TASS

DR.PUSHPANJALI
Introduction :

• Initially referred to as sterile endophthalmitis

or postoperative uveitis of unknown cause.
• Accurately termed TOXIC ANTERIOR
SEGMENT SYNDROME (TASS)by Monson et
al in 1992.
• Toxic endothelial cell destruction (TECD)
syndrome : a variant of TASS with localized
endothelial damage.
Definition :

TOXIC ANTERIOR SEGMENT

SYNDROME
Sterile, acute postoperative inflammatory
reaction in which a noninfectious substance
enters the anterior segment and induces toxic
damage to the intraocular tissues that may
occur following any anterior segment surgery.
 Outbreak of toxic anterior segment syndrome
after vitreous surgery
• Arch Soc Esp Oftalmol. 2009 Aug;84(8):403-5.
• Andonegui J, Jiménez-Lasanta L, Aliseda D, Lameiro F.
• Servicio de Oftalmología, Hospital de Navarra, 31008 Pamplona, España.
( jandonen@cfnavarra.es)
• CASE REPORT: An outbreak of Toxic Anterior Segment Syndrome after
vitreoretinal surgery is reported.
• Two patients underwent exclusively vitrectomy while the other three patients
were operated of vitrectomy and some other anterior segment procedure.
• DISCUSSION: Toxic Anterior Segment Syndrome is a sterile postoperative
inflammation due to any non infectious substance that reaches the anterior
segment during surgery. It occurs in outbreaks and while most of the cases
have been reported after anterior segment procedures, this case demonstrates
that development after vitreoretinal surgery is also a possibility.
 Severe Intraocular Inflammation after Intravitreal
Injection of Bevacizumab.
• Ophthalmology. 2010 Mar;117(3):512-516.e2. Epub 2010 Jan 19.
• Sato T, Emi K, Ikeda T, Bando H, Sato S, Morita SI, Oyagi T, Sawada K.
• Department of Ophthalmology, Osaka Rosai Hospital, Sakai, Japan.
• PURPOSE: To report 5 cases of severe intraocular inflammation that developed after an intravitreal
injection of the same lot of bevacizumab.
• PARTICIPANTS: Patients treated with an intravitreal injection of bevacizumab (lot B3003B01).
• METHODS: The clinical charts of 35 eyes of 35 consecutive patients who were treated with intravitreal
injection of lot B3003B01 bevacizumab from December 18, 2008, through January 20, 2009, were
reviewed.
• MAIN OUTCOME MEASURES: Incidence of intraocular inflammation, results of bacterial cultures, best-
corrected visual acuity (BCVA), and endothelial cell density.
• RESULTS: Five (14.3%) of the 35 cases had severe intraocular inflammation, and the inflammation had
some characteristics of toxic anterior segment syndrome (TASS). Five of the 5 cases had a predominantly
anterior chamber reaction, and 4 of the 5 cases were accompanied by hypopyon. Undiluted samples
collected from both the aqueous and vitreous of the 5 cases were culture negative. The BCVA was 0.66+/-
0.29 (mean+/-standard deviations) logarithm of the minimum angle resolution (logMAR) units, and the
endothelial cell density was 2683.6+/-97.3/mm(2) before the intravitreal bevacizumab. At the final visit,
the BCVA was 0.44+/-0.36 logMAR units, and the cell density was 2679.0+/-217.5/mm(2). These
differences were not significant (P = 0.171 and 0.964).
• CONCLUSIONS: These observations indicate that an intravitreal injection of bevacizumab can induce sterile
endophthalmitis that has characteristics of TASS. 
Pathophysiology :

• TASS results from the inadvertent entry of toxic substances

into the anterior chamber.
• The histopathologic hallmark of TASS is toxic anterior
segment damage.
• Cellular necrosis and/or apoptosis and extracellular damage
occur, resulting in the severe acute inflammatory response.
• The corneal endothelium is often the most damaged
structure because of its inability to regenerate and replace
dead cells.
• Trabecular meshwork damage - IOP
Presentation :
• The hallmark of TASS is an inflammatory reaction in the
anterior segment of the eye that starts within 12 to 48 hours
after surgery.
• The most common clinical findings in patients are
(1) diffuse, limbus-to-limbus corneal edema,
(2) increased inflammation in the anterior chamber with
hypopyon formation, and the deposition of fibrin.
(3) a dilated pupil with an irregularity of the iris and
(4) potential damage to the trabecular meshwork with
subsequent secondary glaucoma.
(5) Cystoid macular edema in few cases.
(6) rapidly improves after topical steroids.
Clinical course :

