Toxic Anterior Segment Syndrome (TASS)
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Toxic anterior segment syndrome (TASS) is an acute postoperative inflammatory reaction in which a noninfectious substance enters the anterior segment and induces toxic damage to the intraocular tissues. Almost all cases occurred after uneventful cataract surgery, and, more recently, it has been reported after phakic intraocular lens implantation. Previously, this syndrome was defined by many names, such as sterile endophthalmitis or postoperative uveitis of unknown cause. Furthermore, a condition termed toxic endothelial cell destruction (TECD) syndrome has been described and is now believed to be a variant of TASS. TASS is shown in the image below.
TASS results from the inadvertent entry of toxic substances into the anterior chamber. This causes a marked inflammatory reaction that varies in intensity depending on the type and duration of the toxin.
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.
Toxic agents specifically induce the acute breakdown of endothelial junctions with loss of the barrier function. This results in the remaining viable endothelial cells to migrate and spread over the damaged areas in an effort to maintain the endothelial pumping system. If significant damage occurs, however, the remaining viable cells will not be able to sufficiently compensate the loss, with ensuing permanent corneal edema being the consequence.
Trabecular meshwork damage can also develop, resulting in decreased drainage, scarring, and peripheral anterior synechiae formation with a subsequent rise in intraocular pressure.
Possible etiologies of TASS include the following:
United States
Data on the incidence of TASS are lacking. Clusters ranging from a few cases to up to 20 cases occur several times each year.
Furthermore, in 2005, audience response during the American Academy of Ophthalmology Annual Meeting revealed that 52% of attendees had seen 1 case of TASS and 7% of attendees reported seeing more than 5 cases.
TASS can induce permanent corneal endothelial damage, in addition to trabecular meshwork damage, thus debilitating vision. Depending on the type and duration of the toxic insult, the visual outcome can range from 20/20 to no light perception. Patients may require further intraocular procedures, such as penetrating keratoplasty and/or glaucoma filtering procedure surgery, to regain visual function.
No racial predilection has been found with TASS.
No known difference exists in the incidence of TASS between men and women.
No known association of TASS exists with increasing age.
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Signs and Symptoms
TASS
Infectious Endophthalmitis
Onset
12-24 hours usually
2-7 days usually
Pain
Usually none but can be mild to moderate
Usually severe
Corneal edema
Limbus to limbus
Specific to area of trauma
Intraocular pressure
May increase suddenly
Usually not elevated
Anterior chamber inflammation
Moderate-to-severe anterior chamber reaction with increased white blood cells and fibrin. Hypopyon may be noted.
Moderate-to-severe anterior chamber reaction. Fibrin is variable. Hypopyon often present (75% of the time).
Vitritis
Very rare
Always present
Pupil
Fixed and dilated
Reactive
Lid swelling
Usually not evident
Often present
Visual acuity
Decreased
Decreased
Response to steroids
Dramatic improvement
Equivocal
Jean Deschênes, MD, FRCSC Professor, Research Associate, Director, Uveitis Program, Department of Ophthalmology, McGill University Faculty of Medicine; Senior Ophthalmologist, Clinical Director, Department of Ophthalmology, Royal Victoria Hospital, Canada
Jean Deschênes, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, Canadian Medical Association, Canadian Ophthalmological Society, International Ocular Inflammation Society, Quebec Medical Association
Disclosure: Nothing to disclose.
Michael Ross, MD Resident Physician, Department of Ophthalmology, McGill University Faculty of Medicine, Canada
Disclosure: Nothing to disclose.
Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society
Disclosure: Nothing to disclose.
Steve Charles, MD Founder and CEO of Charles Retina Institute; Clinical Professor, Department of Ophthalmology, University of Tennessee College of Medicine
Disclosure: Received royalty and consulting fees for: Alcon Laboratories.
Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.
Richard W Allinson, MD Associate Professor, Department of Ophthalmology, Texas A&M University Health Science Center; Senior Staff Ophthalmologist, Scott and White Clinic
Richard W Allinson, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, Texas Medical Association
Disclosure: Nothing to disclose.
Ahmed R Al-Ghoul, MD, FRCSC Clinical Lecturer, Department of Surgery, Division of Ophthalmology, University of Calgary Faculty of Medicine, Canada
Ahmed R Al-Ghoul, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Canadian Medical Association, Canadian Ophthalmological Society
Disclosure: Nothing to disclose.
Puwat Charukamnoetkanok, MD Assistant Professor of Ophthalmology, University of Pittsburgh School of Medicine
Puwat Charukamnoetkanok, MD is a member of the following medical societies: Phi Beta Kappa
Disclosure: Nothing to disclose.
Deepinder K Dhaliwal, MD Associate Professor of Ophthalmology, University of Pittsburgh School of Medicine; Director of Refractive Surgery and Director of Cornea and External Disease Service, University of Pittsburgh Medical Center Eye Center; Medical Director of Laser/Vision Center, University of Pittsburgh Medical Center; Founder and Director, Center for Integrative Eye Care, University of Pittsburgh Medical Center
Deepinder K Dhaliwal, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Eye Bank Association of America, International Society of Refractive Surgery
Disclosure: Nothing to disclose.
Toxic Anterior Segment Syndrome (TASS)
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