Highlights
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Among the 162 eyes implanted with a foldable acrylic IOL (Lentis Comfort/LS-313 MF15), 7 eyes (4.3%) developed toxic anterior-segment syndrome in 2 tertiary hospitals.
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Although the inflammation responded to topical steroid therapy, surgical interventions were required to treat accompanying secondary angle closure due to pupillary obstruction.
Purpose
To report a cluster of cases of toxic anterior-segment syndrome (TASS) in eyes implanted with a specific foldable acrylic intraocular lens (IOL) model.
Design
Retrospective case series.
Methods
The medical records were reviewed for 7 eyes of 4 patients diagnosed with TASS after cataract surgery at Shimane University and Matsue Red Cross Hospital between July and November 2020.
Results
Among the 162 eyes implanted with the Lentis Comfort/LS-313 MF15 IOL, acute anterior chamber (AC) inflammation with fibrin formation developed 1-15 days after uneventful surgeries in 7 (4.3%) eyes (cataract surgery alone, n=4 eyes; combined cataract and minimally invasive glaucoma surgery, n=3 eyes). Other than local steroid use, fibrin membrane removal, YAG laser membranotomy, pars plana vitrectomy, and AC washout were performed to treat inflammation and/or secondary angle closure due to pupillary obstruction.
Conclusion
We experienced a cluster of TASS cases in eyes implanted with the Lentis Comfort/LS-313 MF15 IOL in a short period of time. To our knowledge, this is the first report of TASS associated with this IOL.
T oxic anterior-segment syndrome (TASS), a rare complication of intraocular surgery first described in 1992, is characterized by acute, noninfectious, anterior-segment (AS) inflammation. Although any surgical instrumentation or environmental conditions can cause TASS, implantation of specific intraocular lens (IOL) models during cataract surgery have been reported previously to have caused TASS. , We report 7 eyes of 4 patients with severe anterior chamber (AC) reactions that developed after implantation of the same IOL model. Three independent surgeons performed the surgeries at 2 different surgical sites during a relatively short period of time.
Subjects and Methods
This case series includes 7 eyes of 4 patients who developed severe AC reactions and were diagnosed with TASS between July and November 2020 at Shimane University or Matsue Red Cross Hospital. The study adhered to the tenets of the Declaration of Helsinki. The institutional review boards of Shimane University Hospital and Matsue Red Cross Hospital did not require an ethics committee review process to report these cases. Each patient provided written informed consent for review and disclosure of medical records. The following were collected from the medical chart review and surgical records: age, gender, past history, surgical procedure, surgical instruments and devices including irrigating solutions, viscoelastic devices, IOLs, perioperative medications, clinical findings, and management of TASS.
Preoperatively, phenylephrine hydrochloride and tropicamide drops (either Mydrephrine P [Nitto Medic Co, Ltd, Toyama, Japan] or Mydrin P [Santen Pharmaceutical, Osaka, Japan]) and phenylephrine hydrochloride (Neosynesin Kowa 5%; Kowa Pharmaceutical Company Ltd, Tokyo, Japan) were applied for preoperative mydriasis. The eyelids were wiped with povidone-iodine (Isodine solution 10%; Mundipharma K.K., Tokyo, Japan), and the eyes were covered with disposable sterilized surgical eye drapes. The conjunctiva tissues were washed with iodine polyvinyl alcohol (PA-Iodo Ophthalmic and Eye Washing Solution; Nitten Pharmaceutical Co Ltd, Nagoya, Japan), and oxybuprocaine hydrochloride (Benoxil Ophthalmic Solution 0.4%; Santen Pharmaceutical) induced topical anesthesia. After creation of side ports at the 2- and 10-o’clock positions, intracameral anesthesia was induced using lidocaine (Xylocaine 1%; Aspen Japan, Tokyo, Japan). A viscoelastic material composed of purified sodium hyaluronate (either Opegan Hi [Santen Pharmaceutical] or Provisc [Alcon Japan, Tokyo, Japan]) and purified sodium hyaluronate and chondroitin sulfate sodium (either Shellgan [Santen Pharmaceutical] or Viscoat [Alcon Japan]) was injected into the AC and a continuous curvilinear capsulorhexis was performed. Hydrodissection and phacoemulsification