There are multiple and varied substances that can cause the inflammation of Toxic Anterior Segment Syndrome, but in the case of intraocular surgical instruments the cause is most likely debris left from inadequate cleaning, residues from improperly dosed or rinsed cleaning chemistries, endotoxins from manual soak or ultrasonic cleaning chambers, lint from towels used to protect instruments or trays, and inorganic salts deposited from the steam in your sterilizer.
First I would like to suggest that you obtain a copy of the “Recommended Practices for Cleaning and Sterilizing of Intraocular Surgical Instruments” from the American Society of Cataract and Refractive Surgery and the American Society of Ophthalmic Registered Nurses and familiarize yourself with it.
That being said let me begin with saying that the care of these (and any other surgical instrument for that matter) begins at the point of use, keeping instruments free of debris and moist, with sterile, distilled or de-ionized, water during the procedure will help insure your technicians will be able to clean and sterilize them properly when the procedure is finished. Also the sooner the instruments are decontaminated, once the procedure is finished, the easier they will be to clean. Since Ophthalmic Viscosurgical Device Solutions can harden in minutes, I would suggest the use of disposable cannulas and tubing whenever possible. Any non-disposable cannulas (or instruments) that come in contact with these solutions should be flushed and keep moist with copious amounts of sterile water to prevent deposits.
Once the instruments arrive in decontamination cleaning should begin immediately. Always follow the instrument manufacturers IFU when it comes to cleaning these instruments. If enzymatic detergents are contraindicated for cleaning, do not use them, if they can be used, I would suggest using a neutral pH enzymatic detergent that is both color and fragrance free (please see my answer to the question “We prefer an enzymatic detergent with coloring and fragrance…” for further discussion on this matter). Always follow the detergent manufacturers IFU, when it comes to the dosing of their detergent in solution for cleaning. If you have an ultrasonic cleaner, only use it with those instruments that can be cleaned in it.
When it comes to the cleaning of ophthalmic instruments, it is highly recommended, weather in the manual soak sink or ultrasonic cleaner, that you change the cleaning solution between each tray, to avoid the deposit of debris from previous trays on instruments. Also more frequent cleaning and disinfection of the chamber of your ultrasonic cleaner and soak sink is highly recommended to prevent the build-up of bacterial endotoxins which can deposit on instruments.
Once the instruments have been cleaned with detergent, rinse them with copious amounts of water to remove any detergent residue, tap water may be used here unless contraindicated by either the equipment or detergent manufacturer. This should be followed by a final rinse with sterile, distilled or de-ionized, water. This rinse should provide flow over and through the instruments. The final rinse water should not be reused and agitation of instruments in a basin of sterile water should not be used since any debris
could redeposit this way.
Following the final rinse all lumened instruments should be dried with medical grade compressed air. When assembling instrument sets, closely inspect all instruments for defects or debris, a lighted magnifying glass is highly recommended here. If you normally use huck-towels to line your instrument sets, please make sure that they are both lint and detergent residue free. Call your linen provider to find out what chemistry is used to wash these towels because a highly alkaline detergent may transfer chemicals from the towels to the instruments during sterilization, I have even seen the dye from new huck-towels transfer to trays so find out from your linen supplier if they have ever had any incidence with this problem. A better choice for tray liners are the specially made disposable dye and residue free paper liners you can get from many sterilization supply companies.
Since dissolved inorganic salts in the steam of your autoclave can deposit on your instruments and my trigger inflammation, have the quality of your steam checked, at least on a yearly basis.