Surgeon incorporates slit lamp exam as part of TASS protocol

Los Alamitos, CA-Larry Geisse, MD, a surgeon in private practice in Los Alamitos, CA, recently encountered a case of toxic anterior segment syndrome (TASS) that might hold lessons for other clinicians in the treatment of TASS.

His first case of the day was a 65-year-old male with no history of eye problems who underwent uneventful cataract surgery in his right eye. About half an hour later, after Dr. Geisse had finished his second procedure, he encountered the first patient in the recovery area where he was waiting for a ride home. He mentioned to Dr. Geisse that vision in the operated eye had become very blurry after being clear immediately following surgery.

"I got a penlight and looked at it, and from that distance it seemed completely clear," Dr. Geisse said. "The only thing I noticed was that the pupil was peaked at 6 o'clock, and that was really unusual."

"I was shocked to see that the whole anterior chamber was full of fibrin material, and it was pulling on the pupil enough in that area to cause it to peak or to point outward," Dr. Geisse said. "It was obvious to me that 30 minutes after surgery I had a big problem on my hands."

Assuming that some toxic substance in the anterior chamber was causing this reaction, he decided to take the patient back to the operating room immediately to clean the chamber and remove the toxin.

He used a different lot number of balanced salt solution and a different irrigation and aspiration handpiece to clean and rinse the chamber, and then administered 0.5 ml of dexa-methasone (Decadron, Merck) subconjunctivally at the end of the case.

He re-examined the patient with the slit lamp after he had been in the recovery area for 15 or 20 minutes and found that the anterior chamber still contained a substantial amount of fibrin, although perhaps only about half as much as before the cleaning and rinsing, and that the pupil was still peaked at 6 o'clock.

At that point, Dr. Geisse placed the patient on the standard postoperative schedule of drops and arranged to see him the following day.

"When I saw him the next day in my office, the eye looked completely normal," he said. "I would not have known that anything had gone wrong had I not seen it the day before."

Visual acuity was 20/20, the cornea was clear, and there was only a minimal amount of flare. No fibrin was apparent, and the pupil was once again round.

"My belief is that if I had not seen him until the next day it would have been a disaster," Dr. Geisse said. "At that point I don't know if it would have been worth going back to the operating room. I was happy that he had brought it up and that I had looked."

This case was one of three incidents of TASS that occurred in a short period at the surgery center where Dr. Geisse works, which prompted a change in their postoperative routine.

"We started taking every patient before he or she went home and looking at the eye under the slit lamp to make sure that everything looked normal," he explained. "We made it a routine in our surgery center to do that for a while until we figured out the cause. It was obvious this worked, and it was too critical to miss it."

Analyzing the three TASS cases, the surgeons realized that each had been the first case of the day and speculated that an enzymatic cleaner used on the instruments overnight was not being thoroughly rinsed, causing a toxic reaction in the first patient of the following day.

The two patients whose cases of TASS were not detected until the following day did not recover as quickly as the patient Dr. Geisse treated.