Transcript GRAND ROUNDS-CASE PRESENTATION

Urrets-Zavalia Syndrome
after Implantation of
Implantable Collamer Lens
The authors have no financial interest in the subject matter of this e-poster
M. K. Kummelil, S. Nagappa, A. Shetty
Cataract and Refractive Surgery Services,
Narayana Nethralaya, Post-Graduate Institute of Ophthalmology
Bangalore, India.
Clinical Features & Pathophysiology
of Urrets-Zavalia Syndrome
• An uncommon post-operative complication where there is acute postoperative glaucoma leading to
pupillary sphincter ischemia and
a fixed dilated pupil
• It can occur secondary to
retained viscoelastics or
pupillary block with recurrent post-operative uveitis.
• This is probably the first report following ICL though it has been reported
following anterior chamber phakic intraocular lens implantation
REFERENCES:
Urrets-Zavalia A. Fixed dilated pupil, iris atrophy and secondary glaucoma: a distinct clinical entity
following penetrating keratoplasty for keratoconus. Am J Ophthalmol.1963; 56:257-65.
Tuft SJ, Buckley RJ. Iris ischemia following penetrating keratoplasty for keratoconus (Urrets-Zavalia
syndrome). Cornea. 1995; 14:618-622.
Maurino V., Allan BDS, Stevens JD, et al. Fixed dilated pupil (Urrets Zavalia syndrome) after air/gas
injection after deep lamellar keratoplasty for keratoconus. Am J Ophthalmol. 2002; 133:266-8.
Yuzbasioglu E, Helvacioglu F, Sencan S. Fixed, dilated pupil after phakic intraocular lens implantation.
J Cataract Refract Surg. 2006 Jan;32(1):174-6.
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Grading
Typically, 3 types of pupil dilatations can be seen:
• Grade I:
– At least 1.5mm larger than the fellow un-operated eye, but
responds to miotic agents (90%)
• Grade II:
– Unreactive and paretic, but slowly returns to normal after
time (some times up to 1 yr)
• Grade III:
– Irreversible dilatation with iris atrophy
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Case History
• 23y old female patient
• Underwent bilateral Implantable Collamer Lens surgery for
high myopia after necessary pre-op evaluation
• Post-operative course in the right eye following ICL was
uneventful.
• The left eye ICL was performed 4 weeks after right ICL and
had a protracted course with recurrent symptoms of pain,
redness, photophobia and blurring of vision
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Summary of events in the left eye
Day 1 post-operative visit: UCDV: 6/12; UCNV: N8
• Acute rise in IOP (48mmHg), despite patent surgical
peripheral iridectomy. Treated with AC wash for removal of
any residual viscoelastics, systemic and topical antiglaucoma
medications started.
• Patient also had severe anterior uveitis and was treated with
topical prednisolone acetate hourly, nepafenac twice daily
and moxifloxacin qid.
• Over the next 10days, IOP came back to normal levels but the
pupil remained noticeably dilated during this period
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1 month post-operative onwards … ...
UCDV: 6/9; UCNV: N6; IOP:11mmHg
• Oval dilated pupil with ICL in place with good vault
• Gonioscopy showed open angles except the nasal quadrant,
which opened upto trabecular meshwork, increased
pigmentation covering inferior angle structures.
• An unsuccessful attempt was made to surgically miose the
pupil, followed postoperatively with hourly steroids and
pilocarpine eye drops
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Current Treatment
• Conservative
• Other options:
– Laqoutte (1983) proposed a regimen of sympatholytic drop
(guanethidine) q4h for 1 day, followed by pilocarpine 2% for several
days.
– Soft coloured contact lenses
– Phakic IOL explantation with clear lens extraction and IOL implantation
with
• large, rigid iris diaphragms, overlapping interdigitating iris rings
• CTR with opaque iris segments
• intracapsular Hermeking iris prosthetic implants
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