Prevention and Management of Pupil Block After Descemet Membrane Endothelial Keratoplasty.

PURPOSE: To assess frequency, associations, and outcomes of full air fill after Descemet membrane endothelial keratoplasty (DMEK). METHODS: This retrospective study reviewed 368 consecutive DMEK cases performed to treat Fuchs dystrophy, bullous keratopathy, or failed keratoplasty. Primary outcomes were air bubble status, intraocular pressure, and incidence of pupil block and air reinjection. RESULTS: Using an air management algorithm, slit-lamp assessment 1 hour after DMEK identified complete air fill in 80/368 eyes (22%). This spontaneously resolved in 45 eyes. Air was removed from 35 eyes (9%). Eyes that required air removal were more likely to have occluded iridotomy than did eyes in which the full air fill spontaneously resolved (23% vs. 6.6%, respectively), P = 0.05. Although full air fill was more likely after DMEK combined with cataract surgery (P = 0.001), air removal was more likely after DMEK-only procedures (P = 0.01). Eyes that underwent air removal tended to have lower rebubble rates, although this did not reach statistical significance (P = 0.06). No cases of pupillary block glaucoma occurred, and full air fill did not significantly affect 6-month postoperative vision or endothelial cell density. CONCLUSIONS: A careful air management strategy successfully prevented pupil block in eyes that developed full air fill. DMEK-only procedures were more likely to require air removal than those combined with cataract surgery, which suggests that decreased zonular flexibility may prevent the air bubble from taking a more spherical shape and more easily allow occlusion of iridotomy.

Update and review of Urrets-Zavalia syndrome.

For more than half a century, Urrets-Zavalia syndrome (fixed dilated pupil) has been described as a postoperative complication of ophthalmic surgery. Since first reported as a complication of penetrating keratoplasty for keratoconus in patients receiving atropine, the characteristic features of Urrets-Zavalia syndrome have been expanded. In previous literature, a total of 110 cases resulted in a fixed and dilated pupil. Increased intraocular pressure (IOP) in the immediate postoperative period, phakia, and air or gas in the anterior chamber appear to be the most important risk factors for Urrets-Zavalia syndrome following ophthalmic procedures. Mannitol, IOP control, the removal of air or gas in the anterior chamber, and iridectomy have all demonstrated utility in managing Urrets-Zavalia syndrome.

Update and review of Urrets-Zavalia syndrome / Atualizando e revisando a síndrome de Urrets-Zavalia

ABSTRACT For more than half a century, Urrets-Zavalia syndrome (fixed dilated pupil) has been described as a postoperative complication of ophthalmic surgery. Since first reported as a complication of penetrating keratoplasty for keratoconus in patients receiving atropine, the characteristic features of Urrets-Zavalia syndrome have been expanded. In previous literature, a total of 110 cases resulted in a fixed and dilated pupil. Increased intraocular pressure (IOP) in the immediate postoperative period, phakia, and air or gas in the anterior chamber appear to be the most important risk factors for Urrets-Zavalia syndrome following ophthalmic procedures. Mannitol, IOP control, the removal of air or gas in the anterior chamber, and iridectomy have all demonstrated utility in managing Urrets-Zavalia syndrome.

RESUMO Por mais de meio século, a síndrome de Urrets-Zavalia (pupila fixa e dilatada) foi descrita como uma complicação pós-operatória em oftalmologia. Desde o primeiro relato após ceratoplastia penetrante em pacientes portadores de ceratocone em uso de atropina, seu conceito foi ampliado. Na literatura, um total de 110 casos resultaram em pupila fixa e dilatada. Aumento da pressão intraocular (PIO) no pós-operatório imediato, facia, ar ou gás na câmara anterior parecem ser fatores de risco importantes para o aparecimento da síndrome. Sua prevenção pode ser alcançada com o uso de manitol, controle adequado da PIO e quantidade de ar ou gás na camâra anterior e iridectomia.

