH or concentration that is toxic to the sensitive
endothelial cells. In addition, residue of materials used
in the cleaning and sterilization of ophthalmic instru-
ments are an increasingly important source of TASS.
Members of industry and the American Society of
Cataract and Refractive Surgery (ASCRS) have joined

Q 2010 ASCRS and ESCRS 0886-3350/$dsee front matter 1073

Published by Elsevier Inc. doi:10.1016/j.jcrs.2010.01.030
1074 COMMON CAUSES OF TASS

to create a TASS task force. The goal of this task force is

to educate anterior segment surgeons on the causes,
symptoms, and treatment of TASS and to help investi-
gate outbreaks of TASS.
Questionnaires are available on the ASCRS web
siteA to facilitate the reporting of TASS cases. The in-
formation entered into the questionnaires is reviewed
by members of the TASS Task Force with the goal of
identifying potential causes of TASS. Recommenda-
tions on preventative measures to stop recurrences
are then made. This study will focus on common
practices that may lead to TASS as well as alternative
measures that will help protect patients having
anterior segment surgery.

MATERIALS AND METHODS

The TASS questionnaires were posted on the ASCRS web Figure 1. Toxic anterior segment syndrome after phakic IOL surgery.
site in 2007. A retrospective analysis was performed on ques- Note the limbus-to-limbus corneal edema.
tionnaires submitted between June 1, 2007, and May 31,
2009. The questionnaires address instrument cleaning and
reprocessing practices and surgical protocols as well as were excluded from analysis. Of those excluded, 5
substances and techniques used for cleaning phaco and were duplicates, 2 did not report any TASS cases,
irrigation/aspiration (I/A) handpieces. They also address and 2 were reporting cases of endophthalmitis. Of
products used extraocularly and intraocularly, such as med-
ications, and the reuse of cannulas and other disposable the centers included, 62 were in the United States; 6 in-
items. Responses were analyzed, and commonly held prac- ternational centers responded, with 1 each from Ar-
tices that lead to cases of TASS are presented here. gentina, Brazil, Italy, Mexico, Spain, and Romania.
In addition, members of the TASS Task Force made site Members of the TASS Task Force made 54 site visits,
visits at the request of centers with TASS cases. The visits all in the United States. Overall, 909 cases of TASS
occurred between October 1, 2005, and May 31, 2009. During
the visits, task force members observed preoperative, intra- were reported in 50 114 cataract surgeries performed
operative, and instrument-processing procedures to identify concurrently at the reporting centers that submitted
practices that could be associated with TASS. The data questionnaires. From January 1, 2006, to date, the 54
gathered from these visits are presented. centers visited by a TASS Task Force member reported
367 cases of TASS in 143 919 procedures performed;
RESULTS 61% of them occurred in 2006.
During the study period, 77 TASS questionnaires were Table 1 shows the cleaning procedures associated
submitted through the ASCRS web site, 9 of which with TASS. Inadequate flushing of the phaco and
I/A handpieces after surgery was the most commonly
observed and reported behavior that can lead to TASS.
Submitted: December 15, 2009.
Final revision submitted: January 25, 2010.
Accepted: January 26, 2010.
From the John A. Moran Eye Center (Cutler Peck, Brubaker,
Mamalis), University of Utah, Salt Lake City, Utah; UT Southwestern
Medical Center (Clouser), Dallas, and Alcon Laboratories, Inc.
(Danford), Fort Worth, Texas; and Emory University (Edelhauser),
Atlanta, Georgia, USA.
Supported in part by unrestricted grants from Research to Prevent
Blindness, Inc., New York, New York, USA, to the Department of
Ophthalmology & Visual Sciences, University of Utah.
Presented at the ASCRS Symposium on Cataract, IOL and
Refractive Surgery, San Francisco, California, USA, April 2009.
Corresponding author: Nick Mamalis, MD, John A. Moran Eye
Center, University of Utah, 65 Mario Capecchi Drive, Salt Lake Figure 2. Hypopyon is seen in the anterior chamber of this patient
City, Utah 84132, USA. E-mail: nick.mamalis@hsc.utah.edu. with TASS.

