• fixed dilated pupil
• deep lamellar keratoplasty
• Urrets-Zavalia syndrome

A fixed dilated pupil following penetrating keratoplasty is a well recognised if rare postoperative complication. We report a case of Urrets-Zavalia syndrome following a deep lamellar keratoplasty (DLK). To our knowledge this association has not been previously described.

The mydriasis following penetrating keratoplasty was first described by Castroviejo (Castroviejo R, personal communication) but it was Urrets-Zavalia who first published his observations on a series of six cases and suggested an association of fixed dilated pupil, iris atrophy, and secondary glaucoma.¹

The incidence of this syndrome is estimated at 5.8%, from pooled data on 445 eyes undergoing penetrating keratoplasty for keratoconus, of which 24 eyes developed a fixed dilated pupil.² Davies and Ruben also found a similar incidence.³ However, other more recent studies find no cases,^4–6 and some even question its continued existence. This may in part reflect improved surgical technique and differing diagnostic criteria.

The pupil can become abnormally dilated following penetrating keratoplasty for keratoconus, particularly if dilating drops are used. There are three main groups of pupillary dilatation.²

(1) A pupil with normal light and near reaction which is at least 1.5 mm larger than its fellow unoperated eye. It fully constricts with topical miotics. An …