Sutureless clear corneal DSAEK with a modified approach for preventing pupillary block and graft dislocation: case series with retrospective comparative analysis.

The purpose of this study was to describe a modified technique of sutureless DSAEK with continuous pressurized internal air tamponade. This was a prospective interventional case series, single-center, institutional study. Twenty-seven patients with corneal decompensation without scarring were included. Aphakic patients and patients with cataractous lens requiring IOL implantation surgery were excluded. Following preparation of the donor tissue, a corneal tunnel was made nasally with two side ports. All incisions were kept long enough to be overlapped by the peripheral part of the donor tissue. Descemet membrane scoring was done using a reverse Sinskey hook, following which it was removed with the same instrument or by forceps. The donor lenticule was then inserted using Busin's glide. Continuous pressurized internal air tamponade was achieved by means of a 30-gauge needle, inserted through the posterior limbus, for 12-14 min. At the end of the surgery, air was partially replaced with BSS, leaving a moderate-sized mobile air bubble in the anterior chamber. At the 6 month's follow-up, CDVA improved from counting fingers at half meter-6/24 preoperatively to 6/9-6/18 postoperatively, and the mean endothelial cell count decreased: to 1,800 from 2,200 cell/mm(2) preoperatively (18.19 % endothelial cell loss). Donor lenticule thickness as documented on AS-OCT was 70-110 µ on Day 1 and 50-80 µ at 6 months postoperative. None of the cases had flat AC or peripheral anterior synechiae formation. None of the patients required a second intervention. There were no cases of primary graft failure, pupillary block glaucomax or donor lenticule dislocation postoperatively. Our modified technique is simple and effective with reduction in postoperative complications associated with DSAEK, thereby maximizing anatomic and functional outcomes associated.

Endothelial keratoplasty a simplified technique to minimize graft dislocation, iatrogenic graft failure, and pupillary block.

PURPOSE: Endothelial keratoplasty is an exciting alternative to full-thickness penetrating keratoplasty for replacing the diseased endothelium, yet 3 of the major complications seen are dislocation of the donor tissue, primary graft failure (PGF), and pupillary block from the residual, supportive air bubble. Surgical strategies were developed to reduce the likelihood of occurrence of these complications in our first 200 consecutive Descemet's stripping automated endothelial keratoplasty (DSAEK) cases. DESIGN: Prospective, noncomparative, interventional case series. PARTICIPANTS: Two hundred eyes of 172 patients with corneal edema. METHODS: An institutional review board-approved, prospective protocol of endothelial keratoplasty was initiated. Four different surgeons performed DSAEK for the initial 200 consecutive cases using a technique of peripheral recipient bed scraping for donor edge adherence and leaving a residual supportive air bubble, which was freely mobile, and

Tissue plasminogen activator to treat impending pupillary block glaucoma in patients with acute fibrinous HLA-B27 positive iridocyclitis.

PURPOSE: To report the use of intracameral tissue plasminogen activator to dissolve fibrinous membranes and break posterior synechiae in patients with acute HLA-B27-positive iridocyclitis with impending pupillary block. METHODS: Two patients with severe acute fibrinous iridocyclitis and seclusio pupillae were identified. Because of the concern of impending pupillary block, intracameral tissue plasminogen activator (12.5 microg in 0.1 ml, Activase; Genentech, Inc, South San Francisco, California) was injected with a 25-gauge needle through the corneal limbus. RESULTS: Both patients showed complete dissolution of fibrin with disruption of posterior synechiae. There were no adverse events after injection. Neither patient required further invasive intervention, and both fully recovered with medical management. CONCLUSIONS: Intracameral tissue plasminogen activator is a safe and effective agent for patients with severe acute iridocyclitis and pupillary seclusion. Patients with clinical signs suggestive of impending pupillary block glaucoma may be considered for tissue plasminogen activator injection to avoid the possible need for emergency surgical iridectomy and synechiolysis.