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 Table of Contents  
CASE SERIES
Year : 2018  |  Volume : 56  |  Issue : 2  |  Page : 102-104

Toxic anteriorsegment syndrome presenting as endothelitis following uneventful phaco emulsification


Ponnammal Duraiswamy Eye Hospital, Coimbatore, Tamil Nadu, India

Date of Web Publication6-Aug-2018

Correspondence Address:
Dr. Anusha Koshal Ram
Ponnammal Duraiswamy Eye Hospital, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjosr.tjosr_13_18

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  Abstract 


Clinical course, presentation profile, response to treatment of two patients who developed a toxic anterior segment syndrome (TASS) following uneventful phacoemulsification. Both the patients underwent slit-lamp examination and dilated fundus examination, in each follow-up and aggressive treatment with topical and systemic steroids. The white to white corneal edema and anterior chamber reaction subsided on follow-up at 1st and 2nd month, respectively, with improvement in vision. The report highlights key features such as relatively quiet eye on the first postoperative day with classical TASS picture seen on the fifth postoperative day and moderate recovery within a month necessitating a thorough examination of patients till the first week of surgery.

Keywords: Endotheliitis, phacoemulsification, toxic anterior segment syndrome


How to cite this article:
Ram AK, Subramanian B. Toxic anteriorsegment syndrome presenting as endothelitis following uneventful phaco emulsification. TNOA J Ophthalmic Sci Res 2018;56:102-4

How to cite this URL:
Ram AK, Subramanian B. Toxic anteriorsegment syndrome presenting as endothelitis following uneventful phaco emulsification. TNOA J Ophthalmic Sci Res [serial online] 2018 [cited 2019 Oct 17];56:102-4. Available from: http://www.tnoajosr.com/text.asp?2018/56/2/102/238489




  Introduction Top


Toxic anterior segment syndrome (TASS) is postoperative anterior segment inflammation. It usually develops after uncomplicated anterior segment surgery.[1] Toxic agents associated with TASS include residue solutions used in sterilization, topical disinfectant, and preservatives in medicine used during surgery. Although cases of TASS have been reported following uneventful phacoemulsification, this case is unique in which the presentation has been a predominant corneal endotheliitis. We report two cases of TASS following uneventful phacoemulsification.


  Case Reports Top


Case 1

A 56-year-old patient, a type 2 diabetic with no retinopathy, underwent uneventful right eye phacoemulsification with implantation of hydrophobic intraocular lens. The postoperative examination on day 1 was normal with 6/6 vision with a clear cornea and quiet eye. He presented on the 5th postoperative day with blurred vision. The vision was 2/60 with a white eye and limbus to limbus corneal edema [Figure 1]a. Anterior chamber reaction was present with cells 2+ and flare 2+ with pigment dispersion. Good fundal glow was present with corneal edema precluding the view of the fundus. The B-scan was normal with a clear vitreous and normal retinochoroid scleral thickness complex. The patient was immediately started on topical steroids and hyperosmotic agents. The corneal edema receded gradually over a period of 3 weeks. By 1 month, the patient had a vision of 6/12 with few Descemet's membrane (DM) folds, pigments on the endothelium and a clear view of the fundus with minimal anterior chamber reaction [Figure 1]b and [Figure 1]c.
Figure 1: (a) Slit lamp; photograph after 5 days of cataract surgery (corneal edema and Descemet's membrane folds), (b) slit lamp; photograph after 2 weeks of cataract surgery (decreasing corneal edema and Descemet's membrane folds), and (c) slit lamp; photograph after 1 month of cataract surgery clear cornea

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Case 2

A 62-year-old patient underwent uneventful right eye phacoemulsification with implantation of a hydrophobic intraocular lens. The postoperative picture on day 1 showed minimal corneal epithelial edema with anterior chamber reaction of 1+ cells and flare 1+ with a vision of 6/9. The patient presented on the 5th postoperative day with defective vision of 1/60 [Figure 2]a. There was a white to white corneal edema with anterior chamber reaction of 3+ cells and flare 3+. The B-scan was normal with a clear vitreous and normal retinochoroid scleral thickness complex thickness. The patient was started on topical and systemic steroids. By postoperative 3rd week, the vision was RE6/60. The corneal edema had decreased with DM folds, fundus was normal. By postoperative 6 weeks, the cornea was clear with a vision of 6/12 [Figure 2]b and [Figure 1]c.
Figure 2: (a) Slit lamp; photograph of the second patient after 5 days of cataract surgery (corneal edema, Descemet's membrane fold, and pigments on endothelium), (b) slit lamp; photograph after 2 weeks of cataract surgery (decreasing corneal edema and Descemet's membrane folds), (c) slit lamp; photograph after 1 month of cataract surgery (clear cornea)

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These two cases highlights the prompt early detection of TASS and the relatively mild symptoms of TASS on the 1st postoperative day with a classical TASS-like presentation on the 5th postoperative day. There was a marked response to steroid in both the cases over a period of 1 month. The theater fluids and sterility check were done for all ocular medications which was normal. Both the eyes were done on separate days. Both eyes received intracameral application of preservative-free moxifloxacin at the end of surgery.