J CATARACT REFRACT SURG - VOL 36, JULY 2010

 COMMON CAUSES OF TASS 1075

Of the 68 centers that filled out questionnaires, more

Table 2. Observations during site visits at centers with diag-
than 60% used less than the recommended 120 cc per nosed cases of TASS.
port (range 2 to 100 cc per port). Other factors were
occluded I/A tips during surgery, a symptom of Frequency of Observation,
inadequate flushing. Observation Category n (%) (N Z 54)
Table 2 shows the observations made during site Inadequate flushing of phaco and 48 (89)
visits at centers with diagnosed cases of TASS. The I/A handpieces and cannulated
top observations were inadequate flushing of phaco equipment
and I/A handpieces and cannulated equipment, use Use of enzymatic cleaners and 43 (80)
of enzymatic cleaners and detergents, use of reusable detergents
cannulas, and inadequate or no manual cleaning of Use of reusable cannulas 37 (69)
instruments. Cleaned instruments were often left on Inadequate or no manual cleaning 35 (65)
towels that were not lint-free, and many centers did of instruments
Use of preserved epinephrine 28 (52)
not train personnel regarding TASS and proper
Reuse of single use 28 (52)
cleaning practices. devices, blades, tips,
Medications given intracamerally or added to a bal- sleeves, etc.
anced salt solution irrigant were another potential Use of tap water with no sterile 27 (50)
source of TASS. Table 3 shows the products associated water final rinse
Inadequate personnel or trays to 23 (43)
allow proper preparation of
Table 1. Cleaning procedures associated with TASS.
instruments
Centers Reporting No immediate cleaning allowing 20 (37)
Practice, n (%) OVD and surgical solutions to
Reported Practice (N Z 68) dry on devices
Use of preserved medicines in the 18 (33)
Amount of flush used for handpieces eye
120 cc or more 18 (26) Reuse of tubing for flushing, latex 20 (37)
!120 cc (range 2100 cc) 42 (62) bulb for irrigation, no training,
Unknown 3 (4) no term sterilization,
Not specified 5 (7) instruments stored on towels
Occluded I/A tips Touching of IOL or patient contact 18 (33)
Yes 27 (40) areas of instruments with
No 41 (60) gloved hands
Final rinse water Off-label use of lidocaine gel 17 (31)
Deionized/distilled 30 (44) Poor instrument maintenance, 15 (28)
Sterile/pyrogen free 22 (32) residual autoclave residue and
Tap 12 (18) instrument mild, rust,
Unknown 2 (3) particulates, lint, etc.
Not specified 2 (3) Use of powdered gloves 15 (28)
Use of enzymatic cleaners Additives added to balanced salt 15 (28)
Yes 36 (53) solution against DFU
No 28 (41) Improper use of prep solutions, 14 (26)
Unknown 4 (6) detergents, and cleaners
Use of US Bath Failure to follow manufacturers 11 (20)
Yes 43 (63) DFU, including
No 25 (37) no air flush, use of unapproved
Frequency of cleaning US bath enzymatics
After each use 8 (19) Use of postoperative ointment in 11 (20)
More than once daily 31 (72) clear cornea cases
Unknown 3 (7) Povidoneiodine placed in eye at 9 (17)
No cleaning protocol 1 (2) end of procedure
Ophthalmic instruments separated for Incorrect concentration of 4 (7)
cleaning detergent and enzymatic
Yes 55 (81) cleaners used
No 9 (13) Lack of routine cleaning of US 2 (4)
Dont know 4 (6)
DFU Z directions for use; I/A Z irrigation/ aspiration; IOL Z intraocu-
I/A Z irrigation/aspiration; US Z ultrasonic lar lens; OVD Z ophthalmic viscosurgical device; US Z ultrasound