– Mild presentation : rapid clearing of the corneal edema

with no long-term corneal or trabecular damage and
normal or near normal visual acuity.
– Moderate presentation : persistent corneal edema that will
take several weeks to clear, intraocular pressure that is
difficult to control, and a moderate effect on visual acuity.
– Severe presentation of TASS : marked corneal edema that
does not clear, iris and trabecular meshwork damage with
resultant glaucoma, and possible cystoid macular edema.
Visual outcome is usually poor despite medical or surgical
intervention.
TASS VERSUS ENDOPHTHALMITIS
 TASS Vs ENDOPHTHALMITIS
1. TIMING OF THE DISEASE 2. PAIN
 TASS Vs ENDOPHTHALMITIS

3. CONJUCTIVAL & LID REACTION 4. CORNEAL EDEMA

 TASS Vs ENDOPHTHALMITIS

5.IRIS FINDINGS 6. IOP

 TASS Vs ENDOPHTHALMITIS

7. THERAPEUTIC RESPONSE
 TASS ENDOPHTHALMITIS
CAUSE Noninfectious reaction to toxic Bacterial, fungal, or viral
agent present in: Infection
BSS solution
Antibiotic injection
Endotoxin
Residue

ONSET 12-24 hours 4-7 days

SIGNS/SYMPTO Blurry vision Decreased VA

MS Pain: none, or mild to moderate
*distinguishing Corneal edema: diffuse, limbus to
limbus*
feature Pupil: dilated, irregular, nonreactive*
Increased IOP*
Anterior chamber: mild to severe
reaction with cells, flare,
hypopyon, fibrin
Signs and symptoms are limited to
anterior chamber*
Gram stain and culture negative
Pain (25% have no pain)
Lid swelling with edema
Conjunctival injection
Hyperemia
Anterior chamber: marked
inflammatory response with
hypopyon
Vitreous involvement
Inflammation in entire
ocular cavity*

TREATMENT Rule out infection Culture anterior chamber

Culture anterior chamber and vitreous
Intensive corticosteroids Intravitreal and topical
Monitor IOP closely for signs of antibiotics
damage to trabecular meshwork Vitrectomy
and side effects of steroids
Watch closely over next few hours
for signs of bacterial infection
 Causes :

1. Substances that accidentally enter the eye during or after

surgery:
• Topical antiseptic
• Topical lidocaine jelly, anesthetic agents
• Powder from gloves
• Particles from tray, lint from drapes
• Air contaminants
• Plain water on instruments
• Preservatives in solutions/ medications used
• Topical ointment (an eye patch that is too tight may cause the wound to
suck the antibiotic back inside the eye)
Causes :

2. Substances that are introduced as part of the OR procedure:

• Improper irrigation solutions (BSS)
• Inappropriate pH (< 6.5 - > 8.5), chemical composition or osmolality
• Addition of medications/ antibiotics (the use of vancomycin is still controversial)
• Toxic preservatives in BSS (benzalkonium chloride - 1000 corneas damaged in India)
• Contaminated BSS:
• – During manufacturing process
• – During addition of epinephrine (e.g. sulfites) or antibiotics
• – Out-dated BSS (contamination with glue that leeches inside the bag)
• Mitomycin-C
• Contaminants on IOL
• – Manufacturer debris
• – Residual polishing compounds (e.g. Memorylens )
• – During manipulation: powder from gloves
Causes :
3. Irritants from surgical instruments due to improper
cleaning/sterilization:
• Dry blood and debris left on instruments
• Tissue and dry visco-elastics found in re-used phaco tips, irrigation/aspiration tips and
cannulated instruments - flushed into the next patient’s eye
• Irritants from deterioration of instruments due to re-processing: re-usable equipment and re-
used single use device (SUD)
• Residue of detergent on instruments not properly rinsed
• Coliforms and metals left on/in instruments (tap water used instead of distilled, sterile water)
• Endotoxins: gram-negative bacteria lodged inside the improperly irrigated cannulated
instruments die during sterilization but release endotoxins that are flushed into the next
patient’s eye (e.g. contaminated ultrasonic cleaning solution with Klebsiella pneumoniae
bacteria )
• Oxidized metal deposits/residues on instruments from Plasma Gas Sterilization System
• Ethylene oxide gas residue on instruments from using E.O. Sterilization Method
Postoperative sterile endophthalmitis
(TASS) associated with the memorylens.
• Faisal S. Jehan MD, Nick Mamalis MD, Terrence S. Spencer MD, Luther L. Fry MD, Richard S. Kerstine
MD and Randall J. Olson MD
• John A. Moran Eye Center, Univeristy of Utah, Salt Lake City, Utah, USA
• Journal of Cataract & Refractive Surgery, Volume 26, Issue 12, December 2000, Page 1777
• Purpose : To report 10 cases of delayed-onset acute intraocular inflammation following cataract extraction
and posterior chamber implantation of the MemoryLens® intraocular lens (IOL).
• Methods : This retrospective study evaluated 10 cases of postoperative inflammation that occurred after
cataract extraction with placement of the posterior chamber MemoryLens IOL. Protocols of the
Intermountain Ocular Research Center used to analyze outbreaks of unexplained postoperative
inflammation as well as medical records were reviewed.
• Results : Nine patients had uneventful cataract extraction and 1 had a small anterior capsule tear with
placement of the MemoryLens IOL. All 10 patients presented with increased anterior segment
inflammation a mean of 7.8 days (range 1 to 21 days) after surgery. Three cases were tapped and were
culture negative, and 7 were presumed noninfectious. The anterior segment inflammation improved in all
patients. Treatment of the 7 patients included intensive topical steroids. Careful analysis of the
inflammation has not revealed an obvious etiology; however, the MemoryLens was associated with all the
cases.
• Conclusions : We postulate that these cases of noninfectious postoperative endophthalmitis may be
associated with the MemoryLens.
Outbreak of toxic anterior segment syndrome
associated with glutaraldehyde after cataract surgery

