Topical ointment implicated in TASS development

The authors describe a case of toxic anterior segment syndrome (TASS) related to antibiotic ointment in the anterior chamber years after cataract surgery. The case highlights the importance of ensuring the integrity of clear corneal incisions and suggests that use of topical ointment at the conclusion of a clear corneal case should be avoided. Surgeons should not forget that ointment gaining intraocular access after surgery can cause very severe TASS, such as the cases described in an article published in the Journal of Cataract & Refractive Surgery in February 2006.

In the current case, after uneventful phacoemulsification at an outside facility, a 79-year-old man experienced worsening vision secondary to chronic cystoid macular edema (CME). He was referred to the Veteran Affairs Boston Healthcare System for review two years and four months after the initial cataract procedure. CME was confirmed, and a large pearly white globule that moved with changes in head position was noted. After surgical removal, nuclear magnetic resonance spectroscopy (NMR) identified the unknown substance as petroleum jelly.

Complete resolution of CME and restoration of excellent visual acuity was achieved with ointment removal, anterior chamber washout, and topical steroid and topical nonsteroidal anti-inflammatory eye drops. However, this raises the question of whether IOL exchange as performed in multiple prior reports is truly necessary. In this case, the largest globule was visibly removed in the operating room. In the immediate postoperative period, tiny globules on the iris surface and in the angle were noted, but over time, these resolved and were likely cleared through the trabecular meshwork.

Prior case reports identify the unknown substance in the anterior chamber as a specific ointment. In this case, NMR spectroscopy confirmed that it is the neutral semisolid petrolatum, used as a protective vehicle and fatty substitute, which lingers in the eye for an extended period of time. Future studies might focus on the need for medications for external application to the eye during the immediate postoperative period medications that have preservative-free vehicles and are well-tolerated by the intraocular environment but have gel properties to ensure they remain in the cul-de-sac longer than drops.