Severe toxic anterior segment syndrome with ocular hypotony: a case report and literature review

Severe toxic anterior segment syndrome with ocular hypotony: a case report and literature review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Severe toxic anterior segment syndrome with ocular hypotony: a case report and literature review Yan Zhu, WeiWei Zhou, YuGuang Zhu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3819399/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background To report a rare case of severe toxic anterior segment syndrome with ocular hypotony after uneventful cataract surgery. Case presentation Toxic anterior segment syndrome (TASS) is an infrequent complication of ocular surgery.Here,we reported a rare TASS case with ocularhypotony after uneventful cataract surgery.A 62-year-old male was presented to our clinic for blurred vision in the right eye.The patient was diagnosed with age-related cataract and the phacoemulsification and intraocular lens implantation was performed uneventfully in the right eye.On the first postoperative day,the diffuse cornea edema and dilated pupil were present in the right eye with a tentative diagnosis of TASS.The medication administration was inffective in the case.The patient developed corneal decompensation 1 year after cataract surgery.Given the resulting corneal edema, the patient underwent Penetrating keratoplasty (PKP),fibrin membrane removal and goniosynechialysis were performed simultaneously.Ocularhypotony developed unexpectedly 2 weeks after PKP and maintained steadily in the case.Ultrasound biomicroscopy (UBM)showed the ciliary body atrophy.Optical coherence tomography (OCT)showed chorioretinal folds caused by hypotony maculopathy after PKP.To the best of our knowledge, we first reported the TASS case with ocularhypotony. Conclusions In the TASS case,the ocular hypotony was thought to be due to severe atrophy of ciliary body caused by uncertain toxic substance. Toxic anterior segment syndrome Cornea edema Ultrasound biomicroscopy Optical coherence tomography Penetrating keratoplasty Ocular hypotony Case report Figures Figure 1 Figure 2 Figure 3 Background TASS is an ocular surgical complication characterized by a sterile anterior chamber inflammatory reaction with multiple etiologies [ 1 , 2 ] .Depending on the severity of intraocular inflammation,the symptoms may be present, such as conjunctival injection,corneal edema,keratic precipitates, hypopyon,anterior vitreous opacities, macular edema and decreased visual acuity [ 1 – 3 ] .Most TASS patients achieve good outcomes after the prompt clinical diagnosis and treatment. According to the reported literature [ 4 – 10 ] ,lower intraocular pressure (IOP) is frequently present during the early TASS course.Severe trabecular meshwork damage may eventually result in ocular hypertension. TASS with ocular hypotony is rare.Ocular hypotony developed after PKP in the case.Here,we present a TASS case with ocular hypotony and analyze the correlation. Case presentation A 62-year-old male was presented to our clinic for progressive blurred vision in his right eye with age-related cataract. Uncorrected distance visual acuity (UDVA) was 0.1 (OD) and 0.8 (OS). Best corrected distance visual acuity (BCVA) was 0.2 (− 0.5D,OD) and 1.0 (− 1.0D,OS).Slit-lamp evaluation and dilated fundus examination revealed nonspecific findings except the cortical cataract opacity in the right eye.bilaterally intraocular pressure measurements (Topcon computerised tonometer) were within normal limits. All preoperative tests were within normal limits.The patient declared no previous systemic disease including diabetes and hypertension.The phacoemulsification and intraocular lens implantation was performed uneventfully in the right eye after informed consent was obtained for the surgery. On the first post-operative day,the patient was reviewed with diffuse cornea edema in the right eye.The visual acuity was counting fingers.The conjunctival injection,limbus to limbus corneal edema,keratic precipitates and fibrin formation in the anterior chamber were present in the right eye.The pupil was dilated and was not sensitive to the light.The patient did not complain of eye pain and foreign body sensation.B-mode ultrasound showed no obvious vitreous opacity. Before beginning topical postoperative medications,a subsequent anterior chamber tap was performed immediately for smear and culture tests.The sample smear and culture reports revealed no microorganisms to rule out infectious endophthalmitis.We looked into the other