Toxic Anterior Segment Syndrome

  • He Li
  • Konstantinos T. Tsaousis
  • Jun J. Guan
  • Nicolas Reiter
  • Nick MamalisEmail author


Toxic anterior segment syndrome (TASS) is an acute, sterile postoperative inflammatory reaction of the anterior segment tissues in response to toxic substances. The term was coined by Monson et al. in 1992 [1]. Other terms used to describe TASS include sterile postoperative endophthalmitis and toxic endothelial cell destruction syndrome. TASS usually manifests within 12–48 h postoperatively and may occur after any anterior segment surgery [2].


  1. 1.
    Monson M, Mamalis N, Olson RJ. Toxic anterior segment inflammation following cataract surgery. J Cataract Refract Surg. 1992;18:184–9.PubMedGoogle Scholar
  2. 2.
    Mamalis N, et al. Toxic anterior segment syndrome. J Cataract Refract Surg. 2006;32:324–33.PubMedGoogle Scholar
  3. 3.
    Bodnar Z, Clouser S, Mamalis N. Toxic anterior segment syndrome: update on the most common causes. J Cataract Refract Surg. 2012;38:1902–10.Google Scholar
  4. 4.
    Sengupta S, Chang DF, Gandhi R, Kenia H, Venkatesh R. Incidence and long-term outcomes of toxic anterior segment syndrome at Aravind Eye Hospital. J Cataract Refract Surg. 2011;37:1673–8.PubMedGoogle Scholar
  5. 5.
    Ronge L. Toxic anterior segment syndrome: why sterile isn’t clean enough. EyeNet. 2002:17–18.Google Scholar
  6. 6.
    Kutty PK, et al. Multistate outbreak of toxic anterior segment syndrome, 2005. J Cataract Refract Surg. 2008;34:585–90.PubMedGoogle Scholar
  7. 7.
    Mamalis N. Anatomy of a TASS outbreak. J Cataract Refract Surg. 2007;33:357–8.PubMedGoogle Scholar
  8. 8.
    Jehan FS, et al. Postoperative sterile endophthalmitis (TASS) associated with the memorylens. J Cataract Refract Surg. 2000;26:1773–7.PubMedGoogle Scholar
  9. 9.
    Sato T, et al. Severe intraocular inflammation after intravitreal injection of bevacizumab. Ophthalmology. 2010;117:512–6, 516.e1–2.PubMedGoogle Scholar
  10. 10.
    Vitale A, Moorthy R, Isbel E III. Focal points on TASS. 2009.Google Scholar
  11. 11.
    West ES, Behrens A, McDonnell PJ, Tielsch JM, Schein OD. The incidence of endophthalmitis after cataract surgery among the U.S. medicare population increased between 1994 and 2001. Ophthalmology. 2005;112:1388–94.PubMedGoogle Scholar
  12. 12.
    Wallin T, Parker J, Jin Y, Kefalopoulos G, Olson RJ. Cohort study of 27 cases of endophthalmitis at a single institution. J Cataract Refract Surg. 2005;31:735–41.PubMedGoogle Scholar
  13. 13.
    Dotan A, Kaiserman I, Kremer I, Ehrlich R, Bahar I. Intracameral recombinant tissue plasminogen activator (r-tPA) for refractory toxic anterior segment syndrome. Br J Ophthalmol. 2014;98:252–5.PubMedGoogle Scholar
  14. 14.
    Nizamani NB, Bhutto IA, Talpur KI. Cluster of Urrets-Zavalia syndrome: a sequel of toxic anterior segment syndrome. Br J Ophthalmol. 2013;97:976–9.PubMedGoogle Scholar
  15. 15.
    Moulick PS, Reddy S, Gurunadh VS, Mohindra VK. Toxic anterior segment syndrome—a sequel of uneventful cataract surgery. Med J Armed Forces India. 2015;71:S205–7.PubMedGoogle Scholar
  16. 16.
    Wallace EJ, Imrie F, Roxburgh S, Coleiro J, Ironside J. Epithelial downgrowth as a complication of toxic anterior segment syndrome. J Cataract Refract Surg. 2007;33:1976–7.PubMedGoogle Scholar
  17. 17.
    Kreisler KR, Martin SS, Young CW, Anderson CW, Mamalis N. Postoperative inflammation following cataract extraction caused by bacterial contamination of the cleaning bath detergent. J Cataract Refract Surg. 1992;18:106–10.PubMedGoogle Scholar
  18. 18.
    Edelhauser HF, Van Horn D, Schultz R, Hyndiuk R. Comparative toxicity of intraocular irrigating solution on corneal endothelium. Am J Ophthalmol. 1976;81:473–81.PubMedGoogle Scholar
  19. 19.
    Gonnering R, Edelhauser HF, Van Horn DL, Durant W. The pH tolerance of rabbit and human corneal endothelium. Invest Ophthalmol Vis Sci. 1979;18:373–90.PubMedGoogle Scholar
  20. 20.
    Edelhauser HF, Hanneken AM, Pederson HJ, Van Horn DL. Osmotic tolerance of rabbit and human corneal endothelium. Arch Ophthalmol. 1981;99:1281–7.PubMedGoogle Scholar
  21. 21.
    Parikh CH, Edelhauser HF. Ocular surgical pharmacology: corneal endothelial safety and toxicity. Curr Opin Ophthalmol. 2003;14:178–85.PubMedGoogle Scholar
  22. 22.
    Kim J. Intraocular inflammation of denatured viscoelastic substance in cases of cataract extraction and lens implantation. J Cataract Refract Surg. 1987;13:537–42.PubMedGoogle Scholar
  23. 23.
