Toxic Anterior Segment Syndrome Following Cataract Surgery In An Autoimmune-Primed Patient: A Case Report And Review Of Literature

Toxic Anterior Segment Syndrome (TASS) is a rare but serious postoperative inflammatory reaction following anterior segment surgery, predominantly cataract extraction. We present the case of a 70-year-old woman with a persistently elevated erythrocyte sedimentation rate (ESR) and a strong family history of autoimmune disease who developed TASS after uneventful cataract surgery. This case highlights the emerging importance of systemic inflammatory predispositions in postoperative anterior segment responses and proposes strategies for risk identification and management. A comprehensive literature review further explores the intersection between autoimmune systemic disease and TASS development.

Standard cataract extraction under topical anesthesia was performed using a 2.4 mm clear corneal incision. Capsulorhexis was completed without complication.

On postoperative day one, the patient exhibited marked corneal edema involving both central and paracentral zones, with prominent fibrin formation in the anterior chamber. No signs of hypopyon or vitritis were present. The IOL was well-centered. The patient’s vision was counting fingers at one meter, and intraocular pressure measured 18 mmHg

Upon clinical diagnosis of TASS, aggressive anti-inflammatory therapy was initiated immediately. The patient was prescribed prednisolone acetate 1% eye drops to be instilled hourly while awake. Cyclopentolate 1% eye drops were administered twice daily to achieve cycloplegia, alleviating ciliary body spasm and preventing posterior synechiae. Although TASS is a sterile process, moxifloxacin 0.5% drops were maintained four times daily during the first postoperative week to guard against superimposed infection.

Intraocular pressure was monitored daily and remained stable, negating the need for pressure-lowering agents. Additionally, ice packs were recommended to reduce episcleral congestion externally.

Given the systemic inflammatory background, further investigations were initiated. Repeat ESR and C-reactive protein levels were obtained, and comprehensive autoimmune serology, including ANA, rheumatoid factor (RF), and anti-CCP antibodies, were ordered.

Clinically, the patient demonstrated rapid improvement. By postoperative day three, corneal clarity had improved significantly, and anterior chamber fibrin reaction was reduced by approximately 50%. BCVA improved to 20/100 within three days. Prednisolone acetate frequency was gradually tapered over subsequent weeks. Cycloplegics were discontinued at the end of week two. 

At 2 weeks, BCVA improved to 20/25 in the left eye with a clear cornea and stable intraocular lens positioning. IOP remained within normal limits.

This case report highlights that TASS is not merely a consequence of exogenous contaminants but can arise due to complex interactions between surgical interventions and systemic patient factors. In patients with autoimmune predispositions or elevated inflammatory markers, the threshold for sterile anterior segment inflammation may be significantly lowered, even under optimal surgical conditions.

The recognition that systemic inflammation can contribute to postoperative ocular complications demands a paradigm shift in preoperative assessment and intraoperative planning. Screening for autoimmune tendencies, careful selection of IOL materials, minimizing intraoperative trauma, and aggressive postoperative anti-inflammatory management.