 Good morning, my name is Abid Faroukhi and I'm also an ophthalmic pathology and research fellow with the mammalis in Warner lab Thank you to my colleagues for giving us such a fascinating talk on intraocular lenses I hate to break the trend, but I'm going to be talking about another subject that I've become very intimately involved with as a member of the ACS ASCRS form task force Toxic anterior segment syndrome So I'll start off with a case presentation and talk about what TAS is that causes diagnosis treatment and how we can kind of Assess the outcomes of TAS So we have a case present to a case report from the VA hospital in Indiana in which five men ages 64 through 81 years Underwent a clear corneal incision Faco emulsification surgery with insertion of an Alcon SN 60 WF lens There was significant past medical history in four out of the five men for hypertension and diabetes However, none of them had any significant ocular history All surgeries had were the similar in respect to the cataract densities The amount of energy dissipated during the procedures and the length of the surgery itself All medications and solutions used were the same For each surgery and there were no recent changes to any medications our surgical procedures our surgical equipment at the VA facility On postoperative day one all patients had a diffuse one plus to two plus corneal edema a two plus to four plus anterior Chamber white blood cells two of the patients had hypopionic vibration Fiber and formation in the anterior chamber and none of the patients complained of ocular pain visual acuity range from 20 70 to 2400 and all patients had normal intraocular pressures These patients were felt to have a diagnosis of toxic anterior segment syndrome and were treated accordingly So I'll refer to toxic anterior segment syndrome as TAS now and TAS is a sterile inflammation of the anterior segment following any anterior segment surgery most commonly this complication arises after cataract surgery however any anterior segment surgery can result in TAS Such as glaucoma surgery or a corneal transplant Presentation of the symptoms of TAS generally occur within 12 to 48 hours Postoperatively with the majority of the patients presenting within the first 24 hours The pathophysiology of this process is thought to be an activation of the inflammatory cascade Mediate by a toxic insult that enters the anterior segment of the eye either Deering or immediately after the surgery this inflammatory cascade causes the toxic Substance is Is damaging to the corneal endothelium and other sensitive tissues in the anterior segment of the eye causing Corneal edema from the damaged corneal endothelium endothelium also the trabecular mesh work in the iris are also sensitive structures in the eye for increasing the risk of glaucoma or other iris defects the prognosis of The inflammation and this Cascade this cascade varies depending on the amount and the type of substance that enters the anterior segment How long that substance is within the anterior segment and how long before treatment is initiated? So some of the symptoms that patients will come into the clinic presenting with our blurred vision Conjunctival injection and photophobia however pain is usually absent and this will be helpful in Distinguishing tasks from another very critical diagnosis, which I will discuss in a few minutes Some of the signs on corn on slit lamp examination is this characteristic Limbis to Limbis corneal edema You'll see increased cell and flare in the anterior chamber You'll also possibly see hypopion formation and Vibrant formation and a dilated or irregular pupil and increased intraclural pressure These last two are more commonly seen with more severe cases of tests However, it is also likely that Patients will present with some of these findings and just a quick note on the increased intraclural pressure Usually most patients will have normal pressures upon presentation But as the healing process resumes their pressures will increase However, some patients will present with a more severe case with damage to the tobacco to mesh work already and we'll have Intraclural pressures up to 50 to 60 So here are some of the pictures of the findings that I was just discussing You'll have a diffuse limbo to limbo corneal edema on the left You see this increased conjunctival injection with the hypopion and it in the anterior chamber and this last picture is a picture of a Severe case of tasks in which there is iris atrophy with a fixed dilated irregularly shaped pupil and iris droma defect allowing for trans illumination of the iris It's difficult to see here, but the haptics are visual are able to be visualized through the iris So one of the distinguishing Diagnoses that is very important to rule out when thinking of tasks is infectious endophthalmitis So this chart right here is to help distinguish some of the main differences between the two entities One of the first I want to draw your attention to is the onset of symptoms in task This generally occurs very acutely within 12 to 48 hours however, and infectious endophthalmitis it takes a little bit longer usually two to seven days postoperatively and Even the most very virulent strains of bacteria won't result in symptoms until a few days after the core corneal edema is Limbis-to-limbis and I hate to sound repetitive, but it's very characteristic in tasks in infectious endophthalmitis You might have focal edema or none at all and in the anterior segment inflammation It's generally a little bit more more severe in infectious endophthalmitis with greater Hypopion and fiber information and also as I mentioned earlier the pain usually with infectious endophthalmitis You'll have the majority of patients complaining of pain Whereas the opposite is true of tasks and if there's any ever if there's ever any Uncertainty about the diagnosis of tasks obtaining a gram