Unilateral Urrets-Zavalia syndrome after Implantable Collamer Lens implantation: a case report and review of the literature

Background Fixed dilated pupil after ophthalmic surgery or Urrets-Zavalia syndrome occurs after anterior segment surgery and usually relates to postoperative elevation of intraocular pressure. Urrets-Zavalia syndrome results in complaints of glare, halo, and photophobia. Retention of the viscoelastic agent during Implantable Collamer Lens implantation can result in postoperative elevation of intraocular pressure and Urrets-Zavalia syndrome. However, reversibility of pupillary dilatation is possible in some cases. Case presentation A 20-year-old Thai man with myopic astigmatism in both eyes underwent Implantable Collamer Lens implantation in the right eye. The preoperative slit-lamp examination of both eyes was normal, and no ectatic changes were detected from corneal tomography. One hour after the uncomplicated surgery of the right eye, intraocular pressure increased to 48 mmHg and was immediately controlled with antiglaucoma medications. Postoperative pupillary dilatation was detected, presumably due to effect of preoperative application of mydriatic drops. At postoperative day 1, the right pupil remained dilated but still reactive to light and pilocarpine 2% eye drops. Two weeks later, the left eye underwent the Implantable Collamer Lens implantation and showed neither postoperative increase in intraocular pressure nor postoperative pupillary dilatation. Two months after surgery, the dilatation of the right pupil partially reversed. Conclusions The findings of the right eye suggested diagnosis of Urrets-Zavalia syndrome. Compared with former reports, we noted an association between immediate control of elevation of postoperative intraocular pressure, light reactivity of the dilated pupil, and reactivity to pilocarpine 2% eye drops as potential predictors for reversibility of Urrets-Zavalia syndrome.

Study of patients with Pseudoexfoliation syndrome undergoing cataract surgery

To analyze the visual outcome in patients with pseudoexfoliation and to know the surgical parameters to cogitate in patients with pseudoexfoliation syndrome. An Observational study which was conducted in the Ophthalmology department in a tertiary care hospital in a rural area from June 2019 to December 2019. A total of 52 eyes of 52 patients aged 40 years and above, of either sex, clinically diagnosed with senile cataract and associated with pseudoexfoliation were enrolled in the study. After assessing best corrected visual acuity (BCVA), a detailed anterior and posterior segment examination was performed along with lacrimal sac syringing, manual keratometry, contact A-scan biometry and intraocular lens (IOL) power was calculated. All patients underwent manual small incision cataract surgery under peribulbar anaesthesia and intraocular lens was implanted. Intraoperative complications were noted during the surgery and was reported .Best corrected visual acuity was recorded on day 1, at 1week and at 1 month of follow up. Out of 52eyes of 52 patients, 29 were females (55.76%) and 38 eyes (73.07%) exhibited bilateral involvement. Distribution of the PXF material in various ocular structures was observed and majority of them (36.53%) had PXF material equally in iris, pupillary margin and lens. Based on the morphology of cataract associated with psudoexfoliation, nuclear cataract was the most commonly observed in 16 eyes (30.76%) and 42 eyes (80.76%) had moderate pupillary dilatation. The intraoperative difficulties observed during cataract surgery was poor pupillary dilatation which was managed by controlled sphincterotomy during the surgery in 3 eyes (5.76%), Iridiodialysis, rhexis extension, zonular dialysis each in 1 eye and posterior capsular rent in 2 eyes. Around 92.30% of the total study population achieved post-operative BCVA of 6/12 or better at 1month of follow up. Decreased visual acuity was noted in 2 (3.84%) eyes due to persistent corneal edema, one eye (1.92%) had posterior capsular opacification and one eye (1.92%) had cystoid macular edema. This study concludes that with careful preoperative assessment and necessary intraoperative precautions, good visual outcome can be achieved in patients with cataract with pseudoexfoliation.