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1076 COMMON CAUSES OF TASS

assistance when cases of TASS occur, in an effort to

Table 3. Products associated with TASS and their use.
prevent future cases, not all cases of TASS may be rec-
Centers Reporting ognized or centers may choose not to report cases if
Product Used Use, n (%) only a small percentage of their cataract surgeries re-
Antibiotic added to BSS
sult in TASS and a problem is not perceived. Because
Vancomycin 16 (24) we do not have a tally of all TASS cases that occur in
Gentamicin 1 (1) the United States, and because those reporting cases
None 50 (74) all reported various timeframes in which the reported
Unknown 1 (1) cases occurred for each center, we cannot calculate the
Intracameral antibiotic agents incidence of TASS from our data.
Vancomycin 7 (10) The most frequently identified practice associated
Cefuroxime 3 (5) with TASS is inadequate cleaning of phaco and I/A
Moxifloxacin 3 (5) handpieces after use. To be most effective, the manu-
Cefazolin sodium 1 (1)
facturers directions for use should be strictly followed
None 54 (79)
and handpieces should be wiped with a lint-free cloth,
Preserved epinephrine in BSS
Yes 18 (36)
immediately immersed in sterile water until they are
No 32 (64)
flushed, or both.13 This was not done at 89% of centers
Preserved intracameral anesthetic visited. This practice is imperative to prevent residual
agent OVD and debris from drying within the handpiece
Yes 3 (6) and tips before they are flushed. This is especially
No 44 (94) important because dried OVD denatures after sterili-
zation at high temperatures and if this or other
BSS Z balanced salt solution
particles or debris are irrigated into the anterior cham-
ber, TASS may result.4 While instruments are still
moist, they must be flushed with 120 mL of fluid per
with TASS. Antibiotic agents were the most common port, or more if indicated in the manufacturers
additives to balanced salt solution; some centers directions for use. This can be performed with tap
added epinephrine with preservatives or stabilizers. water as deionized water. However, the final flush
Slightly more than 20% of centers used intracameral must then consist of sterile distilled or sterile deionized
antibiotic agents; 17 centers (31%) used preserved water. If cleaned instruments are stored on towels, the
topical lidocaine gel preoperatively. towels should be lint free.3,5,6
Poor instrument maintenance was also pervasive. In addition to addressing the problem of inadequate
Autoclaves were found to have autoclave residue, flushing, it is important to address some of the reasons
instrument milk, rust, particulates, or lint at more it occurs. Even if an adequate cleaning protocol is in
than a quarter of the sites. Other sites failed to follow place, if surgical centers are understaffed or there are
manufacturers directions for use when cleaning too few surgical trays to allow proper cleaning of
instruments; this included omitting an air flush of instruments between cases (as observed at 43% of cen-
cannulated equipment, although this had been recom- ters visited), time constraints will lead to insufficient
mended, or using enzymatics during processing when flushing and patients will be placed at risk for TASS.
this was not approved. The reuse of tubing for flushing and latex bulbs for
In centers in which non-ophthalmologic surgeries irrigation is also a potential issue. These items are
were performed, ophthalmic instruments were pro- difficult to clean and hard to sterilize, which can lead
cessed along with instruments from other types of to improper processing between cases.
surgeries at 9 (13%) centers responding by question- It is imperative that surgical centers ensure that
naire; 4 (6%) respondents did not know whether there are adequate numbers of personnel and surgical
instruments were separated at the time of processing. trays to allow all steps of cleaning and sterilization to
be completed between uses of ophthalmic instru-
ments. It is also crucial that personnel are trained
DISCUSSION sufficiently in the causes of TASS and the proper steps
The data in this analysis were self-reported in the case of cleaning and sterilization.2,3,79
of the questionnaires or the result of self-referrals for Eighty percent of surgical centers visited and 53% of
site inspection in relation to TASS cases. The data those responding via questionnaire were using enzy-
from the site visits were taken from written reports matic detergents in the processing of their ophthalmic
submitted at the end of the visit. Although there is mo- instruments. The benefit of using enzymatic deter-
tivation on the part of surgical centers to obtain gents to clean ophthalmologic instruments has not

