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Toxic Anterior Segment

Toxic Anterior Syndrome (TASS) is a rare and devastating complication
of intraocular surgery. TASS is an acute sterile anterior chamber
inflammatory reaction that develops 12-48 hours after anterior
segment surgery. The condition is responsive to topical steroids in
most cases
The etiology of TASS may be multi-factorial with numerous potential causes.
Bacterial endotoxins or particulate contamination of balanced salt solutions
Intraocular irrigating solutions with abnormal PH, osmolarity or ionic composition
Denatured Ophthalmic Viscosurgical Devices (OVD)
Intraocular medications (antibiotics in the irrigation solutions or intracameral
Topical ointments
Inadequate sterilization of surgical instruments and tubing
Inadequate flushing of instruments between cases resulting in build-up of
ophthalmic viscosurgical devices (OVD)
Metallic precipitate
General Pathophysiology
Severe inflammatory reactions in response to the contamination,
toxins, imbalanced solutions, medications or preservative in the
medications. This is a sterile anterior segment reaction. There is no
bacterial or fungal infection, although one potential cause of the
inflammatory reaction is secondary to bacterial endotoxins.
Primary Prevention
Use of proper balance salt solution (BSS) with the correct pH, osmolarity,
and ionic composition
Good filtration of the BBS at the manufacturing site to eliminate particulate
contamination and endotoxins
Avoid any kind of preservatives in intraocular solutions, intracameral
medications or irrigating solutions
Use of fresh ophthalmic visosurgical devices
Adequate sterlization of instruments and tubing according to the
manufacturer's protocol
Standard and clear operative and instrument processing procedures
(SOP) need to be implemented
The staff and surgeon should be well aware of the SOPs

Vision loss or blurry vision within 12-48 hours after surgery

Pain ranging from mild to severe


Acute severe inflammatory reaction of anterior chamber within 12-48 hours after
Corneal edema limbus to limbus
Dilated or irregular pupil
Increased intraocular pressure
Lack of bacterial or fungal growth from cultures of intraocular taps
Good response to topical ophthalmic steroid drops
Diagnostic Procedures
All patients should have a slit lamp exam and dilated fundus exam.
The posterior pole may be difficult to view if there is severe anterior
chamber reaction. In these situations, the patient should have an
ultrasound B-scan to rule out any posterior reaction. Both aqueous
and vitreous taps are sent for culture to investigate for an infectious
Differential diagnosis

Infectious endophthalmitis
Retained lens material
Severe inflammation
Vision loss
Iris atrophy either dilated or irregular pupil
Cornea endothelial damage with corneal edema
Trabecular meshwork damage with possible secondary glaucoma
Medical therapy

Most TASS patients respond well to topical corticosteroids (1%

Prednisolone acetate) given hourly. Patients with mild cases will
respond to steroids rapidly as evidenced by clearing of the
inflammation and decrease in intraocular pressure. In cases of
moderate TASS, the clearing may take up to 3-6 weeks which is a
longer response than in mild cases. In the severe case, there may be
permanent damage, persistent corneal edema, chronic persistent
inflammation, fixed dilated pupil, refractory glaucoma secondary to
trabecular meshwork damage and cystoid macular edema. In severe
cases there may be a need for systemic steroid treatments
Follow Up
Frequent follow-ups are needed to monitor eye pressure, vision, detail Slit-Lamp
examination to track inflammation, cornea endothelial function, and iris.
Close observation for bacterial infection
Infectious etiology needs to be ruled out
Gonioscopy examination
Dilated fundus exam
Corneal recovery needs to be followed closely. In a severe case of TASS the
patient may need corneal transplant
In refractory glaucoma, the eye pressure should be closely monitored. In a severe
case, if the pressure is non responsive to medication and there is no sign of
recovery then there is a need for glaucoma surgery