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Round mechanical mydriasis as a first sign of epithelial downgrowth after penetrating keratoplasty
  1. Josep Torras1,2,3,
  2. Elena Arrondo1,4,
  3. Antoni Salvador1
  1. 1Hospital Mutua de Terrassa, Barcelona, Spain
  2. 2Hospital Clínic, Barcelona, Spain
  3. 3University of Barcelona, Barcelona, Spain
  4. 4Instituto Microcirugía Ocular, Barcelona, Spain
  1. Correspondence to Dr Josep Torras, Institut Clinic Oftalmologia, University of Barcelona, Sabino Arana s/n, Barcelona 08028, Spain; jts29206{at}

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A 46-year-old Arabic man underwent an uncomplicated penetrating keratoplasty for pseudophakic bullous keratopathy secondary to a presumed toxic endothelial anterior segment surgery syndrome occurring at another centre. The early postoperative period manifested no complications. The corneal graft was sutured using eight interrupted stitches and one continuous suture. Six months after surgery and removal of several interrupted stitches, uncorrected visual acuity (UCVA) was 20/40 and best corrected visual acuity (BCVA) was 20/25, with spectacle correction of 160° −1 +2, 75.

Two months later, the patient complained of anisocoria due to a paralitic enlargement of the pupil (7 mm) in the penetrating keratoplasty eye (figure 1A). No increase in intraocular pressure (IOP) was observed.

Figure 1

Spontaneous mydriasis in a keratoplasty patient. See the answer to question 1 (A). Evolution of the mydriasis. See the answer to question 1 (B).

After 3 weeks, the patient complained of pain and visual acuity loss. An anterior segment evaluation detected an IOP of 47 mm Hg, mild corneal oedema, cellular tyndall and an enlarged mydriasis. Topical timolol and brimonidine and oral acetazolamide were administered to lower IOP. In the follow-up period, increased mydriasis was noted (more than 10 mm), which resulted in total eclipse of the iris (figure 1B). This required the implementation of an antiglaucomatous device to control the IOP (Ahmed valve, New World Medical, Inc., Rancho Cucamonga, California, USA).

Clinical and pathologic evaluations were completed (figure 2), and the condition was identified as a proliferation of corneal epithelial cells into the anterior chamber, known in medical literature as epithelial downgrowth.1

Figure 2

White dots over iris. See the answer to question 2 (A). Membrane biopsy …

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  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.