• Ünal M, Yücel I, Akar Y; J Cataract Refract Surg vol. 32, 1696 - 1701, 2006

• Purpose:  To present clinical findings of a cluster of cases of toxic anterior segment
syndrome (TASS) after uneventful phacoemulsification cataract surgery.
• Setting:  Department of Ophthalmology, Akdeniz University, Antalya, Turkey.
• Methods:  Six eyes of 6 patients developed TASS after uneventful
phacoemulsification cataract surgery with implantation of a 3-piece acrylic IOL
performed by 2 ophthalmologists on the same day. Clinical findings included
corneal edema, Descemet's membrane folds, anterior chamber reaction, fibrin
formation, and irregular, dilated, and unreactive pupils.
• Results:  Glutaraldehyde 2% solution was used inadvertently by the operating
room staff who cleaned and sterilized reusable ocular instruments before
autoclaving. None of the affected corneas improved. Additional surgical
procedures were required and included penetrating keratoplasty, trabeculectomy,
and glaucoma tube implantation.
• Conclusions: Glutaraldehyde in concentrations generally used for cold sterilization
is highly toxic to the corneal endothelium. The operating room staff involved in
sterilizing instruments should be well educated about and careful to follow the
protocols to properly clean and sterilize reusable ocular instruments.
Outbreak of toxic anterior segment syndrome following cataract surgery
associated with impurities in autoclave steam moisture.

• Infect Control Hosp Epidemiol. 2006 Mar;27(3):294-8. Epub 2006 Feb 22.

• Hellinger WC, Hasan SA, Bacalis LP, Thornblom DM, Beckmann SC, Blackmore C, Forster TS, Tirey JF, 
Ross MJ, Nilson CD, Mamalis N, Crook JE, Bendel RE, Shetty R,Stewart MW, Bolling JP, Edelhauser HF.
• Division of Infectious Diseases, Mayo Clinic, Jacksonville, FL 32224, USA.
• METHODS: Medical records of patients who underwent cataract surgery during the outbreak were
reviewed, and surgical team members who participated in the operations were interviewed. Potential
causes of TASS were identified and eliminated. Feedwater from autoclave steam generators and steam
condensates were analyzed by use of spectroscopy and ion chromatography.
• RESULTS: During the outbreak, 8 (38%) of 21 cataract operations were complicated by TASS, compared
with 2 (0.07%) of 2,713 operations performed from January 1996 through November 2002. Results of an
initial investigation suggested that cataract surgical equipment may have been contaminated by
suboptimal equipment reprocessing or as a result of personnel changes. The frequency of TASS decreased
(1 of 44 cataract operations) after reassignment of personnel and revision of equipment reprocessing
procedures. Further investigation identified the presence of impurities (eg, sulfates, copper, zinc, nickel,
and silica) in autoclave steam moisture, which was attributed to improper maintenance of the autoclave
steam generator in the outpatient surgical center. When impurities in autoclave steam moisture were
eliminated, no cases of TASS were observed after more than 1,000 cataract operations.
• CONCLUSION: Suboptimal reprocessing of cataract surgical equipment may evolve over time in busy,
multidisciplinary surgical centers. Clinically significant contamination of surgical equipment may result
from inappropriate maintenance of steam sterilization systems. Standardization of protocols for
reprocessing of cataract surgical equipment may prevent outbreaks of TASS and may be of assistance
during outbreak investigations.
Toxic anterior segment syndrome and possible association with
ointment in the anterior chamber following cataract surgery.