cases which the same batch of viscoelastics,saline infusion or intraocular lenses were used. None of the remaining cases had similar ocular manifestations after surgery. At this time,A tentative diagnosis of TASS was suspected.The patient applied 0.5% moxifloxacin (Vigamox, Alcon) four times daily for 2 weeks,0.1% bromfenac sodium (BRONUCK; Santen) twice daily,and 1% prednisolone acetate (Predforte; Allergan) four times daily for 8 weeks.In addition to topical medications, Oral prednisolone (up to 40 mg per day) was prescribed for 2 months with the standard slow-tapering regimen. The medication proved ineffective for TASS progression in the first 2 months after surgery.IOP maintained within the normal range (10 ~ 13mmHg).Diffuse corneal edema,dense fibrin membrane formation and peripheral anterior synechia were present in the right eye. Hence,an additional course of topical steroids medication was applied for persistent anterior chamber inflammation for 10 months. UBM showed prominent cornea edema,dense fibrin membrane formation and ciliary body atrophy in the right eye before PKP (Fig. 1). PKP was done because of corneal endothelial decompensation and bullous keratopathy 12 months after cataract surgery.Fibrin membrane removal and goniosynechialysis were performed simultaneously.0.01%Tacrolimus eye drops combined with 1% prednisolone acetate were applied for 2 months after PKP.Oral prednisolone was prescribed for 2 months.Topical steroids medication was applied during the follow-up. Ocular hypotony developed 2 weeks after PKP.IOP was 5 ~ 6 mmHg and retained in a steady state during the follow-up. The vision improved temporarily for 1 month and deteriorated gradually to counting fingers due to thickening fibrous membrane,ciliary body atrophy (Fig. 2) and hypotony maculopathy (Fig. 3) at 2-month follow-up after PKP. It is worth noting that the corneal graft remained transparent.Corneal graft endothelial cell density is 880/mm 2 at 10-month follow-up after PKP. Finally, the patient was diagnosed with TASS with ocular hypotony.IOP was maintained at 5 ~ 6 mmHg. To our knowledge, we first reported the TASS case with ocular hypotony.Thereafter, the changes of the graft and IOP required continuous review. Discussion and conclusion To summarize,we reported a deteriorating TASS case with ocular hypotony following cataract surgery.The hypotony was thought to be due to extensive atrophy of ciliary body caused by uncertain toxic substance. TASS is an uncommon surgical complication characterized by the sterile postoperative inflammation reaction of anterior segment after ocular surgery [ 1 , 2 ] .The inflammation developed as a result of toxic substances used during the surgery.The causes of TASS were not identified in most of TASS cases even after a careful search [ 2 ] . In the TASS case,the etiology and toxic substances were not found. TASS often occurs after cataract surgery [ 11 , 12 ] , it also developed after other ocular surgeries such as keratoplasty [ 13 ] ,ICL implantation [ 14 ] , Trabeculectomy [ 15 ] , pterygium surgery [ 16 ] and posterior segment surgeries [ 17 ] . Most TASS cases have been anecdotal with various clinical manifestations. In general, TASS may be considered a localized anterior segment entity without significant posterior segment involvement.Vitreous opacities may sometimes be detected as “spillover” of the anterior segment inflammation. Spectral domain optical coherence tomography (SD-OCT) enables research of posterior segment involvement that was not detected on the regular examination. TASS may have a transient effect on the choroid [ 18 , 19 ] . Transient retinal changes can be related to the surgery itself. [ 20 – 22 ] Persistent cystoid macular edema might require additional therapy [ 23 , 24 ] . Although the inflammation could affect uveal structures,the permanent uveal changes may not be identified clinically in TASS cases.In the TASS case, the toxic substances may result in severe ciliary body damage.Permanent ciliary body dysfunction may lead to ciliary body atrophy and reduced aqueous humor production. UBM imaging showed extensive atrophy of the ciliary body in the right eye before PKP. TASS may lead to decreased IOP in the early perioperative period followed by a possible IOP increase due to trabecular meshwork dysfunction [ 4 ] . At present, IOP is considered to be the most important modifiable risk factor for glaucoma onset and progression.Hence, the effect of TASS on the IOP is an important subject. IOP changes were considered as an alarming feature of TASS [ 4 – 