to present a unique case of a 58-year - old female with toxic anterior segment syndrome ( tass ) , following a triple procedure : descemet 's stripping automated endothelial keratoplasty ( dsaek ) , phacoemulsification and posterior chamber intraocular lens implantation .
the patient was treated with topical dexamethasone sodium phosphate 0.1% and topical atropine sulfate 1% . due to a slow improvement in her clinical status , oral prednisone 1 mg / kg / day was added .
the anterior chamber reaction improved gradually , with tapering down of topical and oral treatment , until a complete resolution of the anterior chamber reaction was observed .
taking into account the estimated volume of dsaek triple procedures performed worldwide , we would expect an annual incidence of several tass cases , following triple dsaek procedures . however , we were unable to find any such previous reports in the literature .
this fact raises questions regarding the cause of reduced tass incidence following triple dsaek procedures .
toxic anterior segment syndrome ( tass ) is an acute , sterile anterior chamber inflammation , which may develop following anterior segment surgery .
most cases are reported after uneventful cataract surgery . in patients requiring both cataract extraction and endothelial keratoplasty , a descemet 's stripping automated endothelial keratoplasty ( dsaek ) triple procedure , consisting of phacoemulsification and intraocular lens ( iol ) implantation , followed by dsaek ,
up to the present , only two reports of keratoplasty - related tass have been published , both following penetrating keratoplasty .
the first was a case series of 8 patients with tass - like , noninfectious , severe , early inflammation .
the second , reported a large outbreak of tass ( 24 cases out of 94 procedures performed ) , presenting as postoperative keratitis with inflammatory anterior chamber reaction  mainly hypopion and cells .
this outbreak was found to be caused by faulty sterilization of the guided trephine system . to our knowledge
herein is presented a case of tass following a triple procedure : dsaek , phacoemulsification and posterior chamber iol implantation .
a 58-year - old female , suffering from bilateral fuchs endothelial dystrophy , bilateral cataract and corneal subepithelial scarring in her left cornea , following an adenovirus infection , underwent an uneventful dsaek triple procedure in her left eye : phacoemulsification , implantation of a posterior chamber iol and dsaek .
intraocular pressure was 13 mm hg , best - corrected visual acuity was 20/200 , and the graft was attached to the recipient cornea , with a deep anterior chamber .
treatment with topical dexamethasone sodium phosphate 0.1% and ofloxacin 0.3% administered four times daily was initiated .
five days following the surgery , the patient presented with decreased vision in her left eye , which had begun 24 h postoperatively . on examination of her left eye ,
1 ) revealed conjunctival hyperemia , a completely attached and centrally located endothelial corneal graft , deep anterior chamber with a cellular reaction of 3 + and prominent flare measuring 3 + .
visualization of the posterior segment was poor due to the clinical status of the anterior segment  no details could be observed , but for a red light reflex .
the patient was started on hourly topical dexamethasone sodium phosphate 0.1% . due to the extensive posterior synechiae ,
the patient received a short and intensive course of topical tropicamide 0.5% and phenylephrine hydrochloride 10% , followed by topical atropine sulfate 1% .
follow - up examination , one day after the initiation of treatment , revealed significant improvement in the anterior chamber cellular reaction with no evident cells or flare , and residual posterior synechiae spanning 60 degrees .
the posterior segment could be well visualized , showing no inflammatory involvement of the retina and vitreous .
fibrin fiber accumulation was only mildly improved and therefore , the patient was started on oral prednisone 1 mg / kg / day . due to the early onset of visual deterioration ( 24 h postoperatively ) , the normal appearing posterior segment ( visualized shortly after initiation of treatment ) and the rapid clinical response to the above treatment , a clinical diagnosis of infectious endophthalmitis was ruled out .
follow - up examinations on days 3 , 8 and 10 following initiation of treatment , revealed gradual absorption of fibrin and no evident posterior synechiae .
8 weeks following the tass diagnosis , the patient 's best - corrected visual acuity was 20/50 , with a spherical correction of + 1.25 diopter and a cylindrical correction of 1.75 diopter ( 170 axis ) .
intraocular pressure was 14 mm hg , with a clear , attached , thin endothelial corneal graft .
no evidence of an anterior chamber reaction , fibrin formation or posterior synechiae was observed .
according to the eye bank of america association , 42,606 corneal transplants were performed in the usa in 2009 , out of which 18,221 were endothelial keratoplasty procedures (  2009 eye banking statistical report , washington , dc , eye bank association of america ) . the world health organization ( who ) estimates that about 120,000 corneal transplants are performed worldwide each year (  human organ and tissue transplantation 
report by the secretariat , submitted at the 112th session of the world health organization executive board , may 2003 ) .
there is no sufficient data in the literature regarding the volume of triple dsaek procedure surgeries performed worldwide .
the frequency of tass reported in the literature is about 0.250.8% [ 5 , 6 ] .
therefore , we would expect an annual incidence of several tass cases , following triple dsaek procedures .
it is probable that the cataract extraction constituent of the triple dsaek procedure is responsible for the occurrence of tass in our patient .
nevertheless , the fact that there is no previous report of tass following such a procedure raises questions regarding the cause of the reduced incidence of tass following triple dsaek procedures . due to the fact that the inflammatory reaction may jeopardize the integrity of the endothelial graft and reduce the chances of a successful transplant
, we intend to closely monitor this patient and apply a more gradual tapering down of her current treatment .
 purposeto present a unique case of a 58-year - old female with toxic anterior segment syndrome ( tass ) , following a triple procedure : descemet 's stripping automated endothelial keratoplasty ( dsaek ) , phacoemulsification and posterior chamber intraocular lens implantation.methodsthe patient was treated with topical dexamethasone sodium phosphate 0.1% and topical atropine sulfate 1% . due to a slow improvement in her clinical status , 
 oral prednisone 1 mg / kg / day was added.resultsthe anterior chamber reaction improved gradually , with tapering down of topical and oral treatment , until a complete resolution of the anterior chamber reaction was observed.conclusionstaking into account the estimated volume of dsaek triple procedures performed worldwide , we would expect an annual incidence of several tass cases , following triple dsaek procedures . 
 however , we were unable to find any such previous reports in the literature . 
 this fact raises questions regarding the cause of reduced tass incidence following triple dsaek procedures . 