Toxic anterior segment syndrome (TASS) developed in four cases after uneventful implantation of a foldable iris-fixated phakic intraocular lens (pIOL). Two cases occurred sequentially in one patient. The TASS subsided without complications in all cases after intensive topical steroid treatment. A multitude of possible causes is considered for the occurrence of these TASS cases. From the sterilization and cleaning of surgical instruments to the possibility of endotoxines in ophthalmic viscosurgical devices (OVD). These rare cases should alert the surgeon to the possibility of TASS after pIOL implantation. 1. Introduction Toxic anterior segment syndrome (TASS) is an acute, sterile anterior segment inflammation following any anterior segment surgical procedure [1]. Usually the anterior segment inflammation starts within 12–48 hours after surgery. Clinically alarming symptoms include diminished visual acuity, increased intraocular pressure, corneal edema, inflammation of the anterior chamber, fibrin, hypopyon, and a fixed pupil [2–4]. TASS results from a noninfectious toxic agent within the anterior chamber [5, 6]. The offending substances include denatured ophthalmic viscosurgical devices (OVDs), preservatives, talc from surgical gloves, topical ophthalmic ointment, inappropriately reconstituted intraocular preparations, altered pH and osmolarity of intraocular fluids, heat stable endotoxins, and detergents [5, 6]. Mild to moderate cases respond well to corticosteroids [3, 4], while severe cases might lead to corneal decompensation, glaucoma, a permanently dilated pupil, and cystoid macular edema [2, 3, 7, 8]. TASS is most commonly reported after cataract surgery and rarely after phakic intraocular lens (pIOL) implantation [1, 9, 10]. In the literature, three TASS cases have been reported after pIOL implantation [11, 12]. This report presents three cases of TASS, two of which occurred sequentially in one patient after foldable Artiflex iris-fixated pIOL implantation. 2. Case Reports Case 1. A 45-year-old woman with high myopia consulted our clinic for a refractive surgical procedure. The patient was not contact lens intolerant. History revealed no allergy, uveitis, rheumatic disease, or herpetic keratitis. Corrected distance visual acuity (CDV) in the right and left eye was, respectively, 1.0 and 0.80 with a manifest refraction of, respectively, ？12.25 and ？15.0–0.50？×？135. Photopic (85 candelas/m2) low contrast (2.5%) visual acuity (LCVA) preoperatively was 0.40 and 0.32 in the right and left eye, respectively. Mesopic (0.7 candelas/m2) LCVA
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