10 ] .Careful monitoring of the IOP is necessary during the TASS course.The inflammation and trabecular meshwork damage caused by toxic substances altered the aqueous humor dynamics [ 25 , 26 ] . The patients frequently have lower IOP in the early postoperative period. Marked inflammatory reaction during the first hours may be associated with decreased IOP due to reduced aqueous humor production and increased uveoscleral outflow [ 27 ] . Increased IOP may be a main clinical feature of TASS in the following several days.As the TASS progresses,the IOP is likely to increase gradually or suddenly up to 40 mmHg and above. In severe TASS cases,the inflammation can result in the chronic trabeculitis and the fibrin formation in the anterior chamber.Peripheral anterior synechia and the trabecular meshwork damage may lead to decreased trabecular meshwork outflow and elevated IOP. Permanent damage of trabecular meshwork may eventually result in ocular hypertension or secondary glaucoma [ 28 ] . The secondary glaucoma may become medically refractory and should probably require surgical intervention. Moulick reported a patient with TASS who developed IOP of 26 mmHg and had to undergo trabeculectomy after no response to medication [ 29 ] . High IOP did not develop in the case due to ciliary body atrophy.The aqueous humor dynamics maintained fragile dynamic balance before PKP and IOP was 10 ~ 13mmHg.Normal IOP implied the poor prognosis in the TASS case. Fibrin membrane removal and goniosynechialysis increased the trabecular outflow and damaged fragile aqueous humor dynamics.As expected,ocular hypotony developed 2 weeks after PKP. IOP was 5 ~ 6 mmHg and retained in a steady state during the follow-up.The ocular hypotony occurred secondary to severe ciliary body atrophy as a result of permanent damage of a toxic substance to the ciliary body. IOP changes required close follow-up in the case.TASS with ocular hypotony is rare.To our knowledge,this is the first paper to report the TASS with ocular hypotony. Abbreviations TASS Toxic anterior segment syndrome PKP Penetrating keratoplasty UBM Ultrasound biomicroscopy OCT Optical coherence tomography IOP intraocular pressure Declarations Acknowledgements The authors would like to express thanks to the patient who participated in this study. Authors’ contributions ZYG designed the study. ZY, ZWW and ZYG review of the literature. ZYG and ZY wrote and revised the paper. ZWW participated in clinical management of the patient. All authors approved the final manuscript. Funding This study was supported in part by grants from the research project of Education Advancement Shandong (No. JCHKT2023423) and the project of educational reform of Weifang Medical University(No. 2023YBD003). The funding body played no role in the study. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate Written informed consent was obtained from the patient for utilising his clinical details for this manuscript. Permission for using the patient data for this report was approved by the Human Ethics Committee of Affiliated Hospital of Shandong Second Medical University(WYFY-2021-KY-05). Consent for publication Written informed consent was obtained from the parents to publish this case report. 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Toxic anterior segment syndrome caused by autoclave reservoir wall biofilms and their residual toxins. J Cataract Refract Surg. 2016 Nov;42(11):1602-1614. doi: 10.1016/j.jcrs.2016.08.030. Ugurbas SC, Akova YA. Toxic anterior segment syndrome presenting as isolated cystoid macular edema after removal of entrapped ophthalmic ointment. Cutan Ocul Toxicol. 2010;29(3):221-3. doi: 10.3109/15569527.2010.485285. Kong X, Liu X, Huang X, Mao Z, Zhong Y, Chi W. Damage to the blood-aqueous barrier in eyes with primary angle closure glaucoma. Mol Vis. 2010;16:2026-32. Lee J, Pelis RM. Drug Transport by the Blood-Aqueous Humor Barrier of the Eye. Drug Metab Dispos. 2016;44(10):1675-81. doi: 10.1124/dmd.116.069369. Baneke AJ, Lim KS, Stanford M. The Pathogenesis of Raised Intraocular Pressure in Uveitis. Curr Eye Res. 2016;41(2):137-49. doi: 10.3109/02713683.2015.1017650. Johnston J. Toxic anterior segment syndrome--more than sterility meets the eye. AORN J. 2006;84(6):969-84; quiz 985-6. doi: 10.1016/s0001-2092(06)63994-x. 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(Suppl 1):S205-7. doi: 10.1016/j.mjafi.2014.01.004. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3819399","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":264204825,"identity":"4865cb1c-117d-4da4-a889-512da5443ae2","order_by":0,"name":"Yan Zhu","email":"","orcid":"","institution":"the Affiliated Hospital of Shandong Second Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yan","middleName":"","lastName":"Zhu","suffix":""},{"id":264204826,"identity":"7ff032b9-4c52-40ce-8204-241409a12aba","order_by":1,"name":"WeiWei Zhou","email":"","orcid":"","institution":"Shandong Second Medical 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03:59:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3819399/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3819399/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49135372,"identity":"ed7c386a-5641-4fa7-aa94-e1300fb01fb5","added_by":"auto","created_at":"2024-01-03 17:05:05","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":405291,"visible":true,"origin":"","legend":"\u003cp\u003eUBM imaging showed prominent cornea edema, dense fibrin membrane formation and ciliary body atrophy in the right eye before PKP\u003c/p\u003e","description":"","filename":"FIG1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3819399/v1/93e26613cf4af86add1f2a72.jpg"},{"id":49135374,"identity":"cf454616-d3dd-4757-974c-57cc15edec6e","added_by":"auto","created_at":"2024-01-03 17:05:05","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":303596,"visible":true,"origin":"","legend":"\u003cp\u003eUBM imaging showed thickening fibrous membrane and ciliary body atrophy at 2-month follow-up after PKP\u003c/p\u003e","description":"","filename":"FIG2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3819399/v1/71419b446e2f5112cbbc2e54.jpg"},{"id":49135825,"identity":"fce375a7-d5a6-46f6-8839-55b3bb4ebd65","added_by":"auto","created_at":"2024-01-03 17:13:05","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":539964,"visible":true,"origin":"","legend":"\u003cp\u003eOCT imaging showed the chorioretinal folds at 2-month follow-up after PKP\u003c/p\u003e","description":"","filename":"FIG3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3819399/v1/ac5d88dd7ab27e2425a868c8.jpg"},{"id":56091769,"identity":"9a79283c-13d1-43da-aef2-0a172e729d25","added_by":"auto","created_at":"2024-05-08 12:34:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":591575,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3819399/v1/1f49086d-3388-40c3-881c-5964c5a14856.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Severe toxic anterior segment syndrome with ocular hypotony: a case report and literature review","fulltext":[{"header":"Background","content":"\u003cp\u003eTASS is an ocular surgical complication characterized by a sterile anterior chamber inflammatory reaction with multiple etiologies\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e.Depending on the severity of intraocular inflammation,the symptoms may be present, such as conjunctival injection,corneal edema,keratic precipitates, hypopyon,anterior vitreous opacities, macular edema and decreased visual acuity\u003csup\u003e[\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e.Most TASS patients achieve good outcomes after the prompt clinical diagnosis and treatment.\u003c/p\u003e \u003cp\u003eAccording to the reported literature\u003csup\u003e[\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e,lower intraocular pressure (IOP) is frequently present during the early TASS course.Severe trabecular meshwork damage may eventually result in ocular hypertension.\u003c/p\u003e \u003cp\u003eTASS with ocular hypotony is rare.Ocular hypotony developed after PKP in the case.Here,we present a TASS case with ocular hypotony and analyze the correlation.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 62-year-old male was presented to our clinic for progressive blurred vision in his right eye with age-related cataract. Uncorrected distance visual acuity (UDVA) was 0.1 (OD) and 0.8 (OS). Best corrected distance visual acuity (BCVA) was 0.2 (\u0026minus;\u0026thinsp;0.5D,OD) and 1.0 (\u0026minus;\u0026thinsp;1.0D,OS).Slit-lamp evaluation and dilated fundus examination revealed nonspecific findings except the cortical cataract opacity in the right eye.bilaterally intraocular pressure measurements (Topcon computerised tonometer) were within normal limits.\u003c/p\u003e\n\u003cp\u003eAll preoperative tests were within normal limits.The patient declared no previous systemic disease including diabetes and hypertension.The phacoemulsification and intraocular lens implantation was performed uneventfully in the right eye after informed consent was obtained for the surgery.