Transcript Urrets-Zavalia Syndrome After Lamellar Corneal Transplant

Urrets-Zavalia Syndrome After
Lamellar Corneal Transplant:
Two Case Reports
Timothy Y. Chou, MD, Sujata P. Prabhu, MD, Justin Dexter, MD
Department of Ophthalmology
SUNY at Stony Brook
Stony Brook, New York, USA
The authors have no financial interests to disclose
Purpose


Urrets-Zavalia originally described the
syndrome of persistent pupillary dilation in
keratoconus patients following penetrating
keratoplasty. The cause is uncertain.
Herein we report two cases analogous to the
Urrets-Zavalia syndrome, but occurring in
atypical clinical settings.
Methods


A retrospective review of the medical records
of two patients noted to have persistent
pupillary dilation following lamellar corneal
transplant surgery.
Data collected included age, sex, preoperative history and medications, surgical
events and complications, and post-operative
course.
Results

An 76 year old Asian male underwent
uncomplicated Descemet’s stripping with
endothelial keratoplasty (DSEK) OS for
pseudophakic bullous keratopathy after
phacoemulsification cataract surgery. He had
underlying Fuchs’ endothelial corneal
dystrophy. Preoperative medications
included tamsulosin for benign prostatic
hypertrophy.
Results


The second patient was a 35 year old African
American male who had corneal scarring
after a chemical injury complicated by
keratomycosis of the left eye. He underwent
deep anterior lamellar keratoplasty (DALK),
using the “big bubble” technique.
During surgery there was a microperforation,
requiring the placement of an intracameral air
bubble.
Results



Air was injected at the end of each case, maximally filling
the anterior chamber for ten minutes. Thereafter the air
was partially aspirated to restore normal intraocular
pressure (IOP).
Both patients were given topical atropine 1% (which was
the mydriatic readily available in the operating room) to
prevent pupillary block.
Postoperatively, in both cases, the pupils became
persistently dilated (figures 1 & 2). Intraoperative
pressure was elevated on the first day only, to 26 mmHg
after the DALK, and treated with acetozolamide.
Figure 1
Persistent pupillary dilation after DSEK
Figure 2
Persistent pupillary dilation after DALK
Conclusions

These two case reports demonstrate that
persistent pupillary mydriasis can occur in
patients following lamellar transplant surgeries
where intracameral air is injected and atropine
1% drops are instilled.
Conclusions

The DALK patient with corneal scarring had no
other inherent corneal disease. This indicates
that Urrets-Zavalia syndrome can occur in the
absence of an underlying corneal disorder such
as keratoconus or a dystrophy.
Conclusions

There was preoperative use of Tamsulosin,
and mild postoperative IOP elevation in the
DSEK patient. It is unclear whether these
may represent additional risk factors for the
syndrome.
References

Urrets Zavalia A Jr. Fixed pupil, iris atrophy and secondary glaucoma: a
distinct clinical entity following penetrating keratoplasty for keratoconus.
Am J Ophthalmol 1963;56:257-265
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Niknam S, Rajabi MT. Fixed dilated pupil (Urrets-Zavalia syndrome)
after deep anterior lamellar keratoplasty. Cornea 2009; 28:1187-1190
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Maurino V, Allan BD, Stevens JD, et al. Fixed dilated pupil (UrretsZavalia Syndrome) after air/gas injection after deep lamellar
keratoplasty for keratoconus. Am J Ophthalmol 2002;133:266-268
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Fournié P, Ponchei C, Malecaze F, et al. Fixed dilated pupil (UrretsZavalia syndrome and anterior subcapsular cataract formation after
Descemet’s stripping endothelial keratoplasty. Cornea 2009;28:11841186.