J Korean Ophthalmol Soc.  2020 Feb;61(2):221-225. 10.3341/jkos.2020.61.2.221.

Urrets-Zavalia Syndrome Following Trabeculectomy

• Park GS
• Won YK
• Kim KN
• Lee YH
• Kim CS

• KMID: 2470747
• DOI: http://doi.org/10.3341/jkos.2020.61.2.221

Abstract

PURPOSE
We report a case of Urrets-Zavalia syndrome with a fixed dilated pupil after an uneventful trabeculectomy.
CASE SUMMARY
Trabeculectomy was performed on a 51-year-old male who had a history of recurrent uveitis in the left eye, with uncontrolled intraocular pressure despite maximally-tolerated medial therapy. There was no unexpected event during surgery. Topical 1% atropine was used for only 2 days after surgery. In the early postoperative period, 1% prednisolone and 0.3% ofloxacin were given four times a day, then gradually reduced. One month later, only 1% prednisolone was given once a day. Intraocular pressure in his left eye was well controlled from 8-14 mmHg after surgery. One month after surgery, the pupils remained dilated. There was no reaction to topical 2% pilocarpine and no relative afferent pupillary defect or posterior synechia.
CONCLUSIONS
Our case, although rare, suggests that Urrets-Zavalia syndrome should be considered in patients with well-controlled intraocular pressure after uneventful trabeculectomy.

Keyword

Dilation; Pathologic; Pupil; Trabeculectomy; Urrets-Zavalia syndrome

MeSH Terms

Atropine
Humans
Intraocular Pressure
Male
Middle Aged
Ofloxacin
Pilocarpine
Postoperative Period
Prednisolone
Pupil
Pupil Disorders
Trabeculectomy*
Uveitis
Atropine
Ofloxacin
Pilocarpine
Prednisolone

Figure

• 

  Figure 1 Anterior segment photographs captured just prior to (A) and immediately after (B) trabeculectomy. (A) Pilocarpine 2% was applied preoperatively and successful miosis was observed. (B) A filtering bleb and iridectomy site were shown in the superior nasal quadrant. There was no pupil injury during surgery, and there was no increase in the diameter of the pupil compared to before surgery.

• 

  Figure 2 Anterior segment photographs, 12 months after trabeculectomy. There was no change in pupil diameter in response to lighting. (A) Under the diffuse illumination of the slit lamp. (B) Under indirect illumination (dim light) of the slit lamp. Round-shaped iris atrophy (arrows) was detected.

• 

  Figure 3 Anterior segment photographs, 7 months after trabeculectomy (A, B). (B) The pupil became slightly dilated after instillation of 0.5% tropicamide and 0.5% phenylephrine mixed eye drops. There was no posterior synechia.

Reference

1. Urrets-Zavalia A Jr. Fixed, dilated pupil, iris atrophy and secondary glaucoma. A distinct clinical entity following penetrating keratoplasty in keratoconus. Am J Ophthalmol. 1963; 56:257–265.

2. Srinivasan M, Patnaik L. Fixed dilated pupil (Urrets-Zavalia syndrome) in corneal dystrophies. Cornea. 2004; 23:81–83.

3. Jastaneiah S, Al-Towerki AE, Al-Assiri A. Fixed dilated pupil after penetrating keratoplasty for macular corneal dystrophy and keratoconus. Am J Ophthalmol. 2005; 140:484–489.

4. Fournié P, Ponchel C, Malecaze F, Arné JL. Fixed dilated pupil (urrets-zavalia syndrome) and anterior subcapsular cataract formation after descemet stripping endothelial keratoplasty. Cornea. 2009; 28:1184–1186.

5. Spadea L, Viola M, Viola G. Regression of Urrets-Zavalia syndrome after deep lamellar keratoplasty for keratoconus: a case study. Open Ophthalmol J. 2008; 2:130–131.

6. Minasian M, Ayliffe W. Fixed dilated pupil following deep lamellar keratoplasty (Urrets-Zavalia syndrome). Br J Ophthalmol. 2002; 86:115–116.

7. Maurino V, Allan BD, Stevens JD, Tuft SJ. Fixed dilated pupil (Urrets-Zavalia syndrome) after air/gas injection after deep lamellar keratoplasty for keratoconus. Am J Ophthalmol. 2002; 133:266–268.