\u003c/p\u003e\n\u003cp\u003eOn the first post-operative day,the patient was reviewed with diffuse cornea edema in the right eye.The visual acuity was counting fingers.The conjunctival injection,limbus to limbus corneal edema,keratic precipitates and fibrin formation in the anterior chamber were present in the right eye.The pupil was dilated and was not sensitive to the light.The patient did not complain of eye pain and foreign body sensation.B-mode ultrasound showed no obvious vitreous opacity.\u003c/p\u003e\n\u003cp\u003eBefore beginning topical postoperative medications,a subsequent anterior chamber tap was performed immediately for smear and culture tests.The sample smear and culture reports revealed no microorganisms to rule out infectious endophthalmitis.We looked into the other cases which the same batch of viscoelastics,saline infusion or intraocular lenses were used. None of the remaining cases had similar ocular manifestations after surgery.\u003c/p\u003e\n\u003cp\u003eAt this time,A tentative diagnosis of TASS was suspected.The patient applied 0.5% moxifloxacin (Vigamox, Alcon) four times daily for 2 weeks,0.1% bromfenac sodium (BRONUCK; Santen) twice daily,and 1% prednisolone acetate (Predforte; Allergan) four times daily for 8 weeks.In addition to topical medications, Oral prednisolone (up to 40 mg per day) was prescribed for 2 months with the standard slow-tapering regimen.\u003c/p\u003e\n\u003cp\u003eThe medication proved ineffective for TASS progression in the first 2 months after surgery.IOP maintained within the normal range (10\u0026thinsp;~\u0026thinsp;13mmHg).Diffuse corneal edema,dense fibrin membrane formation and peripheral anterior synechia were present in the right eye. Hence,an additional course of topical steroids medication was applied for persistent anterior chamber inflammation for 10 months.\u003c/p\u003e\n\u003cp\u003eUBM showed prominent cornea edema,dense fibrin membrane formation and ciliary body atrophy in the right eye before PKP (Fig.\u0026nbsp;1).\u003c/p\u003e\n\u003cp\u003ePKP was done because of corneal endothelial decompensation and bullous keratopathy 12 months after cataract surgery.Fibrin membrane removal and goniosynechialysis were performed simultaneously.0.01%Tacrolimus eye drops combined with 1% prednisolone acetate were applied for 2 months after PKP.Oral prednisolone was prescribed for 2 months.Topical steroids medication was applied during the follow-up.\u003c/p\u003e\n\u003cp\u003eOcular hypotony developed 2 weeks after PKP.IOP was 5\u0026thinsp;~\u0026thinsp;6 mmHg and retained in a steady state during the follow-up.\u003c/p\u003e\n\u003cp\u003eThe vision improved temporarily for 1 month and deteriorated gradually to counting fingers due to thickening fibrous membrane,ciliary body atrophy (Fig.\u0026nbsp;2) and hypotony maculopathy (Fig.\u0026nbsp;3) at 2-month follow-up after PKP.\u003c/p\u003e\n\u003cp\u003eIt is worth noting that the corneal graft remained transparent.Corneal graft endothelial cell density is 880/mm\u003csup\u003e2\u003c/sup\u003e at 10-month follow-up after PKP.\u003c/p\u003e\n\u003cp\u003eFinally, the patient was diagnosed with TASS with ocular hypotony.IOP was maintained at 5\u0026thinsp;~\u0026thinsp;6 mmHg. To our knowledge, we first reported the TASS case with ocular hypotony.Thereafter, the changes of the graft and IOP required continuous review.\u003c/p\u003e"},{"header":"Discussion and conclusion","content":"\u003cp\u003eTo summarize,we reported a deteriorating TASS case with ocular hypotony following cataract surgery.The hypotony was thought to be due to extensive atrophy of ciliary body caused by uncertain toxic substance.\u003c/p\u003e \u003cp\u003eTASS is an uncommon surgical complication characterized by the sterile postoperative inflammation reaction of anterior segment after ocular surgery\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e.The inflammation developed as a result of toxic substances used during the surgery.The causes of TASS were not identified in most of TASS cases even after a careful search\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. In the TASS case,the etiology and toxic substances were not found.