TOXIC ANTERIOR SEGMENT SYNDROME AFTER UNCOMPLICATED CATARACT SURGERY

1
TOXIC ANTERIOR SEGMENTSYNDROME AFTER
UNCOMPLICATEDCATARACT SURGERY

• Kadir Eltutar, M.D., Burak Bilgin, M.D., N.
  Demet Ozcelik, M.D.

Istanbul Education and Research Hospital
Opthalmology Department, Turkiye Almangoz
Eye Center, Nisantasi, Istanbul, Turkiye
The authors state that they have no proprietary
interest and they have not received any grants or
funds in support of the study.
2
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.

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METHODS

• Fourteen eyes of 14 patients were enrolled.
• Best corrected visual acuity ( BCVA ),
  biomicroscopic anterior segment examination,
  intraocular pressure measurement ( IOP ) and
  fundus examination were performed to assess TASS
  occuring during post-operative 12- 48 hours
  after uncomplicated phacoemulsification surgery.
• Mean follow-up time 2,2 0,35 months.
• Mean age 64,07 5,40 years.
• Visual impairment, corneal edema, tyndalisation,
  fibrin formation, hypopyon, vitritis and response
  to steroid therapy were evaluated prospectively.

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METHODS

• Pupilla was dilated with tropicamide 1 and
  cyclopentolate 1 before surgery.
• Operations were performed under sub-tenon
  anesthesia achieved by prilocaine 2 .
• Antisepsis of the lids, eye lashes and
  conjunctiva was achieved by povidone-iodine 5
  before the procedure .
• BSS plus containing 0.05 mg/ 500 cc ( 110000 )
  epinephrine was used as infusion fluid.
• The procedure was ended with intracameral
  cefuroxime axetile injection for infection
  prophylaxy.
• Postoperative topical steroid drops (
  prednisolone acetate 1 ) were instilled every
  hour in combination with topical antibiotics (
  ofloxacin ) and mydriatics t.i.d., with gradual
  tapering.

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RESULTS

• After topical steroid therapy lasting for one
  week, the visual acuity improved in 11 ( 78,57
  ) eyes .
• No significant visual improvement occurred in 3 (
  21,42 ) eyes.
• Significant corneal edema was found in 4 ( 28,57
  ) and mild corneal edema was observed in the
  other 10 ( 71,42 ) eyes.
• Fibrin reaction occurred in 5 ( 35,71 ) eyes
  and tyndalisation in various degrees was positive
  in all eyes.
• There was 1 mm hypopyon in 1 ( 7,14 ) patient.
  
• There was no sign of vitritis and steroid
  therapy was effective in all of the patients.
• In addition to topical treatment with steroids,
  mydriatics and antibiotic drops systemic and
  subconjunctival steroids were used in 3 ( 21,42
  ) patients who had fibrin formation and in one
  patient who had hypopyon ( 7,14 ) .

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RESULTS

• The samples collected from the patients were
  Gram-stain and culture negative.
• None of our patients had severe visual loss,
  permanent corneal edema or glaucoma.
• No specific causative agent or a predisposing
  factor was detected in our cases.

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Statistical evaluation of LogMAR BCVA ( mean SD
) improvement during the applied visits, and
comparative values of BCVA between the
examinations using repeated measures and
Bonferonni test ( p lt 0,05 ).
8
Statistical evaluation of IOP measured by GAT
during the applied visits, and comparative
values of IOP between the examinations using
repeated measures and Bonferonni test ( p lt 0,05
).
GAT Goldmann Applanation Tonometry
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CONCLUSIONS

• After uncomplicated cataract surgery, toxic
  anterior segment may occur in early postoperative
  period, which is treated succesfully with
  steroids.
• Throughout the literature search gathered about
  the outbreaks and single cases there was no
  significant data to suggest a single factor was
  responsible in the etiopathogenesis of TASS.
• Cleaning and sterilisation of intraocular
  instruments may be considered as the most
  important factor between multiple potential risk
  factors related to TASS.
• The outcomes of topical steroid drops and close
  monitoring in the management of TASS are
  excellent, as reported in many cases and so as in
  our series.

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The possible factors of anterior segment toxicity
are

• Inproper concentration of intracameral
  antibiotics, toxicity of intracameral medications
  containing preservatives or additives,
• Retained cortex,
• Prolonged surgery,
• Reusable cannulated instruments, reusable
  inserters of intraocular lenses or I/A tips,
• Excessive iris manipulation with the metal
  instruments,
• Metal ion residues, residues of denaturated OVD
  or debris due to inadequate rinsing,
• Hemorrhage of limbal vessels that is entering
  from the clear corneal incision,
• Hypersensitivity to any of the materials or
  solutions used, immunologic differences and,
• Instruments with inappropriately dried lumens.

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CONCLUSIONS

• Though response to steroid therapy is excellent,
  it should be kept in mind that severe
  complications like irreversible visual loss,
  permanent endothelial damage , corneal
  decompensation, permanently dilated pupil,
  cystoid macular edema or glaucoma due to
  permanent damage to trabecular meshwork may occur
  after TASS .

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CONCLUSIONS

• As cataract surgery is the most common procedure
  applied to older population, TASS should be
  considered as one of the most important
  complications of the procedure and treated
  strictly .
• If there is any doubt about the differential
  diagnosis, unless proven, the patient should be
  treated as having infectious endophthalmitis as
  both conditions may be presented similarly in
  early stages.
• More studies have to be done to understand the
  multifactorial risk factors affecting the
  etiopathogenesis of this syndrome.