CLINICAL COMMUNICATION
Endophthalmitis or toxic anterior segment syndrome?
Clin Exp Optom 2016
Matthew Hao Lee* MBBS (Hons)
Dean Cugley BMedSci MBBS (Hons)
Alp Atik BMed BMedSci (Hons I) MPH
MMed (Ophth Sci)
Ghee Soon Ang MBChB FRCOphth
FRANZCO
*Ophthalmology Department, Alfred Health,
Melbourne, Victoria, Australia
Royal Victorian Eye and Ear Hospital, Melbourne,
Victoria, Australia
E-mail: matthewhaolee@gmail.com
Submitted: 30 October 2015
Revised: 13 January 2016
Accepted for publication: 18 February 2016
Key words: cataract, endophthalmitis, toxic
anterior segment syndrome, visual acuity
Severe anterior segment inammation after
cataract surgery often alerts the ophthalmolo-
gist to two main differential diagnoses toxic
anterior segment syndrome (TASS) and
acute post-operative endophthalmitis. TASS
is a sterile post-operative inammatory reac-
tion caused by a non-infectious substance that
enters the anterior segment, resulting in toxic
damage to intraocular tissues.1 Visual progno-
sis is usually excellent due to its responsive-
ness to topical steroids. Sengupta and
colleagues2 found that the mean visual acuity
(VA) was 0.11 logMAR (approximately 6/7.5
Snellen acuity) one month after treatment.2
Classic features of TASS include early (day
zero or one post-operatively), intense, pain-
less anterior segment inammation without
vitreous involvement.3 The hallmark of TASS
is its rapid onset, usually within 12 to
24 hours. Rarely, TASS can present as delayed
onset post-operative inammation, which
can make it difcult to distinguish from acute
post-operative endophthalmitis.4,5
Acute post-operative endophthalmitis re-
fers to a serious intraocular inammatory
disorder resulting from direct inoculation of
organisms during surgery, causing an
2016 Optometry Australia
infection of the vitreous cavity.6 Visual prog-
nosis is often poor. Ng and colleagues7 found
that 52.5 per cent of patients had a VA of 6/
60 or worse at discharge and that one-third
of patients in his study had a VA of worse than
6/18 six months after admission for endoph-
thalmitis. Signicant predictors of poor visual
outcome include an initial VA of light percep-
tion or worse and infection by virulent
organisms such as Staphylococcus aureus, strep-
tococcal species and Gram-negative bacteria.8
Compared to TASS, infectious endophthal-
mitis often has a later presentation (peaks
between days three and seven), with signi-
cant pain and vitritis. These features are
summarised in Table 1. Onset, rapidity of
symptom progression and the presence or ab-
sence of pain and vitritis are the key differen-
tiating features between TASS and infectious
endophthalmitis; however, both conditions
can present with poor visual acuity, corneal
inammation and signicant anterior cham-
ber reaction. Our case illustrates this diagnos-
tic dilemma, as the patient had features
suggestive of both TASS (presentation on
day one post-operatively, absence of pain,
sporadic occurrence) and endophthalmitis
(vitritis).
CASE HISTORY
Acute symptoms and signs in the days soon af-
ter cataract surgery can be alarming and
need prompt diagnosis. We report a case in-
volving a 74-year-old woman with bilateral
macular degeneration, who underwent cata-
ract surgery in the left eye associated with a
nuclear sclerotic cataract graded 3 plus. Pre-
operative VAs were 6/60 in the left eye and
counting ngers at 30 centimetres in the
right eye. Her left eye was receiving four-
monthly Lucentis (ranibizumab) intravitreal
injections and her most recent injection one
month earlier was uneventful.
The procedure involved uncomplicated
phacoemulsication and posterior chamber
intraocular lens implantation with routine
use of povidone iodine preoperatively and
intracameral cephazolin at the end of
DOI:10.1111/cxo.12426
surgery. She presented early on the rst
post-operative day complaining of blurred vi-
sion and oaters without any specic pain.
On examination, she had a VA of hand
movements in the left eye with an intraocu-
lar pressure of 22 mmHg. Slitlamp exami-
nation revealed mild corneal oedema with
Desemets folds, a negative Seidels test, a
small inferior hypopyon measuring less
than one millimetre in height, no pupil ab-
normality, intense anterior chamber activ-
ity (graded 2 plus) and vitreous cells with
no fundus view. A B-scan ultrasound
conrmed vitritis and excluded a retinal
detachment.
Based on the one-day presentation of in-
ammation, mild corneal oedema, small
hypopyon and absence of signicant pain,
the patient was diagnosed with TASS
and commenced on one-hourly topical
Prednefrin Forte. With no demonstrable
improvement after 24 hours, the patient
underwent an anterior chamber tap and vit-
reous biopsy. Despite a successful anterior
chamber tap, vitreous biopsy was abandoned
after three unsuccessful attempts with a 25
gauge needle and the development of vitre-
ous haemorrhage and hypotony. The patient
received intravitreal ceftazidime (2.25 mg/
0.1 ml), vancomycin (1 mg/0.1 ml) and dexa-
methasone (0.4 mg/0.1 ml).
After three days of inpatient monitoring,
she remained pain-free and maintained a
VA of hand movements in the left eye. Clin-
ical ndings at this time included
Desemets folds in the cornea graded 3
plus, hyphaema measuring 0.3 mm, 2 plus
anterior chamber cells and vitreous haemor-
rhage obstructing the fundal view. Despite
no microbial growth on anterior chamber
tap, the patient was diagnosed with an infec-
tious endophthalmitis. She was discharged
on topical Prednefrin Forte (prednisolone
1%/phenylephrine 0.12 per cent) six times
a day, topical ooxacin (0.3 per cent) four
times a day, topical atropine (one per cent)
twice a day and oral ciprooxacin 750 mg
twice a day. Left pars plana vitrectomy
was performed three weeks later for
Clinical and Experimental Optometry 2016
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Endophthalmitis or toxic anterior segment syndrome? Lee, Cugley, Atik and Ang

