Analysis of the Etiologies and the Classification of Fixed Dilated Pupil after Intraocular Surgery

Yong Chan Kim; Jong Kyung Na; Man Soo Kim

doi:10.3341/jkos.2015.56.1.47

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Kim, Na, and Kim: Analysis of the Etiologies and the Classification of Fixed Dilated Pupil after Intraocular Surgery

Original Article

J Korean Ophthalmol Soc 2015;56(1):47-54.

Published online: 6 September 2015

DOI: https://doi.org/10.3341/jkos.2015.56.1.47

Analysis of the Etiologies and the Classification of Fixed Dilated Pupil after Intraocular Surgery

Yong Chan Kim, MD, Jong Kyung Na, MD, Man Soo Kim, MD, PhD

Department of Ophthalmology and Visual Science, Seoul St. Mary’s Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea

Address reprint requests to Man Soo Kim, MD, PhD, Department of Ophthalmology, College of Medicine, The Catholic University of Korea, Seoul St. Mary’s Hospital, #222 Banpo-daero, Seocho-gu, Seoul 137-701, Korea, Tel: 82-2-2258-1188, Fax: 82-2-599-7405 E-mail: mskim@catholic.ac.kr

Received 21 July 201423 October 2014 Accepted 20 December 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To seek for mechanisms to prevent fixed dilated pupil including Urrets-Zavalia syndrome after intraocular surgery by analyzing and classifying the causes of such cases.

Methods

Medical records and anterior segment photographic images of patients with fixed dilated pupil who underwent pene-trating keratoplasty, lamellar keratoplasty, or cataract surgery were analyzed in a retrospective manner from April, 1984 to February, 2014.

Results

Among 15 cases of postoperative fixed dilated pupil, 8 eyes of keratoconus eyes had received penetrating keratoplasty done and 7 eyes with ocular disorders other than keratoconus underwent intraocular surgeries. In cases 1 and case 2, which received penetrating keratoplasty for keratoconus, dilated pupil with regular pupil border, iris atrophy, and secondary glaucoma oc-curred; these cases were classified as group 1 and diagnosed as Urrets-Zavalia syndrome. Cases from 3 to 8 which also received penetrating keratoplasties due to keratoconus, irregularly dilated pupil, severe iris atrophy, posterior synechiae after moderate to severe inflammation in the anterior chamber, and fibrotic membrane on the anterior capsule occurred; these cases were classified as group 2. Finally, cases 9 to 15, which had mild inflammation, no fibrotic membrane, and regularly fixed dilated pupil after receiving other intraocular surgeries were classified as group 3.

Conclusions

Differences exist between definite Urrets-Zavalia syndrome and postoperative fixed dilated pupil with regards to regularity of pupillary margin, degree of iris atrophy, posterior synechiae, fibrotic membrane, and posterior subcapsular opacity. Therefore, a new classification of fixed dilated pupil after intraocular surgery which addresses these characteristics is required and various trials to prevent the adverse postoperative complications of fixed dilated pupil should be performed. Preventive measures may include careful control of intraocular pressure, restricting atropine use, completely removing of viscoelastics, and minimal air or gas injection.

Keywords: Fixed dilated pupil, Penetrating keratoplasty, Urrets-Zavalia syndrome

References

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Figure 1.

Case 1. Eleven years postoperatively, regularly dilated pupil is sustained with posterior synechiae at 7 o’clock in the left eye.

Figure 2.

Case 5. Twelve years postoperatively, the fixed dilated pupil, iris atrophy, and diffuse posterior synechiae is sustained in the left eye.

Figure 3.

Case 4. Twelve years postoperatively, fixed dilated pupil, severe iris atrophy, and diffuse posterior synechiae are seen in the left eye.

Figure 4.

Case 12. Two months postoperatively, fixed dilated pupil in the left eye.

Figure 5.

Case 12. Ten years postoperatively, sustained fixed dilated pupil in the left eye.

Figure 6.

Case 13. Five years postoperatively, fully dilated pupil in the left eye.

Table 1.