were performed through a 2.2-mm-wide clear corneal incision. The Centurion and the Active Sentry handpiece (Alcon Japan) and balanced salt solution (BSS Plus; Alcon Japan) were used as the surgical instrument and infusion fluid, respectively. After filling the AC with the same viscoelastic material, a hydrophilic soft acrylic IOL (Lentis Comfort LS-313MF15 IOL; Santen Pharmaceutical) was inserted into the capsular bag through the same clear corneal incision in all cases. The viscoelastic material was removed by irrigation and aspiration, and the incision ports were closed using the corneal stromal hydrating balanced salt solution. In 3 eyes of 2 patients, glaucoma surgeries including ab interno trabeculotomy or iStent (Glaukos Corporation, San Clemente, California, USA) injection were performed after IOL implantation. Microhooks (Inami & Co, Ltd, Tokyo, Japan) were used for ab interno trabeculotomy. Using a Swan-Jacob gonioprism lens (Ocular Instruments, Bellevue, Washington, USA) to observe the angle, a microhook was inserted into the AC through the corneal incision. The tip of the microhook was inserted into the Schlemm canal and moved circumferentially to incise the inner wall of the Schlemm canal and trabecular meshwork over 3 clock hours. Using the same procedure, trabeculotomy was performed in the opposite angle. An iStent was injected into the nasal Schlemm canal and an iStent Inject W (Glaukos Corporation) was injected at the 2:30- and 4-o’clock positions. At the end of surgery, 1.65 mg of dexamethasone sodium phosphate (Decadron; Aspen Japan) or 2 mg of betamethasone sodium phosphate (Rinderon; Shionogi Pharma Co, Ltd, Osaka, Japan) was injected subconjunctivally, and 0.3% ofloxacin ointment (Tarivid; Santen Pharmaceutical) was applied. Finally, 1.5% levofloxacin (Levofloxacin; Pfizer Japan Inc, Tokyo, Japan) and 0.1% betamethasone (Sanbetason; Santen Pharmaceutical) were applied topically 4 times daily postoperatively in all cases.
Results
Supplementary Tables 1 and 2 summarize the details of the cases.
Case 1, performed by YI at the Matsue Red Cross Hospital, was that of a 71-year-old woman diagnosed with retinitis pigmentosa and uveitis of unknown etiology with low activity who underwent cataract surgeries in both eyes on different days. On postoperative day (POD) 1, marked AS inflammation was observed in the left eye ( Figure 1 , A). Postoperative endophthalmitis was suspected, and a pars plana vitrectomy with vitreous injection of vancomycin and ceftazidime was performed immediately. Based on the intraoperative findings and negative bacterial culture from the intraocular fluid, TASS was considered and the topical steroid was continued. Five days later, the inflammation improved ( Figure 1 , B). The surgery in the right eye was performed 100 days after the first surgery. On POD 6, a complete fibrin membrane similar to that in the left eye also was seen in the right eye ( Figure 1 , C). Because TASS was suspected based on the course of the left eye, she was treated with a topical steroid only and the inflammation improved similarly ( Figure 1 , D). During the cataract surgery, because of poor mydriasis, an iris retractor was used at the 2-, 4-, 8-, and 10-o’clock positions in both eyes.
Case 2, performed by KS at Shimane University Hospital, was that of a 76-year-old woman with cataract and exfoliation glaucoma who underwent cataract surgery combined with an iStent Inject W implantation in her right eye and an iStent in the left eye 2 days apart. Slit-lamp and AS optical coherence tomography (AS-OCT) examinations showed severe AC inflammation with a thick fibrin membrane across the pupil and corneal edema on POD 11 in the right eye ( Figure 2 , A and C), and a thin membrane covered the pupil on POD 13 in the left eye ( Figure 2 , B and D). Because of the fibrin membrane pupillary block, the intraocular pressure (IOP) increased to 45 mm Hg in the right eye. The onset in this case occurred between the onset of TASS in the left and right eyes in Case 1. Based on the clinical findings, TASS was suspected and she underwent bilateral removal of fibrin membrane and continued the topical steroid. At an evaluation 2 weeks later, the anterior inflammation decreased with flat irises bilaterally ( Figure 2 , E and G, right eye; Figure 2 , F and H, left eye), and the IOP decreased to 7 mm Hg in the right eye.
