What is the recommended treatment for a patient with suspected Toxic Anterior Segment Syndrome (TASS) following ocular surgery?

Treatment of Toxic Anterior Segment Syndrome (TASS)

Immediate intensive topical corticosteroid therapy is the cornerstone of TASS treatment, with frequency ranging from hourly to every 3 hours depending on severity, and should be initiated as soon as TASS is suspected to prevent permanent vision loss from corneal decompensation and intractable glaucoma. 1

Immediate Recognition and Treatment Initiation

TASS typically presents within 12-48 hours after uncomplicated ocular surgery with painless blurred vision, limbus-to-limbus corneal edema, anterior chamber cells and flare, and fibrinous inflammation—without the pain, purulent discharge, chemosis, or lid involvement seen in infectious endophthalmitis 1, 2, 3. This distinction is critical because misdiagnosis can lead to inappropriate antibiotic therapy that delays proper steroid treatment 2.

Primary Treatment Protocol

• Topical corticosteroids are the first-line therapy and should be administered aggressively:

  • Prednisolone acetate 1% or dexamethasone 0.1% every 1 hour for severe cases 3
  • For moderate cases, dosing 3-4 times daily may be sufficient 3
  • Continue intensive therapy until inflammation resolves, then taper gradually over 3-5 weeks 4

• Topical NSAIDs can be added as adjunctive therapy to control inflammation, particularly preservative-free formulations like ketorolac 0.45% or nepafenac 5, 4, 6

• IOP monitoring and management is essential, as both TASS itself and corticosteroid therapy can cause elevated intraocular pressure:

  • Use carteolol 2% twice daily or other IOP-lowering agents if ocular hypertension develops 3
  • Monitor IOP closely throughout the treatment course 4

Treatment Duration and Monitoring

• Continue intensive steroid therapy for 4-5 weeks in severe cases, with gradual tapering as inflammation resolves 7
• Most cases respond well to topical steroids alone, with corneal clearing in approximately 75% of cases 3
• Follow-up should occur at day 1, weeks 1-2, and 1 month to assess treatment response and monitor for complications 5, 8

Sight-Threatening Complications to Monitor

Permanent corneal endothelial decompensation occurs in approximately 25% of TASS cases despite treatment and represents the most serious long-term complication 3. Other complications include:

• Intractable glaucoma requiring ongoing management 1
• Cystoid macular edema 1
• Persistent corneal edema requiring eventual corneal transplantation 3

Critical Pitfall: Distinguishing TASS from Infectious Endophthalmitis

The most dangerous error is treating TASS as infectious endophthalmitis with antibiotics while delaying steroid therapy 2. Key distinguishing features:

• TASS: painless, occurs within 12-48 hours, no purulent discharge, limbus-to-limbus corneal edema 1, 2
• Endophthalmitis: painful, purulent discharge, lid involvement, may occur later (3-7 days) 2

When in doubt, cultures should be obtained, but steroid therapy should not be delayed if TASS is strongly suspected based on clinical presentation 1.

Prevention Considerations

While not directly treatment-related, understanding that TASS is caused by contaminated surgical equipment, solutions, medications, or ophthalmic devices (including viscoelastic substances) helps prevent future cases 6, 2. Once TASS is identified, immediate investigation of surgical materials and sterilization procedures is warranted to prevent additional cases 6, 2.