\u003c/p\u003e \u003cp\u003eTASS often occurs after cataract surgery\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e, it also developed after other ocular surgeries such as keratoplasty\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e,ICL implantation\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e, Trabeculectomy\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e, pterygium surgery\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e and posterior segment surgeries\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMost TASS cases have been anecdotal with various clinical manifestations. In general, TASS may be considered a localized anterior segment entity without significant posterior segment involvement.Vitreous opacities may sometimes be detected as \u0026ldquo;spillover\u0026rdquo; of the anterior segment inflammation.\u003c/p\u003e \u003cp\u003eSpectral domain optical coherence tomography (SD-OCT) enables research of posterior segment involvement that was not detected on the regular examination. TASS may have a transient effect on the choroid\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Transient retinal changes can be related to the surgery itself.\u003csup\u003e[\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e Persistent cystoid macular edema might require additional therapy\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAlthough the inflammation could affect uveal structures,the permanent uveal changes may not be identified clinically in TASS cases.In the TASS case, the toxic substances may result in severe ciliary body damage.Permanent ciliary body dysfunction may lead to ciliary body atrophy and reduced aqueous humor production. UBM imaging showed extensive atrophy of the ciliary body in the right eye before PKP.\u003c/p\u003e \u003cp\u003eTASS may lead to decreased IOP in the early perioperative period followed by a possible IOP increase due to trabecular meshwork dysfunction\u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. At present, IOP is considered to be the most important modifiable risk factor for glaucoma onset and progression.Hence, the effect of TASS on the IOP is an important subject.\u003c/p\u003e \u003cp\u003eIOP changes were considered as an alarming feature of TASS\u003csup\u003e[\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e.Careful monitoring of the IOP is necessary during the TASS course.The inflammation and trabecular meshwork damage caused by toxic substances altered the aqueous humor dynamics\u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe patients frequently have lower IOP in the early postoperative period. Marked inflammatory reaction during the first hours may be associated with decreased IOP due to reduced aqueous humor production and increased uveoscleral outflow\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIncreased IOP may be a main clinical feature of TASS in the following several days.As the TASS progresses,the IOP is likely to increase gradually or suddenly up to 40 mmHg and above.\u003c/p\u003e \u003cp\u003eIn severe TASS cases,the inflammation can result in the chronic trabeculitis and the fibrin formation in the anterior chamber.Peripheral anterior synechia and the trabecular meshwork damage may lead to decreased trabecular meshwork outflow and elevated IOP. Permanent damage of trabecular meshwork may eventually result in ocular hypertension or secondary glaucoma\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe secondary glaucoma may become medically refractory and should probably require surgical intervention. Moulick reported a patient with TASS who developed IOP of 26 mmHg and had to undergo trabeculectomy after no response to medication\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eHigh IOP did not develop in the case due to ciliary body atrophy.The aqueous humor dynamics maintained fragile dynamic balance before PKP and IOP was 10\u0026thinsp;~\u0026thinsp;13mmHg.Normal IOP implied the poor prognosis in the TASS case.\u003c/p\u003e \u003cp\u003eFibrin membrane removal and goniosynechialysis increased the trabecular outflow and damaged fragile aqueous humor dynamics.As expected,ocular hypotony developed 2 weeks after PKP. IOP was 5\u0026thinsp;~\u0026thinsp;6 mmHg and retained in a steady state during the follow-up.The ocular hypotony occurred secondary to severe ciliary body atrophy as a result of permanent damage of a toxic substance to the ciliary body.\u003c/p\u003e \u003cp\u003eIOP changes required close follow-up in the case.TASS with ocular hypotony is rare.To our knowledge,this is the first paper to report the TASS with ocular hypotony.