Outbreak of toxic anterior segment syndrome following cataract surgery associated with impurities in autoclave steam moisture.
BACKGROUND
Toxic anterior segment syndrome (TASS), a complication of cataract surgery, is a sterile inflammation of the anterior chamber of the eye. An outbreak of TASS was recognized at an outpatient surgical center and its affiliated hospital in December 2002.


METHODS
Medical records of patients who underwent cataract surgery during the outbreak were reviewed, and surgical team members who participated in the operations were interviewed. Potential causes of TASS were identified and eliminated. Feedwater from autoclave steam generators and steam condensates were analyzed by use of spectroscopy and ion chromatography.


RESULTS
During the outbreak, 8 (38%) of 21 cataract operations were complicated by TASS, compared with 2 (0.07%) of 2,713 operations performed from January 1996 through November 2002. Results of an initial investigation suggested that cataract surgical equipment may have been contaminated by suboptimal equipment reprocessing or as a result of personnel changes. The frequency of TASS decreased (1 of 44 cataract operations) after reassignment of personnel and revision of equipment reprocessing procedures. Further investigation identified the presence of impurities (eg, sulfates, copper, zinc, nickel, and silica) in autoclave steam moisture, which was attributed to improper maintenance of the autoclave steam generator in the outpatient surgical center. When impurities in autoclave steam moisture were eliminated, no cases of TASS were observed after more than 1,000 cataract operations.


CONCLUSIONS
Suboptimal reprocessing of cataract surgical equipment may evolve over time in busy, multidisciplinary surgical centers. Clinically significant contamination of surgical equipment may result from inappropriate maintenance of steam sterilization systems. Standardization of protocols for reprocessing of cataract surgical equipment may prevent outbreaks of TASS and may be of assistance during outbreak investigations.
Division of Infectious Diseases, Mayo Clinic, Jacksonville, FL 32224, USA. hellinger.walter@mayo.edu
Walter C
WC
Hellinger
Saiyid A
SA
Hasan
Laura P
LP
Bacalis
Deborah M
DM
Thornblom
Susan C
SC
Beckmann
Carina
C
Blackmore
Terri S
TS
Forster
Jason F
JF
Tirey
Mary J
MJ
Ross
Christian D
CD
Nilson
Nick
N
Mamalis
Julia E
JE
Crook
Rick E
RE
Bendel
Rajesh
R
Shetty
Michael W
MW
Stewart
James P
JP
Bolling
Henry F
HF
Edelhauser
D000869:Anterior Eye Segment; D002387:Cataract Extraction / Q000706:statistics & numerical data*; D004196:Disease Outbreaks; D004866:Equipment Contamination; D006801:Humans; D007249:Inflammation / Q000453:epidemiology* / Q000209:etiology / Q000473:pathology; D008499:Medical Records; D014876:Water Pollution