• J Cataract Refract Surg. 2006 Feb;32(2):227-35.

• Werner L, Sher JH, Taylor JR, Mamalis N, Nash WA, Csordas JE, Green G, Maziarz EP, Liu XM.
• John A. Moran Eye Center, University of Utah, Salt Lake City, Utah 84132, USA.
• PURPOSE: To report clinical and laboratory findings of 8 cases of TASS related to an oily
substance in the anterior chamber of patients foll. cataract surgery with intraocular lens (IOL)
implantation.
• METHODS: 8 patients had uneventful phacoemulsification by the same surgeon via clear
corneal incisions with implantation of the same 3-piece silicone IOL design. Postop
medications included antibiotic/steroid ointment and pilocarpine gel; each eye was firmly
patched at the end of the procedure. On 1st POD, some patients presented with diffuse
corneal edema, increased IOP, and an oily film-like material within the anterior chamber
coating the corneal endothelium. The others presented with an oily bubble floating inside the
anterior chamber, which was later seen coating the IOL. Additional surgical procedures
required included penetrating keratoplasty, IOL explantation, and trabeculectomy. 2 corneal
buttons were analyzed histopathologically. 2 explanted IOLs had gross and light microscopic
analyses (as well as surface analyses of 1 of them), and 4 other explanted IOLs had gas
chromatography-mass spectrometry.
• RESULTS: Pathological examination of the corneas showed variable thinning of the
epithelium with edema. The stroma was diffusely thickened and the endothelial cell
layer was absent. Evaluation of the explanted IOLs confirmed the presence of an oily
substance coating large areas of their anterior and posterior optic surfaces. Gas
chromatography-mass spectrometry of the lens extracts identified a mixed chain
hydrocarbon compound that was also found in the gas chromatography-mass
spectrometry analyses of the ointment used postoperatively.
• CONCLUSIONS: The results indicate that the ointment gained access to the eye,
causing the postoperative complications described. These cases highlight the
importance of appropriate wound construction and integrity, as well as the risks of
tight eye patching following placement of ointment.
Update on toxic anterior segment syndrome.

• Current opinion in ophthalmology     Volume:  18     ISSN:  1040-8738     ISO

• Publication Date:  2007 Feb 
• PURPOSE OF REVIEW: To review, summarize and update our present understanding of toxic
anterior segment syndrome.
• RECENT FINDINGS: Toxic anterior segment syndrome has emerged within the last 2 years as a
complication of increasing frequency following uneventful cataract surgery. Over 100 North
American clinics reported toxic anterior segment syndrome cases to a specially constituted
task force over a 4-month period in 2006. Toxic anterior segment syndrome is now recognized
as a specific, noninfectious condition presenting as anterior segment inflammation that
occurs within days of surgery and is responsive to topical steroids. Specific causes have been
identified such as endotoxin contamination of balanced salt solutions and antibiotic ointment
accessing the anterior chamber, although most cases appear to result from inadequate
instrument sterilization and preparation. Outcomes are usually excellent, but delayed
treatment and severe cases may result in glaucoma and persisting corneal edema requiring
penetrating keratoplasty.
• SUMMARY: Toxic anterior segment syndrome has become a significant complication of
cataract surgery. Rapidly increasing knowledge made possible by ophthalmic organizations
and the prompt dissemination of research findings, however, appear to have provided the
information necessary to help prevent and resolve this condition.
Toxic anterior segment syndrome after cataract
surgery--Maine, 2006.
• MMWR (Morb Mortal Wkly Rep.) 2007 Jun 29;56(25):629-30.
• Centers for Disease Control and Prevention (CDC).
• Toxic anterior segment syndrome (TASS), an acute, noninfectious inflammation of the anterior
segment of the eye, is a complication of anterior segment eye surgery; cataract extraction is
the most common form of this type of surgery. Various contaminants, usually from surgical
equipment or supplies, have been implicated as causes of TASS. The syndrome typically
develops within 24 hours after surgery and is characterized by corneal edema and
accumulation of white cells in the anterior chamber of the eye. Although most cases of TASS
can be treated successfully with topical steroids, topical nonsteroidal antiinflammatory
agents, or both, the inflammatory response associated with TASS can cause serious damage
to intraocular tissues, resulting in vision loss. In October 2006, the Maine Department of
Health and Human Services (MDHHS) received a report of a cluster of TASS cases among
outpatients who had undergone cataract surgery at a hospital in Maine. MDHHS and CDC
investigated the cluster and worked with the treating ophthalmologist and the hospital to
prevent additional cases. This report describes the results of that investigation and the
subsequent prevention measures implemented. Although the specific cause of the outbreak
was not identified, no additional cases were reported after two series of changes were made
to the materials and equipment used for surgery. Prevention of TASS requires careful
attention to solutions, medications, and ophthalmic devices and to cleaning and sterilization
of surgical equipment because of the numerous potential causes of the condition.
Multistate outbreak of toxic anterior segment
syndrome, 2005.