A STUDY OF THE POTENTIATING EFFECT OF TOPICAL PROPARACAINE 0.5% ON TROPICAMIDE 0.8% AND PHENYLEPHRENE 5% INDUCED MYDRIASIS IN A SOUTHINDIAN POPULATION

Objectives: Pupillary dilatation is an integral part of comprehensive ophthalmic examination. It is also essential for cataract surgery and outpatient laser procedures. Rapid and sustained dilatation is often required. It has been proposed that prior instillation of proparacaine 0.5% can potentiate the effect of the routinely used tropicamide 0.8% phenylephrine 5% combination mydriatic agent. However, certain studies have shown that it is not effective in dark colored iris as compared to light colored iris; hence, this study was done on a predominantly South Indian population with dark iris. Methods: Hundred eyes of 50 patients requiring pupillary dilatation as part of routine ophthalmic evaluation were included in the study. The patients were divided into two groups. The study group was given 0.5% proparacaine before instillation of mydriatic agent and the control group was given only tropicamide 0.8% and phenylephrine 5% eye drops. Pupillary dilatation was measured after 15 min and 30 min in both eyes. The end point was taken as 6 mm pupillary dilatation. Results: There was a statistically significant difference in the rate of pupillary dilatation between the control and the study group at 15 min and 30 min after instillation of eye drops. Conclusion: The study concluded that prior instillation produced faster dilatation even in patients with dark colored iris; hence, we suggest the use of topical anesthetic proparacaine 0.5% in situations where rapid mydriasis is required.

COMPARISON OF THE EFFECT OF TOPICAL BROMFENAC AND TOPICAL FLURBIPROFEN IN MAINTAINING MYDRIASIS DURING CATARACT SURGERY

At the time of cataract surgery, one of the challenges a surgeon encounters is intraoperative miosis. This might increase the chances of intraoperative and postoperative complications. Thus, maintainence of adequate pupillary dilatation is necessary during cataract surgery. Aim of the study was to compare the effectiveness of prophylactic administration of topical bromfenac (0.09 % w/V) and topical flurbiprofen (0.03 % w/V) in maintaining mydriasis during the cataract surgery. A total of 100 patients were randomly divided into two groups of 50 each. Group 1 received topical bromfenac (0.09 %) and Group 2 received topical flurbiprofen (0.03 %). The mean percentage loss of mydriasis from the baseline was lesser in bromfenac group compared to flurbiprofen group (p < 0.001). Topical bromfenac was found to be more effective in maintaining mydriasis during the cataract surgery when compared to the topical flurbiprofen.

Slit Lamp profile of Pseudoexfoliation eyes

Background: Pseudoexfoliation syndrome is an age-related systemic microfibrillopathy, caused by progressive accumulation and gradual deposition of extracellular grey and white material over various tissues. It is associated with many intraocular abnormalities like poor pupillary dilatation, zonular dehiscence, glaucoma etc. Hence it is important to do detailed slit lamp examination with dilated pupil to detect the pseudoexfoliative deposits in eye, especially in elderly to prevent unforeseen complications. Aims and Objective: To study pattern of distribution of pseudoexfoliative material in eyes with pseudoexfoliation syndrome and to study the dilatation profile of pupil in such eyes. Materials and Methods: This observational study was conducted on patients with pseudoexfoliation syndrome who attended OPD in the Upgraded Department of Ophthalmology, Government Medical College, Jammu from 1st April 2018 for a period of 6 months. The clearance was taken from ethical committee for the study in reference. Informed consent was taken from all the patients enrolled in the study. Results: Pupillary margin was found to be the most common site for deposition of pex material i.e. 51 (75%) patients followed by anterior surface of lens in 32(47.05%) patients. Patients had simultaneous deposition of pex material over various parts of the eye. 64 (94.12%) patients had pex material deposited on pupil or lens. Only 1(1.47%) patient had pex deposits over cornea. 56 (82.35%) patients attained good to moderate dilatation of pupil with 0.8% tropicamide e/d. 12(17.65%) patients had pupillary dilatation of ≤4mm hence poor dilatation. Conclusion: Pseudoexfoliation presents challenges that must be adequately addressed with detailed slit lamp examination. Cases may go undetected due to failure to dilate the pupil or to examine with slit lamp after dilatation. Adequate pre-operative assessment should especially be done before cataract surgery with the aim to identify problems like the possibility of fragile zonules and inadequate mydriasis which could increase intraoperative complications arising from undue manipulations.