stain and culture obtaining aqueous and vitreous fluid for a gram stain and culture and Is very important in ruling out Infectious endophthalmitis so here are some of the findings characteristic of infectious endophthalmitis the Conjunctival injection is much greater. There isn't a diffuse limbo-to-limbo corneal edema. However, there is greater Hypopion and then also the Visualization of the posterior pole will be obscured by a classification of the vitreous so moving on to the causes of tasks given that the causes of tasks are numerous and varied Evaluation of all surgical procedures and protocols when a case of tasks arises to simplify I'll break down I'll categorize the causes of tasks into two of the more common causes intracular medications and solutions can Commonly cause tasks balanced solutions any solutions using the eye can cause tasks if there is an irregular pH measurements Ionic composition is off our even Or if there's some contamination within the solution more commonly topical ophthalmic drops that contain preservatives and stabilizing agents are Damaging to the corneal endothelium which is very sensitive to these agents and that's more one of the more common causes of tasks FNF RIN that's added to VSS during the surgery to help with pupil dilation commonly contains stabilizing agents Like bicell fights and metal cell fights are preservatives like Benz alconium chloride and these will are very toxic to the corneal endothelium Also, I would just want to bring your attention to OVD's ophthalmic viscoseurgical devices which are toxic in and of themselves if they're left in the eyes, but they're also There's also a chance that if the surgical equipment used is not cleaned properly that they may retain some in the lumen and Upon subsequent surgical procedures these can be released into the anterior chamber of the eye causing Causing of inflammatory reaction one of the other major causes of tasks that was noted to be One of the most common causes during a 2006 Six tasks outbreak in North America was a cleaning and sterilization of instruments this includes reusable cannulas and hand pieces and Also, it talks about the enzymes and detergents and ultrasound baths like I mentioned earlier these lumens of these hand pieces may have retained cortical material or Dried OVD that is not removed sufficiently Through the sterilization process these are these persist and allow for further contamination and subsequent surgeries The enzymes and detergents are also noted to not be necessary given that the bio burden accumulated on these equipments during the procedure itself is not so great compared to other general surgery surgical techniques and instruments therefore the toxicity of the enzymes and detergent detergents if not rinsed away properly Will create more problems than than they Then they help and ultrasound baths similarly are not necessary given that low bio burden during During cataract surgeries and these have a tendency to get contaminated with gram-negative bacteria producing endoscores that are not That are not denatured during sterilization and finally poorly constructed wounds can also cause Allow for substances to enter the anterior segment during surgery and after surgery Treatment as I mentioned prevention is the best form of treatment so making sure that surgical procedures and protocols are adhered to strictly is the best way to avoid a complication of tasks however if there is a complication of tasks you'd want to immediately Treat them to reduce the inflammatory response removing any residual material that may be causing the toxic insult is necessary But then the medical treatment is generally a topical prednisolone acetate 1% every one hour with close observation and follow-ups to visualize improvement of the Inflammate inflammation in the anterior chamber and also to make sure that intraclore pressures are maintained and then it's also important to analyze the outbreak These a SCRS has created an ad hoc task force that will help analyze any of these outbreaks of tasks. It's a It's readily available on a website that I'll just mention soon and just going to the prognosis and outcomes of tasks Usually mild most cases of tasks are mild and they'll be Resolution of the anterior segment inflammation and corneal edema within days to weeks With no residual sequelae moderate tasks, there's a little bit longer timed for resolution of the corneal edema and the Anterior segment inflammation some will have mild residual corneal edema most will resolve completely and these This group is more susceptible to elevated intraclore pressure increases and in severe tasks There is permanent damage to the anterior segment of the eye. You'll have persistent corneal edema Possible assistoid macular edema, iris atrophy like that fixed dilated pupil that we saw in the picture with a thinned iris stroma and Severe glaucoma that is difficult to treat medically and will usually require some surgical intervention and rarely these Severe tasks cases will require systemic medical treatment so in summary if you see a Defeat a patient with diffuse limbo to limbo corneal edema arising 12 to 48 hours post Anterior segment surgery think of tasks. However, it's imperative to rule out infectious and alphal mitis And also initiate treatment immediately and monitor closely for any progression of the disease and also it's important to analyze the outbreak if you Have a task outbreak. There's a Standardized protocol and survey that is available on the ASCRS website that will allow you to receive Receive advice on an evaluation on what may be causing the task by a task created task force That's an awful anyways, I Will be one of those individuals this year that would help to analyze the Outbreak as well as is ours dr. Mamelis Here are my references and thank you for listening. Yes The At the university a lot of stuff, they couldn't pop up and