• J Cataract Refract Surg. 2008 Apr;34(4):585-90.

• Kutty PK, Forster TS, Wood-Koob C, Thayer N, Nelson RB, Berke SJ, Pontacolone L, Beardsley TL, Edelhauser
HF, Arduino MJ, Mamalis N, Srinivasan A.
• PURPOSE: To present the findings of an outbreak of toxic anterior segment syndrome (TASS).
• SETTING: Six states, 7 ophthalmology surgical centers, United States.
• METHODS: Cases were identified through electronic communication networks and via reports to a national
TASS referral center. Information on the procedure, details of instrument reprocessing, and products used
during cataract surgery were also collected. Medications used during the procedures were tested for
endotoxin using a kinetic assay.
• RESULTS: The search identified 112 case patients (median age 74 years) from 7 centers from July 19, 2005,
through November 28, 2005. Common presenting clinical features included blurred vision (60%), anterior
segment inflammation (49%), and cell deposition (56%). Of the patients, 100 (89%) had been exposed to a
single brand of balanced salt solution manufactured by Cytosol Laboratories and distributed by Advanced
Medical Optics as AMO Endosol. Two patients continued to have residual symptoms. There were no
reports of significant breaches in sterile technique or instrument reprocessing. Of 14 balanced salt solution
lots, 5 (35%) had levels exceeding the endotoxin limit (0.5 EU/mL). Based on these findings, the balanced
salt solution product was withdrawn, resulting in a termination of the outbreak.
• CONCLUSIONS: This is the first known report of an outbreak of TASS caused by intrinsic contamination of a
product with endotoxin. Ophthalmologists and epidemiologists should be aware of TASS and its common
causes. To facilitate investigations of adverse outcomes such as TASS, those performing cataract surgeries
should document the type and lot numbers of products used intraoperatively.
Development of toxic anterior segment syndrome
immediately after uneventful phaco surgery.

• Korean J Ophthalmol. 2008 Dec;22(4):220-7.

• Choi JS, Shyn KH.
• Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea.
• PURPOSE: We report on 15 cases of suspected toxic anterior segment syndrome after uneventful phaco
surgery.
• METHODS: We retrospectively reviewed the charts of patients who had developed toxic anterior segment
syndrome (TASS) after uneventful phacoemulsification for senile cataracts between April and December of
2005. Clinical features and all possible causes were investigated including irrigating solutions or drugs,
surgical instruments or intraocular lenses, sterilization techniques for instruments, or any other
accompanying disease.
• RESULTS: The patients consisted of 2 males and 13 females with an average age of 64.7+/-10.9 years. Five
different surgeons had performed their phaco surgeries. No abnormal preoperative or operative findings
were reported. Nevertheless, all 15 patients developed a moderate degree of corneal edema. Ordinary
treatments were not helpful. We suspect that lack of sterilization resulted in the development of the
syndrome, because after ethylene oxide gas sterilization was replaced with autoclaving, no such incidents
have occurred.
• CONCLUSIONS: Toxic anterior segment syndrome requires special attention and thorough management,
including sterilization of reused surgical instruments.
Identification of unknown intraocular material after cataract
surgery: evaluation of a potential cause of toxic anterior
segment syndrome.

• J Cataract Refract Surg. 2008 Mar;34(3):465-9.