Contralateral pupillary dilatation and hemiparesis: Kernohan’s notch revisited

Intracranial mass lesions can lead to transtentorial uncal herniation, and pupillary asymmetry is a well-recognized sign of impending cerebral herniation. Impending uncal herniation can lead to ipsilateral, bilateral, or uncommonly the contralateral pupillary dilatation. We report a case of a 22-year old, who had contralateral pupillary dilatation due to expanding intracranial mass lesion and recovered well after neurosurgical intervention. This case illustrates contralateral pupillary dilatation (“false-localizing” sign) in a sub-group of patients, and if untreated and ICP continues to rise, this is followed by ipsilateral pupil dilatation.

Effect of Topical Proparacaine 0.5% on Tropicamide- Induced Mydriasis

Purpose: The topical anesthetic proparacaine (0.5%) is recommended to enhance the rate and magnitude of pupillary dilatation if it is instilled before mydriatic tropicamide. However there is scarcity of data supporting this. Therefore we conducted a study to analyze if preinstillation of topical proparacaine (0.5%) can potentiate the mydriatic efficacy of 0.8% tropicamide. Methods: The patients were divided into two groups for pupillary dilatation. The study group was given a drop 0.5% proparacaine before instilling one drop of tropicamide while the control group was given the tropicamide alone. The pupillary size was measured and recorded before the instillation of tropicamide at 0 min, 15 min, 30 min. The end point was taken as 6 mm pupillary size (clinically effective diameter). Results: There was a statistically significant difference in rate of pupillary diameter between the control and the study group. The rate of pupillary dilatation at 15min and 30 min was statistically significantly different between the control and study group. Conclusion: The study concluded that prior instillation of topical proparacaine produced a statistically significant difference in the rate of pupillary dilatation at 30 mins. Therefore, we suggest the use of a topical anesthetic before tropicamide induced mydriasis.

The Effect of Short Acting Mydriatics on Intraocular Lens power Measurement Using IOLMaster® Biometry

Objective In this study, we aimed to investigate the dynamics affecting IOL power calculations and the effect of pupillary dilation on these dynamics. Patients and Methods Thirty eyes of cataract patients who visited Embaba ophthalmic hospital outpatient clinic were included in this study. Patients with past history of ocular trauma, ocular surgeries, corneal opacities, Ocular pathology like glaucoma, uveitis, retinal disease or any systemic disease were excluded from this study. Our candidates were subjected to full ophthalmological examination including VA, slit lamb biomicroscopy, BCVA, applanation tonometry, fundus examination and IOL power measurement using IOL Master 700 before and after pupillary dilatation using 1 % tropicamide eye drops. Results Our study revealed that dilatation does not affect the Holladay 2 calculated IOL power and we found that AL and keratometric biometry (K1, K2) were not affected by dilatation (p-value was 0.584, 0.804, 0.436, respectively); however, the ACD was significantly increased post-dilatation (with mean difference 0.056; P-value &lt; 0.05), that may be because the lens and iris plane move backward on dilatation. Conclusion This study revealed that biometric measurements as axial length (AL), K1 and K2 were not affected by pupillary dilatation. While ACD was significantly affected with p value 0=024. Although anterior chamber depth (ACD) was affected it did not affect IOL power. Which means that IOL power measured with dilatation is reliable and it can be used to decide IOL used in cataract surgery.