8. Niknam S, Rajabi MT. Fixed dilated pupil (urrets-zavalia syndrome) after deep anterior lamellar keratoplasty. Cornea. 2009; 28:1187–1190.

9. Kim YC, Na JK, Kim MS. Analysis of the etiologies and the classification of fixed dilated pupil after intraocular surgery. J Korean Ophthalmol Soc. 2015; 56:47–54.

10. Yuzbasioglu E, Helvacioglu F, Sencan S. Fixed, dilated pupil after phakic intraocular lens implantation. J Cataract Refract Surg. 2006; 32:174–176.

11. Tan AK, Humphry RC. The fixed dilated pupil after cataract surgery- is it related to intraocular use of hypromellose? Br J Ophthalmol. 1993; 77:639–641.

12. Jain R, Assi A, Murdoch IE. Urrets-Zavalia syndrome following trabeculectomy. Br J Ophthalmol. 2000; 84:338–339.

13. Klezlova A, Liebezeit S, Prokosch-Willing V, et al. Urrets-Zavalia syndrome after combined trabeculotomy-trabeculectomy surgery. J Glaucoma. 2018; 27:e80–e83.

14. Park SH, Kim SY, Kim HI, et al. Urrets-Zavalia syndrome following iris-claw phakic intraocular lens implantation. J Refract Surg. 2008; 24:959–961.

15. Ha CI, Park JI, Choi SK, et al. Three cases of Urrets-Zavalia syndrome following deep lamellar keratoplasty (DLKP). J Korean Ophthalmol Soc. 2008; 49:1857–1861.

16. Tuft SJ, Buckley RJ. Iris ischaemia following penetrating keratoplasty for keratoconus. (Urrets-Zavalia syndrome). Cornea. 1995; 14:618–622.

17. Figueiredo GS, Kolli SS, Ahmad S, et al. Urrets-Zavalia syndrome following penetrating keratoplasty for keratoconus. Graefes Arch Clin Exp Ophthalmol. 2013; 251:809–815.

18. Chelnis JG, Sieminski SF, Reynolds JD. Urrets-Zavalia syndrome following goniotomy in child. J AAPOS. 2012; 16:312–313.

19. Davies PD, Ruben M. The paretic pupil: its incidence and aetiology after keratoplasty for keratoconus. Br J Ophthalmol. 1975; 59:223–228.

20. Naumann GO. Iris ischaemia following penetrating keratoplasty for keratoconus (Urrets-Zavalia syndrome). Cornea. 1997; 16:120.

21. Espana EM, Ioannidis A, Tello C, et al. Urrets-Zavalia syndrome as a complication of argon laser peripheral iridoplasty. Br J Ophthalmol. 2007; 91:427–429.

22. Uribe LE. Fixed pupil following keratoplasty. Evaluation of six cases. Am J Ophthalmol. 1967; 63:1682–1686.

23. Mocan MC, Bozkurt B, Irkec M, Orhan M. Urrets-Zavalia syndrome following iatrogenic pupil dilation in eyes with pigment dispersion. Can J Ophthalmol. 2009; 44:216–217.

24. Bertelsen T, Seim V. Irreversible mydriasis following keratoplasty in keratoconus [proceedings]. Acta Ophthalmol Suppl. 1975; (125):45–46.

25. Pouliquen Y, Ginmaraes R, Petroutsos G, et al. The syndrome of Urrets-Zavalia: is it still there? J Fr Ophtalmol. 1983; 6:325–326.

26. Gharbiya M, Colica C, Campagna O, et al. Urrets-Zavalia syndrome after glaucoma filtration device implantation. Clin Ter. 2013; 164:e381–e382.

27. Marsh RJ, Easty DL, Jones BR. Iritis and iris atrophy in Herpes zoster ophthalmicus. Am J Ophthalmol. 1974; 78:255–261.

28. Kido S, Sugita S, Horie S, et al. Association of varicella zoster virus load in the aqueous humor with clinical manifestations of anterior uveitis in herpes zoster ophthalmicus and zoster sine herpete. Br J Ophthalmol. 2008; 92:505–508.