• Mathys KC, Cohen KL, Bagnell CR.
• Department of Ophthalmology, Microscopy Services Laboratory, University of North Carolina at Chapel
Hill, School of Medicine, University of North Carolina Hospitals, Chapel Hill, North Carolina 27599-7040,
USA.
• PURPOSE: To describe and identify unknown opaque material between the optic of an AR40 intraocular
lens (IOL) injected with the Emerald Series implantation system (both AMO, Inc.) and the posterior capsule
at the conclusion of routine phacoemulsification to prevent an outbreak of toxic anterior segment
syndrome (TASS).
• METHODS: After coaxial phacoemulsification in multiple patients, opaque material was present between
the optic of a posterior chamber IOL and the posterior capsule. Although there was no TASS, the material
was removed from 2 eyes and analyzed with scanning electron microscopy (SEM) and x-ray microanalysis
(XRM). Similarly, crystalline lens, Klenzyme (Steris Corp.), Viscoat (sodium hyaluronate 3.0%-chondroitin
sulfate 4.0%), and Provisc (sodium hyaluronate 1.0%) were analyzed.
• RESULTS: On SEM, the material had an irregular undulating surface similar to that of Provisc. Viscoat and
the crystalline lens had smoother surfaces. On XRM, the material contained sodium, chlorine, and calcium,
like Viscoat and Provisc, and phosphorous and sulfur, like Viscoat. The material also contained silicone,
magnesium, aluminum, titanium, iron, and zinc. Klenzyme had smaller peaks of sodium, chlorine, and
calcium and a higher carbon background than the unknown material.
• CONCLUSIONS: The material was likely ophthalmic viscosurgical device that was chemically and
structurally altered by the cleaning and sterilization process. The silicone and metallic elements were
probably from the Emerald Series implantation system as the disposable cartridge is coated with silicone
and the reusable injector is metal.
 Toxic Anterior Segment Syndrome (TASS): studying an
outbreak

• Farm Hosp. 2008 Nov-Dec;32(6):339-43.

