Toxic Anterior Segment Syndrome Caused by Autoclave Reservoir Wall Biofilms and Their Residual Toxins

Purpose: To identify etiology of toxic anterior segment syndrome (TASS) after uneventful phacoemulsification.

Setting: EyeMD Laser and Surgery Center, Oakland, California.

Design: Retrospective case series.

Methods: Patient charts with TASS were reviewed. Reservoirs of 2 autoclaves associated with these cases were cultured for bacterial contamination. Cultures were performed on 23 other autoclave reservoirs at surgery centers in the local area. The main outcome measures were the incidence of TASS and prevalence of bacterial biofilm contamination of autoclave reservoirs. RESULTS: From 2010 to 2013, 11 935 consecutive cataract surgeries were performed at 1 center by multiple surgeons with no reported TASS. Between January 1, 2014, and January 15, 2015, 10 cases of TASS occurred out of 3003 cataract surgeries; these patients’ charts were reviewed. Cultures of 2 Statim autoclave reservoir walls grew Bacillus species, Williamsia species, Mycobacterium mucogenicum, and Candida parapsilosis. Scanning electron microscopy of reservoir wall sections showed prominent biofilm. The 2 autoclaves were replaced in January 2015. Subsequently, 2875 cataract surgeries were performed with no reported TASS (P < .001, c2 test). Eighteen of 23 additional regional autoclaves were also contaminated with bacterial biofilms.

Conclusions: Toxic anterior segment syndrome was strongly associated with bacterial biofilm contamination of autoclave reservoirs. An etiological mechanism might involve transport of heatstable bacterial cell antigens in the steam with deposition on surgical instrumentation. Data suggest widespread prevalence of bacterial biofilms on fluid-reservoir walls, despite adherence to manufacturer guidelines for cleaning and maintenance. Prevention or elimination of autoclave fluid-reservoir biofilms might reduce the risk for postoperative TASS.

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