  Discussion Top


TASS is postoperative anterior segment inflammation. It usually develops after uncomplicated anterior segment surgery.[1] Toxic agents associated with TASS include residue solutions used in sterilization,[2],[3] topical disinfectant, and preservatives in medicine used during surgery.[4]

The presentation in the two patients was corneal edema noticed in the 2nd postoperative visit with a normal-appearing cornea in the 1st postoperative day. This was a toxic endotheliitis noticed beyond the 1st postoperative day.

Diffuse corneal edema is usually seen in TASS. Anterior segment reaction with progressive cell,[1] flare, and hypopyon formation and fibrin reaction are also observed. Secondary glaucoma due to iris and trabecular meshwork damage may be seen. Visual outcome changes from 20/20 to no light perception.[5]

TASS may be seen as sporadic cases or in outbreaks. A study describes an outbreak of TASS that appeared after uneventful cataract surgery, possibly due to intracameral use of 1 mg/0.1 cc cefuroxime.[5] Outbreaks associated with sterilization methods and endotoxin contamination of balanced salt solution have been reported.[6],[7],[8] The use of moxifloxacin has been reported with use of TASS.[7],[8],[9] In our two cases of TASS, preservative-free moxifloxacin was used. None of the other cases done on the same day showed evidence of inflammation. The probable etiology, in this case, is a toxic endotheliitis presenting with corneal edema noticed beyond the 2nd day. The inflammation subsided over a period of 1 month. These two cases highlights the fact that a TASS presenting as endotheliitis can make its appearance after the 1st postoperative day, necessitating careful examination of patients till the 1st postoperative week.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


  Conclusion Top


TASS can make its presence even beyond the 1st postoperative day, necessitating thorough examination of patients till the 1st week.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sorkin N, Varssano D. Toxic anterior segment syndrome following a triple descemet's stripping automated endothelial keratoplasty procedure. Case Rep Ophthalmol 2012;3:406-9.  Back to cited text no. 1
    
2.
van Philips LA. Toxic anterior segment syndrome after foldable artiflex iris-fixated phakic intraocular lens implantation. J Ophthalmol 2011;2011:982410.  Back to cited text no. 2
    
3.
Sato T, Emi K, Ikeda T, Bando H, Sato S, Morita S, et al. Severe intraocular inflammation after intravitreal injection of bevacizumab. Ophthalmology 2010;117:512-6, 516.e1-2.  Back to cited text no. 3
    
4.
Cutler Peck CM, Brubaker J, Clouser S, Danford C, Edelhauser HE, Mamalis N, et al. Toxic anterior segment syndrome: Common causes. J Cataract Refract Surg 2010;36:1073-80.  Back to cited text no. 4
    
5.
Sarobe Carricas M, Segrelles Bellmunt G, Jiménez Lasanta L, Iruin Sanz A. Toxic anterior segment syndrome (TASS): Studying an outbreak. Farm Hosp 2008;32:339-43.  Back to cited text no. 5
    
6.
Kutty PK, Forster TS, Wood-Koob C, Thayer N, Nelson RB, Berke SJ, et al. Multistate outbreak of toxic anterior segment syndrome, 2005. J Cataract Refract Surg 2008;34:585-90.  Back to cited text no. 6
    
7.
Unal M, Yücel I, Akar Y, Oner A, Altin M. Outbreak of toxic anterior segment syndrome associated with glutaraldehyde after cataract surgery. J Cataract Refract Surg 2006;32:1696-701.  Back to cited text no. 7
    
8.
Hellinger WC, Hasan SA, Bacalis LP, Thornblom DM, Beckmann SC, Blackmore C, et al. Outbreak of toxic anterior segment syndrome following cataract surgery associated with impurities in autoclave steam moisture. Infect Control Hosp Epidemiol 2006;27:294-8.  Back to cited text no. 8
    
9.
Espiritu CR, Caparas VL, Bolinao JG. Safety of prophylactic intracameral moxifloxacin 0.5% ophthalmic solution in cataract surgery patients. J Cataract Refract Surg 2007;33:63-8.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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