• Sarobe Carricas M, Segrelles Bellmunt G, Jiménez Lasanta L, Iruin Sanz A.
• Servicio de Farmacia, Hospital de Navarra, Pamplona, España. msarobec@cfnavarra.es
• INTRODUCTION: An effect associated with cataract surgery known as Toxic Anterior Segment Syndrome (TASS) has
been reported in recent years. It is an inflammatory non-infectious process which appears within the first few
hours after surgery and generally resolves well with topical steroids if the course of treatment is started promptly.
• In this paper we describe the syndrome and analyze the possible causes for the TASS outbreak that occurred in
our hospital and affected 5 patients.
• METHODS: As the syndrome may be due to multiple causes, the members of a research team created at the
hospital reviewed all the procedures involved. The washing and sterilization methods applied to the materials
were analyzed, as well as the drugs and substances used which might have caused the outbreak. We verified the
substances prepared by the Pharmacy Department, specially the irrigating solution which was used in all the
cases.
• RESULTS: According to the results obtained in the biochemical, micro-biological, pH, osmolarity and endotoxins
assays, the solutions prepared by the Pharmacy Department were all correct.
• DISCUSSION: Since the results obtained in the analyses of the substances used were correct and no adverse effect
was observed after the re-administration of the substances, we may conclude that the outbreak would be related
to the washing process performed previously to the sterilization of the instrumentation used in the surgery,
mainly because the recommendation to use distilled and sterile water for this purpose was not followed and, on
the contrary, tap water continued to be used.
Toxic Anterior Segment Syndrome Following
Penetrating Keratoplasty
• Philip Maier, MD; Florian Birnbaum, MD; Daniel Böhringer, MD; Thomas Reinhard, MD .
• Arch Ophthalmol. 2008;126(12):1677-1681.
• Objectives  To describe an outbreak of toxic anterior segment syndrome (TASS) following
penetrating keratoplasty (PK) and to examine its possible causes.
• Methods  Owing to a series of TASS following PK between June 6, 2007, and October 2, 2007,
we reviewed the records of all patients who had undergone PK during that time. In
addition to routine microbial tests on organ culture media, we looked for specific pathogens
and endotoxins in all of the materials  used for organ culture or PK. Furthermore, we analyzed
all of the perioperative products and instrument processing.
• Results  Of the 94 patients who underwent PK, we observed 24 cases of postoperative sterile
keratitis. Causal research revealed that the accumulation of cleaning substances or heat-
stable endotoxins on the surface of the routinely used guided trephine system was most likely
responsible for the TASS.
• Conclusions  To our knowledge, this is the first report on TASS following PK. Suboptimal
reprocessing of surgical instruments may be an important cause of TASS as in this series the
TASS-like symptoms resolved after modified instrument-cleaning procedures.  The
standardization of protocols for processing reusable trephine systems might prevent
outbreaks of TASS following PK.
Toxic anterior segment syndrome following iris-
supported phakic IOL implantation with viscoelastic
Multivisc BD.
• Eur J Ophthalmol. 2009 Nov 30. [Epub ahead of print]
• Kremer I, Levinger E, Levinger S.
• TA University, Tel Aviv; and "Enaim" Medical Center - Jerusalem and Sackler School of Medicine, Jerusalem
- Israel.
• Purpose. To report on the association between Multivisc BD and toxic anterior segment syndrome (TASS)
post phakic intraocular lens (IOL) implantation.
• Methods and Patients. Two patients developed severe toxic anterior chamber inflammation following
implantation of phakic iris fixated IOL with Multivisc BD viscoelastic. Anterior chamber washout was
performed with intracameral antibiotic injection. Local antibiotics were continued until cultures were
found to be negative. Thereafter, intensive local and systemic steroids were initiated and gradually tapered
down.
• Results. The inflammatory reaction disappeared completely and the visual acuity improved from hand
motion to 6/9 without correction within 1 week.
• Conclusions. Any viscoelastic material may be contaminated by heat-stable bacterial endotoxic as it is
prepared by gene-coded bacteria. It is suggested that Multivisc BD was the etiologic factor of TASS.
Refractive surgeons should be aware of this rare complication of phakic IOL implantation whenever they
use a new viscoelastic material.
Retrospective analysis of clinical characteristics
of toxic anterior segment syndrome
• Zhonghua Yan Ke Za Zhi. 2009 Mar;45(3):225-8.
• Yang SL, Yan XM.
• Department of Ophthalmology, Peking University First Hospital, Beijing 100034, China.
• OBJECTIVE: To investigate the etiology, clinical features, treatment and prognosis of toxic anterior segment
syndrome (TASS).
• METHODS: It was a retrospective series case study. The clinical data of eight definite diagnosed TASS cases were
retrospectively analyzed.
• RESULTS: Among eight TASS cases, seven were post cataract surgery cases and one was post cornea penetrating
injury. Three cases were caused by residual povidone iodine on instruments, 2 cases resulted from the misuse of
distilled water as intraocular irrigating liquid during cataract surgery, 2 cases were produced by the countercurrent
of antibiotic solution via the cornea-scleral incision into anterior chamber during subconjunctival injection at the
end of the surgery, and 1 case was induced by the injection of the distilled water into the anterior chamber at the
end of the surgery. Three TASS cases occurred during operation and 5 cases occurred at 1 day after operation. All
eight cases suffered from the painless blurred vision. Three cases occurred during operation presented with
decrease of corneal transparence and depigmentation of iris. On the first day after operation, all cases had diffuse
corneal stroma edema and severe anterior uveitis. Dexamethasone 0.1% or prednisolone acetate 1% eye drops,
three times per day or one time per hour was used in all cases. Carteolol 2% eye drop, two times per day, was used
for the cases with ocular hypertension. The cornea was clear in 6 cases, but corneal endothelial decompensation
in 2 cases after therapy.
• CONCLUSION: Various toxic agents injected into anterior chamber by misuse can result in TASS. All these misuse
can be avoided. Early diagnosis and proper management may be important to improve the prognosis of TASS.
Toxic anterior segment syndrome after
uncomplicated cataract surgery.
• Eur J Ophthalmol. 2010 Jan-Feb;20(1):106-14.
• Ozcelik ND, Eltutar K, Bilgin B.
• Ophthalmology Department, Istanbul Education and Research Hospital, Istanbul, Turkey.
• PURPOSE: To evaluate the anterior segment examination findings and the response to medical therapy of
patients who had toxic anterior segment syndrome (TASS) after uncomplicated cataract surgery.
• METHODS: Fourteen eyes of 14 patients were enrolled in the study. Visual acuity, biomicroscopic anterior
segment examination, intraocular pressure measurement, and fundus examination were performed to assess
TASS occurring during postoperative 12-48 hours after uncomplicated phaco surgery. The visual impairment,
corneal edema, tyndallization, fibrin formation, hypopyon, vitritis, and response to steroid therapy were
evaluated prospectively.
• RESULTS: After topical steroid therapy lasting for 1 week, visual acuity improved in 11 eyes. No significant
visual improvement occurred in 3 eyes. Significant corneal edema was found in 4 and mild corneal edema was
observed in the other 10 eyes. Fibrin reaction occurred in 5 and tyndallization in various degrees was positive
in all eyes. There was a 1-mm hypopyon in 1 patient. There was no sign of vitritis and steroid therapy was
effective in all of the patients. In addition to topical treatment with steroid and antibiotic drops; systemic and
subconjunctival steroids were used in 3 patients who had fibrin formation and in one patient who had
hypopyon .
• CONCLUSIONS: After uncomplicated cataract surgery, toxic anterior segment may occur in the early
postoperative period, which is treated successfully with steroids. More studies are needed to understand the
multifactorial risk factors affecting the etiopathogenesis of this syndrome.
 Toxic Anterior Segment Syndrome - A Reality

