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Urrets-Zavalia Syndrome after Implantation of Implantable Collamer Lens. M. K. Kummelil, S. Nagappa, A. Shetty Cataract and Refractive Surgery Services, Narayana Nethralaya, Post-Graduate Institute of Ophthalmology Bangalore, India. .

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urrets zavalia syndrome after implantation of implantable collamer lens

Urrets-Zavalia Syndrome after Implantation of Implantable Collamer Lens

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
Clinical Features & Pathophysiology of Urrets-Zavalia Syndrome
  • An uncommon post-operative complication where there is acute post-operative 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.
grading
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
case history
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
summary of events in the left eye
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
1 month post operative onwards
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
current treatment
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