Demographics of each patient with fixed dilated pupil after intraocular surgeries

Case	Sex	Age	Age at Dx	. Eye	Diagnosis	Operation P	Preop. BCVA	Preop. IOP (mm Hg)	Mydriatics
1	F	37	22	OS	Keratoconus	PKP	0.02	12	Atropine
2	F	40	27	OD	Keratoconus	PKP	0.02	9	Atropine
3	M	33	21	OS	Keratoconus	PKP	0.06	12	-
4	M	40	28	OS	Keratoconus	PKP	0.16	13	-
5	M	31	19	OD	Keratoconus	PKP	FC/50 cm	9	-
6	M	37	28	OD	Keratoconus	PKP	FC/50 cm	11	-
7	M	28	19	OS	Keratoconus	PKP	FC/10 cm	9	-
8	M	38	36	OD	Keratoconus	PKP	FC/50 cm	17	-
9	M	51	21	OD	Corneal opacity	PKP	0.02	12	-
10	M	48	35	OS	Leukoma corneae	PKP	FC/40 cm	14	-
11	F	32	24	OD	ICE syndrome	PKP	FC/50 cm	14	-
12	M	54	54	OS	Macular dystrophy	PKP	0.06	8	-
13	M	48	42	OS	PRK scar	Lamellar KP	0.32	14	-
14	M	54	33	OS	Adult cataract	Phaco + PCL	0.1	15	-
15	F	82	64	OD	Senile cataract	ECCE + PCL	0.15	13	-

Dx = diagnosis; Preop = preoperative; BCVA = best corrected visual acuity; IOP = intraocular pressure; ICE syndrome = iridocorneal endothelial syndrome; PRK = photorefractive keratectomy; PKP = penetrating keratoplasty; KP = keratoplasty; Phaco + PCL = phacoemulsification and posterior chamber lens insertion; ECCE + PCL = extracapsular cataract extraction and posterior chamber lens insertion; FC = finger count.

Table 2.

Characteristics of each patient with fixed dilated pupil after intraocular surgeries

Case	POD#1^∗ IOP (mm Hg)	FDP^† (days)	Anterior chamber cells	Aqueous flare	Fibrotic memb.	Pupillary margin	Iris atrophy	Posterior synechiae
1	60	1	+	-	-	Regular	Mild	Localized
2	43	1	+	-	-	Regular	Mild	Absent
3	34	2	+++	+++	+	Irregular	Moderate	Multiple
4	29	3	++++	+++	+	Irregular	Severe	Multiple
5	38	2	++++	++++	+	Irregular	Severe	Multiple
6	22	2	+++	++	+	Irregular	Moderate	Localized
7	42	1	++++	++++	+	Irregular	Severe	Multiple
8	46	1	+++	+++	+	Irregular	Moderate	Multiple
9	34	1	+	-	-	Regular	Absent	Absent
10	35	1	++	+	-	Regular	Mild	Absent
11	37	1	++	+	-	Regular	Mild	Localized
12	37	1	+	-	-	Regular	Absent	Absent
13	59	2	+	-	-	Regular	Absent	Absent
14	33	1	++	-	-	Regular	Mild	Localized
15	26	1	+	+	-	Regular	Mild	Absent

IOP = intraocular pressure; Memb = membrane.

^∗ Postoperative 1 day

^† Postoperative day at fixed dilated pupil.

Table 3.

Classification of fixed dilated pupil after intraocular surgeries

	Group 1	Group 2	Group 3
	(case 1 and 2)	(case 3-8)	(case 9-15)
Viscoelastic material	Used	Used	Used
FDP^∗	1.00 day	1.83 days	1.14 days
Pupillary margin	Regular	Irregular	Regular
Iris atrophy	Absent or mild	Moderate or severe	Absent or mild
Posterior synechiae	Absent or localized	Multiple or localized	Absent or localized
Anterior chamber cells	Mild	Severe	Mild
Aqueous flare	Nil	Marked or intense	Nil or just detectable
Fibrotic membrane	-	+	-
Features	Mild A/C cells	Severe A/C cells	Mild A/C cells
	Fibrotic membrane (-)	Fibrotic membrane (+)	Fibrotic membrane (-)
	Regular pupil margin	Irregular pupil margin	Regular pupil margin
	Mild iris atrophy	Severe iris atrophy	Mild iris atrophy
D/Dx. point	Atropine use	Postop. severe A/C inflammation	Intra A/C air or gas injection
	PAS

D/Dx = differential diagnosis; Postop = postoperative; A/C = anterior chamber; PAS = peripheral anterior synechiae.

^∗ Postoperative day at fixed dilated pupil.

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