complex by the fact that the affected eye was

Toxic anterior segment her better eye, which inuenced the aggres-
Endophthalmitis syndrome
siveness of our approach and investigation
History and treatment for endophthalmitis were initi-
ated despite the possibility of TASS and only
Time-course 37 days after surgery 13 days after surgery
after 24 hours of steroid therapy.
Presence of pain Pain is present in 75% of patients Minimal to none
This case also serves as a reminder that a
Occurring in clusters Sporadic Presents in outbreaks vitreous tap can have serious complications
Examination such as vitreous haemorrhage requiring fur-
Visual acuity Severe reduction Mild to severe ther surgery. Nevertheless, our recommenda-
Elevated intraocular Common Uncommon tion in ambiguous situations is still to treat
pressure empirically as infectious endophthalmitis via
vitreous tap and intravitreal antibiotics, given
Corneal reaction Rarely produces limbus to limbus Limbus to limbus corneal
corneal odema oedema the devastating consequences of undiag-
nosed disease and the inability of clinical fea-
Anterior chamber Cells 3+ Cells 13+
tures to reliably differentiate it from TASS.
reaction Fibrin variable Fibrin 13+ Therefore, we strongly recommend urgent
Hypopyon 3+ Hypopyon 1+ referral to an ophthalmologist in patients
Pupil Round, reactive Mydriatic, dyscoric - but usually with features consistent with TASS or
in later stages infectious endophthalmitis after intraocular
Vitreous reaction Vitritis always present Clear but spillover possible; surgery.3
vitritis rare
Management
REFERENCES
Steroid response Worsens Improves
1. Mamalis N, Edelhauser HF, Dawson DG et al. Toxic
Antibiotic response Improves Worsens anterior segment syndrome. J Cataract Refract Surg
Prognosis Generally poor Generally good 2006; 32: 324333.
2. Sengupta S, Chang DF, Gandhi R et al. Incidence
and long-term outcomes of toxic anterior segment
syndrome at Aravind Eye Hospital. J Cataract Refract
Table 1. Differentiating toxic anterior segment syndrome versus infectious Surg 2011; 37: 16731678.
endophthalmitis 3. Holland SP, Morck DW, Lee TL. Update on toxic an-
terior segment syndrome. Curr Opin Ophthalmol
2007; 18: 48.
persistent vitreous haemorrhage. The out- attributed to other causes, such as retained 4. Miyake G, Ota I, Miyake K et al. Late-onset toxic an-
come was favourable with a two-week post- cortex and previous uveitis.3 terior segment syndrome. J Cataract Refract Surg 2015;
operative VA of 6/15. Dramatic improvement with intense topi- 41: 666669.
5. Suzuki T, Ohashi Y, Oshika T et al. Outbreak of late-
cal steroids is a known feature of TASS but
onset toxic anterior segment syndrome after implan-
its usefulness as a differentiating feature is tation of one-piece intraocular lenses. Am J
DISCUSSION limited at presentation given that a clinical re- Ophthalmol 2015; 159: 934939.
sponse is usually only seen after a three-day 6. Lemley CA, Han DP. Endophthalmitis: a review of
A review of the literature suggests that onset course of steroids given every 30 to 60 mi- current evaluation and management. Retina 2007;
of symptoms as a differentiating factor nutes.3 The clinician also risks worsening 27: 662680.
between TASS and infectious endophthalmi- 7. Ng JQ, Morlet N, Pearman JW et al Management
the course of the disease if the diagnosis is in- and outcomes of postoperative endophthalmitis
tis is unreliable. There are reports of Staphy- fectious endophthalmitis. Although clinical since the endophthalmitis vitrectomy study: the En-
lococcus epidermidis3 and Bacillus cereus3,9 deterioration could help conrm the diagno- dophthalmitis Population Study of Western
endophthalmitis, which had TASS-like early sis, it is a risky decision and one that we were Australia (EPSWA)s fth report. Ophthalmology
presentations.9 Clinicians should also be not willing to take in our patient, given that
2005; 112: 11991206.
wary of the use of pain as a differentiating 8. Group TEVS. Microbiologic factors and visual out-
the eye in question was her better-seeing eye. come in the endophthalmitis vitrectomy study. Am J
factor as pain in endophthalmitis is only Our case report highlights a clinical conun- Ophthalmol 1996; 122: 830846.
present in about 75 per cent of patients.10 drum in severe post-operative inammation. 9. Rishi E, Rishi P, Sengupta S et al. Acute postopera-
Furthermore, despite TASS being known to Distinguishing between TASS and endoph- tive Bacillus cereus endophthalmitis mimicking
occur in clusters, Sengupta and colleagues2 thalmitis at day one after surgery is difcult
toxic anterior segment syndrome. Ophthalmology
found that 52 per cent of cases were spo- 2013; 120: 181185.
but important, due to the seriousness of the 10. Ozcelik ND, Eltutar K, Bilgin B. Toxic anterior
radic. There is also often under-reporting conditions and the divergent treatment strat- segment syndrome after uncomplicated cataract
of sporadic cases. Such cases may be egies. Our patients situation was made more surgery. Euro J Ophthalmol 2010; 20: 106114.

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