J CATARACT REFRACT SURG - VOL 36, JULY 2010

 COMMON CAUSES OF TASS
been established and may actually be prohibited in the
manufacturers directions for use for specific products.
Furthermore, the use of detergents mixed at the wrong
concentration has been linked to TASS outbreaks.10
Seven percent of centers visited were using the wrong
concentration of detergents, putting their patients at
risk for TASS as a result of residual detergents and in-
complete rinsing.
Enzymatic detergents often have the exotoxin sub-
tilisin or a-amylase enzymes as their active ingredi-
ents. These are only deactivated at temperatures
higher than 140 C, and most autoclaves do not reach
temperatures higher than 120 C to 130 C. Thus, it is
likely that residue from enzymatic detergents will
build up on reused instruments.11 Human and rabbit
studies evaluating the effect of enzymatic detergents
on the anterior chamber showed dose-related corneal
swelling; ultrastructural damage to the endothelial
layer, leading to increased corneal permeability; and
an increased inflammatory response in the iris.12
The purpose behind the use of enzymatic detergents
is to rid ophthalmic instruments of debris. If instru-
ments are kept moist immediately after use before
flushing and if proper flushing with an adequate
volume is performed, there should be no adherent
debris and thus no need for enzymatic detergents. If
detergents are used, it is imperative that strict
attention is paid to the dilution and expiration date.
Furthermore, instruments processed with detergents
must be rinsed with copious amounts of fluid accord-
ing to the manufacturers directions for use. Recom-
mended volumes should be considered a minimum
volume, and the final rinse should be performed
with sterile distilled or sterile deionized water.1
Sixty-three percent of reporting facilities used an
ultrasonic bath as part of the processing of their
ophthalmologic instruments. This has been associated
with the accumulation of heat-stable endotoxins
produced by bacteria in the bath water.13 Endotoxin
remaining on instruments after cleaning and steriliza-
tion can induce the inflammatory reaction of TASS.
As with enzymatic detergents, the purpose of the
ultrasonic bath is to dislodge dried debris from instru-
ments, particularly OVDs. Again, if instruments are
kept moist after use and then properly flushed with
an adequate volume of water, there should be no
adherent debris and thus no need for an ultrasonic
bath.
If an ultrasonic bath is used, the manufacturers
directions for use for instruments should be verified
because some instruments should not be processed
in this manner. In addition, the ultrasonic bath should
be designated for medical use only and the manufac-
turers directions for maintenance should be strictly
followed. Furthermore, all gross material should be
J CATARACT REFRACT SURG - VOL 36, JULY 2010
1077
completely removed from instruments before they
are immersed in bath water. Then, after each use,
and if in accordance with the manufacturers direc-
tions for use, the bath water should be emptied and
the tub cleaned with an Environmental Protection
Agencyregistered facility-approved disinfectant.
This should be followed with a rinse using volumes
of sterile or tap water adequate to remove the cleaning
agent completely. Then, 70% to 90% ethyl or isopropyl
alcohol should be used to clean the tub if this is in
accordance with the manufacturers directions for
use and not associated with a risk of fire. Endotoxin
can be removed from the walls of the bath by wiping
the walls with ethyl or isopropyl alcohol.1,14 The tub
should then be dried completely with a lint-free cloth
and refilled immediately before use.
This process of cleaning must be followed after each
use to prevent endotoxin buildup. However, only 19%
of centers responding to the questionnaire cleaned the
ultrasonic bath after each use as recommended and 4%
of centers visited had no protocol for routine cleaning
of the ultrasonic bath.
Of centers reporting via questionnaire, 25% added
antibiotic agents to the balanced salt solution irrigant
and 21% used intracameral antibiotic agents. The use
of antibiotic agents may be associated with toxicity
when they are included in anterior chamber irrigant
and when injected intracamerally at the end of
a case.7 If antibiotic agents are improperly mixed, the
concentration may be too high or the pH incorrect,
both of which can prove toxic to the anterior chamber
tissues.
The use of vancomycin and gentamicin sulfate in
anterior segment surgery has been described for
prophylaxis against endophthalmitis.15 However, the
use of these products is associated with concerns
over vancomycin-resistant organisms as well as
aminoglycoside-related macular toxicity, respectively.
Furthermore, the concentration used in irrigating
solution and the time of contact with a possible
contaminant is inadequate for their bacteriostatic or
bacteriocidal properties to function.
Studies to evaluate intraocular cefotaxime for endo-
thelial toxicity have been performed. A prospective
randomized masked study of 66 patients by
Kramann16 found no toxicity with 0.4 mL of 0.25%
cefotaxime in the anterior chamber. Other studies
evaluating the use of cefuroxime17,18 found no toxicity
and a role for the agent in endophthalmitis prevention.
These findings were strengthened with the results in
a prospective randomized partially masked study in
which 1.0 mg cefuroxime in 0.1 mL normal saline
injected into the anterior chamber after surgery de-
creased the risk for endophthalmitis (0.05% incidence
rate when counting all endophthalmitis cases)
1078 COMMON CAUSES OF TASS
compared with a placebo or perioperative treatment
with a third-generation fluoroquinolone drop.19 How-
ever, an endophthalmitis incidence of 0.056% was
found with the perioperative use of a fourth-
generation fluoroquinolone drop.20
At this time, because there are effective alternatives
and because there is a risk for TASS from toxicity due
to the wrong concentration or pH of an improperly
mixed antibiotic agent, use of intracameral antibiotic
agents must be viewed with caution.7
Of surgical centers visited, 52% were using preserved