    Carter LM, Duncan G. Effects of detergents on the ionic balance and permeability of isolated bovine cornea. Exp Eye Res. 1973;17(5):409–16.PubMedGoogle Scholar
  24. 24.
    Parikh C, Sippy BD, Martin DF, Edelhauser HF. Effects of enzymatic sterilization detergents on the corneal endothelium. Arch Ophthalmol. 2002;120:165–72.PubMedGoogle Scholar
  25. 25.
    Green K, Hull DS, Vaughn ED, Malizia AA, Bowman K. Rabbit endothelial response to ophthalmic preservatives. Arch Ophthalmol. 1977;95:2218–21.PubMedGoogle Scholar
  26. 26.
    Cutler Peck CM, et al. Toxic anterior segment syndrome: common causes. J Cataract Refract Surg. 2010;36:1073–80.PubMedGoogle Scholar
  27. 27.
    American Society of Cataract and Refractory Surgery & American Society of Ophthalmic Registered Nurses. Recommended practices for cleaning and sterilizing intraocular surgical instruments. J Cataract Refract Surg. 2007;33:1095–100.Google Scholar
  28. 28.
    American Society of Ophthalmic Registered Nurses. Recommended practices for cleaning and caring for surgical instruments and powered equipment. AORN J. 2002;75:627–41.Google Scholar
  29. 29.
    Association for the Advancement of Medical Instrumentation. Comprehensive guide to steam sterilzation and sterility assurance in health care facilities. 2006.Google Scholar
  30. 30.
    Breebaart AC, Nuyts RM, Pels E, Edelhauser HF, Verbraak FD. Toxic endothelial cell destruction of the cornea after routine extracapsular cataract surgery. Arch Ophthalmol. 1990;108:1121–5.PubMedGoogle Scholar
  31. 31.
    Franken KLMC, et al. Purification of His-tagged proteins by immobilized chelate affinity chromatography: the benefits from the use of organic solvent. Protein Expr Purif. 2000;18:95–9.PubMedGoogle Scholar
  32. 32.
    Gills J. Filters and antibiotics in irrigating solution for cataract surgery. J Cataract Refract Surg. 1991;17:385.PubMedGoogle Scholar
  33. 33.
    Kramann C, et al. Effects of intraocular cefotaxime on the human corneal endothelium. J Cataract Refract Surg. 2001;27:250–5.PubMedGoogle Scholar
  34. 34.
    Montan PG, Wejde G, Koranyi G, Rylander M. Prophylactic intracameral cefuroxime: efficacy in preventing endophthalmitis after cataract surgery. J Cataract Refract Surg. 2002;28:977–81.PubMedGoogle Scholar
  35. 35.
    Montan PG, Wejde G, Setterquist H, Rylander M, Zetterström C. Prophylactic intracameral cefuroxime: evaluation of safety and kinetics in cataract surgery. J Cataract Refract Surg. 2002;28:982–7.PubMedGoogle Scholar
  36. 36.
    Britton B, Hervey R, Kasten K, Gregg S, McDonald T. Intraocular irritation evaluation of benzalkonium chloride in rabbits. Ophthalmic Surg. 1976;7:46–55.PubMedGoogle Scholar
  37. 37.
    Liu H, Routley I, Teichmann KD. Toxic endothelial cell destruction from intraocular benzalkonium chloride. J Cataract Refract Surg. 2001;27:1746–50.PubMedGoogle Scholar
  38. 38.
    Eleftheriadis H, et al. Corneal toxicity secondary to inadvertent use of benzalkonium chloride preserved viscoelastic material in cataract surgery. Br J Ophthalmol. 2002;86:299–305.PubMedPubMedCentralGoogle Scholar
  39. 39.
    Althomali T. Viscoelastic substance in prefilled syringe as an etiology of Toxic Anterior Segment Syndrome. Cutan Ocul Toxicol. 2016;35(3):237–41.PubMedGoogle Scholar
  40. 40.
    Hellinger WC, 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.PubMedGoogle Scholar
  41. 41.
    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.PubMedGoogle Scholar
  42. 42.
    Duffy RE, et al. An epidemic of corneal destruction caused by plasma gas sterilization. The Toxic Cell Destruction Syndrome Investigative Team. Arch Ophthalmol. 2000;118:1167–76.PubMedGoogle Scholar
  43. 43.
    Werner L, et al. Toxic anterior segment syndrome and possible association with ointment in the anterior chamber following cataract surgery. J Cataract Refract Surg. 2006;32:227–35.PubMedGoogle Scholar
  44. 44.
    Georgopoulos M, Polak K, Prager F, Prünte C, Schmidt-Erfurth U. Characteristics of severe intraocular inflammation following intravitreal injection of bevacizumab (Avastin). Br J Ophthalmol. 2009;93:457–62.PubMedGoogle Scholar
  45. 45.
    Suzuki T, et al. Outbreak of late-onset toxic anterior segment syndrome after implantation of one-piece intraocular lenses. Am J Ophthalmol. 2015;159:934–939.e2.PubMedGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2020

Authors and Affiliations

  • He Li
    • 1
  • Konstantinos T. Tsaousis
    • 1
  • Jun J. Guan
    • 1
  • Nicolas Reiter
    • 1
  • Nick Mamalis
    • 1
    Email author
  1. 1.John. A Moran Eye Center, University of UtahSalt Lake CityUSA

Personalised recommendations