Relationship Between Postphaco TASS and U/S Tip and Sleeve Lumen Soaked in Ortho-Phthalaldehyde Guadalupe Cervantes-Coste MD Victoria Mercado-Banegas MD Authors have no financial interest Asociación Para Evitar la Ceguera en México, Hospital “Dr. Luis Sánchez- Bulnes”

Toxic Anterior Segment Syndrome Sterile post-op inflammatory reaction caused non-infectious substance TOXIC damage to intraocular tissues ACUTE… …after anterior segment Surgery 12- 48 hours post-op

Etiologies: Clinical Findings: Ocular medications Antiseptics Preservatives Sterilizing agents Cleaning agents Talc IOLs Viscosurgical devices Endotoxins Clinical Findings: Descemet´s membrane folds Anterior segment inflammation Diffuse, limbus-to-limbus, corneal edema Widespread endothelial damage Fibrin deposits Irregular and unreactive pupil Ocular hypertension & trabecular damage

Clinical Case: Phaco tip and sleeve cleaned Uneventful phacoemulsification cataract surgery + acrylic IOL Infinity Alcon, 2.8 mm incision , continuous OZil CDE: 9 trans-op medication: Intracameral vacomycin Phaco tip and sleeve cleaned Ortho-Phthalaldehyde 2% solution

TASS Medical History: Anterior segment: DM II treated with insulin 48 yr woman with metabolic cataracts OU DM II treated with insulin BCVA: OU: Count fingers 2 m Anterior segment: OU: Cataracts : N+++ posterior sub capsular opacity + (LOCS III) IOL calculation (immersion ultrasound) SRK-T formula power: +24.00 D

Treatment: 1st day post-phaco: moderate ocular pain conjunctival injection limbus-to-limbus corneal edema +++ , irregular endothelium cells +++ fibrin bands in 4 quadrants mydriatic and a-reflective pupil IOP 10 mmHg Treatment: Transeptal , topical and oral steroids Topical antibiotic

Adding treatment: Ultrasound: normal Pain decreased, blurring 3er day post-phaco: Ultrasound: normal Pain decreased, blurring Anterior segment: no changes Adding treatment: Hypotensors , NaCl 0.5% & vitamin C 13 days post-phaco: No pain but blurring Corneal edema in 3 quadrants Fibrin bands at 360° Cells +++ Iridocorneal synechiaes

Same treatment Decreased pain BCVA: 1/10 Corneal edema in 3 quadrants 20 days post-phaco: Decreased pain BCVA: 1/10 Corneal edema in 3 quadrants Cells ++ Fibrin bands extending to irido-corneal angle IOP 18 mmHg Same treatment

Anterior capsulotomy (YAG) 22 days post-phaco: intense ocular pain, headache and blurring conjunctival injection epithelial corneal edema cells ++ IOP: 38 mmHg 360° angle closure Unresponsive to treatment Charbonic anhidrase inhibitors Beta- blocker Adrenergic agonist

Amhed Valve implant clear cornea, Valve tube in-situ 1st day post-Valve: clear cornea, Valve tube in-situ AC: cells ++ IOP: 4 mmHg optic nerve cup: 7/10 Treatment: Topical steroids & antibiotics Lubricants 8–15 days post-Valve: vision “subjectively” improved clear cornea IOP 7 -12 mmHg fibrin membrane without changes

“Corneal decompensation” 22 days post-Valve: intense pain and blurring ciliary injection ++ epithelial corneal edema AC: cells++ IOP: 38 mmHg 360° angle closure Unresponsive to treatment: 1 month post-Valve: “blurring” , VA: CF 10 cm diffuse corneal edema in 4 quadrants IOP 14 mmHg Final diagnosis: “Corneal decompensation”

Differential Diagnosis signs of infectious absent ultrasound NO disturbance of vitreous NO response topical prednisolone and non-steroidal final Visual Acuity NO improvement during follow-up irregular pupil NOT reactive to light or medication Conclusions colorless liquid & best disinfectant cold sterilization enzymes of detergents deactivated to 140° C or most autoclaves reach 120 to 130° C small lumen instruments… … possibly reservoirs sterilizing solution residue TASS from sterilizing solutions residue PREVENTABLE Glutaraldehyde