epinephrine in balanced salt solution and 37% were
using other preserved medications intracamerally. In
addition, at least 36% of questionnaire respondents
were adding preserved epinephrine to balanced salt so-
lution. Although bisulfites are not technically a preser-
vative but rather an antioxidant, they can also cause
ocular toxicity. Benzalkonium chloride (BAC), a com-
monly used preservative, is highly toxic to ocular tis-
sues,21 and rabbit studies22 show a dose-response
pattern of conjunctivitis, flare, iritis, and corneal
changes. In the rabbit study, a safety factor of 10 was
used to set the safest intraocular concentration at
0.001%, a level at which the preservative efficacy is
questionable.
An outbreak of TASS was associated with the use of
Eye Stream rinse solution (Alcon Laboratories) pre-
served with 0.01% BAC, in which a concentration of
0.013% was inadvertently irrigated into the anterior
chamber.23 Toxic anterior segment syndrome has
also been reported after use of OVD preserved with
BAC,24 and the use of lidocaine gel preserved with
BAC was recently implicated in a TASS outbreak
(unpublished data). We recommend that no products
with preservatives or additives (stabilizers), such as
bisulfites and metabisulfites, be used in the anterior
chamber.7,11
Twenty percent of sites visited were using intraocular
ointment after clear corneal cases. This practice was
associated with a TASS outbreak in 8 cases. Of the
patients affected, 4 required penetrating keratoplasty
and glaucoma with no light perception developed in
1 patient. Examination of each of these patients showed
that petroleum-based ophthalmic ointments had
gained access to the anterior chamber through a clear
corneal wound that was patched postoperatively.25
Site visits showed that 69% of centers were using
reusable cannulas. Cleaning cannulas is difficult to
perform and validate, and there are no manufacturers
directions for use. Furthermore, if the cannulas are
processed with enzymatic detergents, residue will
likely build up and then be irrigated into the anterior
chamber. Therefore, when possible, disposable cannu-
las should be used.7,11 In addition, it is important that
single-use devices, such as cannulas, blades, tips, and
J CATARACT REFRACT SURG - VOL 36, JULY 2010
sleeves, not be reused. Fifty-two percent of centers vis-
ited were reusing these items. The reprocessing of
these items is regulated and enforced by the U.S.
Food and Drug Administration.B
Poor autoclave maintenance, including autoclave
residue, instrument milk, rust, particulates, and lint
within the autoclave, was documented at 28% of cen-
ters visited. Any such contaminants would be suspect
for causing TASS. One documented example of poor
maintenance leading to heavy-metal contamination
of instruments showed carryover of sulfate, silica,
copper, zinc, and nickel from feedwater into steam
condensates associated with TASS outbreaks.26 This
was found to be the result of changing from flushing
and draining the steam generator once a week to
once every 4 to 8 weeks when maintenance was
outsourced.
Surgical centers should make sure that preventive
maintenance, cleaning, and inspection of autoclaves
are performed as directed by the manufacturers direc-
tions for use and also be documented. In addition, it
should be verified that the sterilizer is functioning
properly on a daily basis where possible, or at least
weekly. Steam sterilization should be performed in
accordance with published guidelines, and instru-
ments should be sterilized according to directions for
use provided by their manufacturer as well as the
sterilizers manufacturer. A terminal sterilization
should be performed at the end of each surgical
day.3,5 Glutaraldehyde should not be used in the
sterilization process because it is highly toxic to the
tissues of the anterior chamber and will cause TASS
if inadequately rinsed.27 Plasma gas sterilization has
also been shown to lead to degradation of brass to
copper and zinc on cannulated surgical instruments
and should not be used because this has led to heavy
metalinduced TASS.28
The use of powdered gloves can also be a source of
TASS because the powder can be toxic to the anterior
chamber structures. Of sites visited, 28 were using
powdered gloves during anterior chamber cases.
Powder-free gloves can also pose a risk for develop-
ing TASS. These gloves are made with a releasing com-
pound that allows the glove to be easily removed from
the mold after production. The releasing compound
stays on the surface of the gloves and can cause ante-
rior chamber toxicity if it comes in contact with IOLs
or any instrument entering the anterior chamber.C
This can occur if the IOL or other instruments entering
the anterior chamber are touched during cataract
surgery, a practice observed at 18 surgical centers
visited (33%).
Of questionnaire respondents, at least 13% indicated
that ophthalmic instruments were processed for clean-
ing alongside dirty surgical trays from other,
 COMMON CAUSES OF TASS
nonophthalmic surgeries. However, ASCRS experts
recommend that all ophthalmic instruments be kept
separate from other types of surgical instruments
during all steps of processing to avoid contamination
with bioburden or cleaning chemicals.1
In conclusion, analysis of data reported in question-
naires as well as in site visits from centers reporting
TASS were analyzed carefully. The most common fac-
tors associated with TASS were inadequate cleaning
and flushing of ophthalmic instruments and handpie-
ces. This included the use of detergents and ultra-
sound water baths. In addition, the use of intraocular
medications with preservatives or additives was
associated with TASS in a significant number of cases.
The proper cleaning and sterilization of ophthalmic in-
struments, as well as proper attention regarding the
use of any intraocular medications during surgery,
can help prevent the occurrence TASS. These findings
continue to validate the need to follow the recom-
mendations detailed in the recommended practices
document created by the TASS Task Force.1
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J CATARACT REFRACT SURG - VOL 36, JULY 2010