we had a private surgeon who would use sometimes the M.I.L.A. to make a number of mics, and you could take Vigamon, which is a non-deserved oxyboxis and out of the mall, really 50% for the right amount, or they would be a surgeon a year ago, I mean, a certain time now, who the pharmacy was preparing this for, and the pharmacy said, oh, he's stuck with oxyboxis and we're just using the M.I.L.A. to make a number of mics, and it's cheaper on the streets than it really is. It has conservative minutes, got only two minutes, and they ignore us. No one can help the surgeon. And so basically the surgeon is just using the M.I.L.A. to make this the next day to get some patients with the M.I.L.A. And so it's difficult because if you put anything in M.I.L.A. that would be not be so, you know what would be useful. So comment about, in regards to the past, and about specifically what we talked about, we've seen how mics like that now, whenever they're back on the streets, they don't possibly sit in the middle of the place. But the debate right now about why lateral, sequential, same-day cataracts is now that they've got a total M.I.L.A. over some of the back and the M.I.L.A. over some of the back. And they're ignoring the fact that all of the things you thought about, that why lateral and not M.I.L.A. is not a big concern. Something like this, it could be a why lateral it's ass. And as Nick knows, when you have it, it's an epidemic in proportion. It's a lot of majority of sometimes all of the patients is going to be part of projects in time. And that tax does not include even worse, if you buy a lot of the M.I.L.A. So I don't know why somehow that's going around. You know, it's hard to do to not assume that people are advocate for the M.I.L.A. unless there's almost a religious who can tell if you work or do I.M. And it was that data that showed conclusively that you have a higher chance of dying in a car accident driving to P730, and you do, you know, developing that out, and applying it. Every time I bring a pass, they say, you know, you've done the millions of these worldwide you've never had a accident. You put that out and you will die from the car accident in most additional visits to the second I.L.A. because of the M.I.L.A. And so it's nothing like you do with that when you say that you've never had a accident. I don't believe it. Yeah, yeah, I know. If you look at the inserts and then it goes on. Sadly, when it occurs, and some of the scariest calls I've had, or someone who had unblocked the circuit instead of 15 patients in an office, all of them are extremely, like, very poor people and the fact that you know, there's a pressure on people too, that's actually a problem. That's the question. Yes. Could you agree that an opening in the first place, you have two I.L.A. that's going to see an action in the day, and make sure that you know, as opposed to... Yes, you know, the promise is to get an official R.F. People would, you know, get an M.I.L.A. and may I offer you gentlemen an open mic that he did have in an I.L.A. So, you know, he was watching himself, but if it occurs in the period of hospitalization, he's going to see a certain amount of I.L.A. hospitalization, and you're watching that. If you want to send an office back to my family this week, you will watch that. And by the end of the day, it's going to remind us that much better than the worst in the past. Much better than there was when we went to the worst. When we went to check the day, there was a lot of pressure on the hospitalization. If there's any questions that could put up a mic, then of course, there's going to be a good after and an amount. But, you know, it's the hardest thing to do is to kind of hold to that and see, you know, if he was getting an I.L.A. there's fewer than that. He's got to watch what he's doing with it. Fortunately, day one and up a mic is uncommon. If you do that, they want to choose a community that is going to come out of C.M.I.L.A. or something like this. Yes. No. I think you can make a viable case for it. As a general thing occurring, the two issues, I think the end-off might as well be small and probably not the biggest concern I see. I still worry about bilateral contacts, but there's no question. You lose the ability to use the public sector. I think that I'm not attempting to use the public sector. I think there will be bilateral cases. I just think this is going to be kind of willingness to accept the government. There's going to be some bad bilateral contacts, but pretty awful situation. It's a bad task. I mean, you're going to get something that you're going to put it both on. I mean, maybe I have one with a pharmacy tech that will assist you to clean throughout the region of B.S.S. across. It's an additive from B.S.S.S. which is a tidy concept. And they have three cases. Fortunately, the patient's actually going to be able to get through the administration and get to all of them first. Now, for a few days, they got through the region, but then all of of them didn't finish their work at the time. But then with the five-hectar that's not the It's hard to know the incident because a lot of people don't recognize it, a lot of people don't recognize it, a lot of people don't recognize it, a lot of people don't know it, a lot of people don't recognize it. It's hard to know the incident because a lot of people don't recognize it, a lot of people don't recognize it, a lot of people don't recognize it. It's hard to know the incident because a lot of people don't recognize it, a lot of people don't recognize it, a lot of people don't recognize it. It's hard to know the incident because a lot of people don't recognize it, a lot of people don't recognize it, a lot of people don't recognize it, a lot of people don't recognize it. It's hard to know the incident because a lot of people don't recognize it, a lot of people don't recognize it.