Toxic Soup Syndrome Treatment Requires Offending Agent Removal

Toxic soup syndrome, also called tear stasis syndrome, can develop when chronic drug-induced or pooled inflammatory mediators are aggravated by punctal or canalicular stenosis, or both, according to research published in Canadian Journal of Ophthalmology. Clearance of the punctal obstruction results in improvement for most of these patients, according to the report.

The researchers performed an electronic medical record database search for the keywords “toxic soup syndrome” and retrospectively reviewed 35 eyes from 25 patients (mean age, 66.8±12.8 years; 18 women, 7 men) who were seen at a single center between January 2017 and December 2021. All eyes had either punctal plugs, cauterized puncta, or punctal or canaliculus stenosis. The primary outcome measure was improvement in ocular surface signs and symptoms following interventions. 

The researchers report that the primary complaint was hyperemia and epiphora in all toxic soup syndrome patients. All patients had rosacea or meibomian gland disease (MGD), 7 patients (28%) had glaucoma, and 7 patients (28%) had limbal stem cell deficiency. 

On presentation, 22 (88%) patients were using topical medications. Treatment of all patients consisted of suspension of all preserved topical medications and institution of some form of anti-inflammatory therapy. 

The study shows that 19 (76%) patients improved following improvement of lacrimal drainage, and 1 patient with severe resistance in the canaliculus needed ongoing preservative-free topical steroids.

“Toxic soup syndrome develops because of pooled inflammatory mediators in eyes with punctal and (or) canalicular stenosis in the context of ocular rosacea, MGD, and (or) preserved topical medications such as antiglaucoma or antibiotic-steroid drops,” according to the researchers. “In these cases, attempting dilation of the puncta is as important as optimization of the ocular surface by eliminating preservative toxicity and treating any ocular surface inflammation present.” 

Study limitations include the retrospective nature and the possibility of underestimating disease prevalence.