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Outbreak of Toxic Anterior Segment Syndrome Following Cataract Surgery Associated With Impurities in Autoclave Steam Moisture

Published online by Cambridge University Press:  21 June 2016

Walter C. Hellinger ,
Saiyid A. Hasan ,
Laura P. Bacalis ,
Deborah M. Thornblom ,
Susan C. Beckmann ,
Carina Blackmore ,
Terri S. Forster ,
Jason F. Tirey ,
Mary J. Ross  and
Christian D. Nilson
...Show all authors
Walter C. Hellinger*
Affiliation:
Division of Infectious Diseases, Mayo Clinic, Jacksonville, Florida
Saiyid A. Hasan
Affiliation:
Department of Ophthalmology, Mayo Clinic, Jacksonville, Florida
Laura P. Bacalis
Affiliation:
Division of Infectious Diseases, Mayo Clinic, Jacksonville, Florida
Deborah M. Thornblom
Affiliation:
Outpatient Surgery Center, Mayo Clinic, Jacksonville, Florida
Susan C. Beckmann
Affiliation:
Outpatient Surgery Center, Mayo Clinic, Jacksonville, Florida
Carina Blackmore
Affiliation:
Florida Department of Health and Epidemiology, Jacksonville
Terri S. Forster
Affiliation:
Water Quality Laboratory, Environmental and Applied Microbiology Section, Epidemiology and Laboratory Branch, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Jason F. Tirey
Affiliation:
Steris Corporation, St. Louis, Missouri
Mary J. Ross
Affiliation:
Steris Corporation, St. Louis, Missouri
Christian D. Nilson
Affiliation:
John Moran Eye Center, Salt Lake City, Utah
Nick Mamalis
Affiliation:
John Moran Eye Center, Salt Lake City, Utah
Julia E. Crook
Affiliation:
Division of Biostatistics, Mayo Clinic, Jacksonville, Florida
Rick E. Bendel
Affiliation:
Department of Ophthalmology, Mayo Clinic, Jacksonville, Florida
Rajesh Shetty
Affiliation:
Department of Ophthalmology, Mayo Clinic, Jacksonville, Florida
Michael W. Stewart
Affiliation:
Department of Ophthalmology, Mayo Clinic, Jacksonville, Florida
James P. Bolling
Affiliation:
Department of Ophthalmology, Mayo Clinic, Jacksonville, Florida
Henry F. Edelhauser
Affiliation:
Emory Eye Center, Atlanta
*
Division of Infectious Diseases, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 (hellinger.walter@mayo.edu)
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Abstract

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.

Conclusion.

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.

Type
Original Articles
Information
Infection Control & Hospital Epidemiology , Volume 27 , Issue 3 , March 2006 , pp. 294 - 298
Copyright
Copyright © The Society for Healthcare Epidemiology of America 2006

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