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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. .

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Urrets-Zavalia Syndrome after Implantation of Implantable Collamer Lens

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  1. 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.

  2. 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.

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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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