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTASS \u0026nbsp; \u0026nbsp;Toxic anterior segment syndrome\u003c/p\u003e\n\u003cp\u003ePKP \u0026nbsp; \u0026nbsp; Penetrating keratoplasty\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUBM \u0026nbsp; \u0026nbsp;Ultrasound biomicroscopy\u003c/p\u003e\n\u003cp\u003eOCT \u0026nbsp; \u0026nbsp;Optical coherence tomography \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIOP \u0026nbsp; \u0026nbsp; intraocular pressure\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express thanks to the patient who participated in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZYG designed the study. ZY, ZWW and ZYG review of the literature. ZYG and ZY wrote and revised the paper. ZWW participated in clinical management of the patient. All authors approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported in part by grants from the research project of Education Advancement Shandong (No. JCHKT2023423) and the project of educational reform \u0026nbsp;of Weifang Medical University(No. 2023YBD003).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe funding body played no role in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ethe corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for utilising his clinical details for this manuscript. Permission for using the patient data for this report was approved by the Human Ethics Committee of \u0026nbsp;Affiliated Hospital of Shandong Second Medical University(WYFY-2021-KY-05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the parents to publish this case report.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHernandez-Bogantes E, Navas A, Naranjo A, et al. Toxic anterior segment syndrome: A review. \u003cem\u003eSurv Ophthalmol\u003c/em\u003e. 2019;64(4):463-476. doi:10.1016/j.survophthal.2019.01.009\u003c/li\u003e\n\u003cli\u003ePark CY, Lee JK, Chuck RS. 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AORN J. 2006;84(6):969-84; quiz 985-6. doi: 10.1016/s0001-2092(06)63994-x. \u003c/li\u003e\n\u003cli\u003eMoulick PS, Reddy S, Gurunadh VS, Mohindra VK. Toxic anterior segment syndrome - A sequel of uneventful cataract surgery. Med J Armed Forces India. 2015;71(Suppl 1):S205-7. doi: 10.1016/j.mjafi.2014.01.004. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Toxic anterior segment syndrome, Cornea edema, Ultrasound biomicroscopy, Optical coherence tomography, Penetrating keratoplasty, Ocular hypotony, Case report","lastPublishedDoi":"10.21203/rs.3.rs-3819399/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3819399/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eTo report a rare case of severe toxic anterior segment syndrome with ocular hypotony after uneventful cataract surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation \u003c/strong\u003eToxic anterior segment syndrome (TASS) is an infrequent complication of ocular surgery.Here,we reported a rare TASS case with ocularhypotony after uneventful cataract surgery.A 62-year-old male was presented to our clinic for blurred vision in the right eye.The patient was diagnosed with age-related cataract and the phacoemulsification and intraocular lens implantation was performed uneventfully in the right eye.On the first postoperative day,the diffuse cornea edema and dilated pupil were present in the right eye with a tentative diagnosis of TASS.The medication administration was inffective in the case.The patient developed corneal decompensation 1 year after cataract surgery.Given the resulting corneal edema, the patient underwent Penetrating keratoplasty (PKP),fibrin membrane removal and goniosynechialysis were performed simultaneously.Ocularhypotony developed unexpectedly 2 weeks after PKP and maintained steadily in the case.Ultrasound biomicroscopy (UBM)showed the ciliary body atrophy.Optical coherence tomography (OCT)showed chorioretinal folds caused by hypotony maculopathy after PKP.To the best of our knowledge, we first reported the TASS case with ocularhypotony.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e In the TASS case,the ocular hypotony was thought to be due to severe \u0026nbsp;atrophy of ciliary body caused by uncertain toxic substance.\u003c/p\u003e","manuscriptTitle":"Severe toxic anterior segment syndrome with ocular hypotony: a case report and literature review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-03 17:05:00","doi":"10.21203/rs.3.rs-3819399/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1298efce-a3a6-4935-ae29-9b30f5308c97","owner":[],"postedDate":"January 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-05-08T11:57:06+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-03 17:05:00","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3819399","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3819399","identity":"rs-3819399","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}