• First Independent Ophthalmic Journal Published from Islamabad, Pakistan; Vol. 7, No. 4 Oct-Dec-
2009
• Dr. Mahfooz Hussain Director & Senior Consultant Ophthalmologist,Dr. Tariq Farooq Babar, Associate Professor & Visiting
Eye Surgeon,Dr. Mir Zaman, Senior Registrar,Dr. Mohammad Younas Khan, Consultant Ophthalmologist,Dr. Anwar Iqbal &
Dr. Naz Jehangir Postgraduate Trainees Pakistan Institute of Community Ophthalmology, Khyber Institute of Medical
Sciences, Hayatabad Medical Complex, Peshawar,Dr. Patricia D. Wade, Consultant Ophthalmology JOS University Teaching
Hospital, Nigeria.
• PURPOSE: The purpose is to report two outbreaks of toxic anterior segment syndrome (TASS) and to emphasize importance
of its early diagnosis, appropriative treatment and prevention which is all the more important.
• PATIETS and MATERIALS: We had two outbreaks of TASS at two different occasions in 2007-08 after routine cataract
extraction with posterior chamber implant. We retrieved clinical records of all patients and collected information on a
specially designed performa. Details of postoperative signs and symptoms and treatment were recorded. All the patients
were followed up for at least 3 months. We also looked at methods of instrument cleaning and sterilization in detail.
• RESULTS: We diagnosed 11 patients with TASS at two different occasions as two clusters. All the patients were correctly
diagnosed and no patient turned out to be infective, which is usually the main concern. All the patients were successfully
treated. Final visual acuity was 6/6 in 7 patients, 6/9 in 3 patients and 6/18 in one patient. Increased IOP in 4 patients
returned to normal at 3 months.
• CONCLUSIONS: It is important to differentiate TASS patients from infective endophthalmitis. Timing of onset and sparing of
posterior segment are important factors for diagnosis along with other clinical features. Early and intensive treatment
with topical steroids, cycloplegics and oral anti-inflammatory drugs can resolve the condition and visual acuity can improve
to preoperatively expected levels.
PREVENTIO
N
Task Force

• When reports of toxic anterior segment syndrome (TASS) in North

America suddenly began to escalate to five times their normal level early in 2006, the
American Society of Cataract and Refractive Surgery (ASCRS) provided support for a task
force convened to investigate the reasons why and develop recommendations for reducing its
incidence.
• Analysis of the data the task force assembled failed to reveal any single cause of the outbreak
and, instead, suggested that a number of etiologic factors could have been involved.
• The analysis also provided support for the belief that the cleaning and sterilization of the
instruments used in cataract surgery appears to be a critical factor in reducing the risk of
TASS.
• The team came up with this Special ASCRS/ASORN Report: “Recommended Practices for
Cleaning and Sterilizing Intraocular Surgical Instruments”.
• Guidelines : Establish written protocols for instrument cleaning and reprocessing, certify
competency of responsible personnel, and monitor compliance
• Use only medications and solutions that are free of preservatives, bisulfites, or metasulfites.
Treatment :

• Medical Care
• Once TASS is confirmed,
patients should be started
on topical steroids.
• Careful assessment and
RULE OUT ENDOPHTHALMITIS
treatment of elevated IOP.
• Nonsteroidal anti-
inflammatory drops.
• Close follow-up.
Treatment :

• Surgical Care
• Intraocular lens exchange.
• Corneal transplantation.
• Trabeculectomy (seton valve procedures).
 TASS TIMELINE
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Sporadic Condition Delayed- softened October TASS at Numerou ASCRS

reports of termed onset city water Increasing Communi s eye created a
severe Toxic TASS that reports of ty centers TASS Task
anterior Anterior associate supplied sterile Hospital in North Force to
segment Segment d with the auto- Inflamma in Maine America investigat
inflamma Syndrome Memory clave tion reported e
tion (TASS) Lens steam linked to an outbreaks
following Monson generator BSS(Endo increase of TASS
cataract et al. JCRS (sulphate sol) incidence and
surgery 1992 impurity) of TASS identify
following causative
Outpatien agents
t cataract
surgery
“Just because something is sterile,
it does not mean it’s not toxic!”
THANK YOU!