UNILATERAL URRETS-ZAVALIA SYNDROME AFTER IMPLANTABLE COLLAMER LENS IMPLANTATION: A CASE REPORT

To describe a rare case of unilateral Urrets-Zavalia Syndrome (UZS) following implantation of a Toric Implantable Collamer Lens (TICL) in a young myopic patient and to describe the clinical course, management, and possible etiological mechanisms related to post-operative intraocular pressure (IOP) elevation.

Drishti Eye Institute, Dehradun, India.

A 25yr old male with bilateral myopia underwent V4c TICL (STAAR Surgical, Switzerland) implantation in both eyes. Preoperative best-corrected visual acuity (BCVA) was 20/30 OD (–7.25D sphere/–2.50D cylinder@30°) and 20/30 OS (–7.00D sphere/–3.00D cylinder@150°),with endothelial cell counts >2600 cells/mm². OU anterior segment and fundus were normal. The intraocular pressure (IOP) were OD 12 mmHg and OS 12 mmHg.  The OCOS sizing software recommended an ICL size of 12.6 mm for both eyes.An ophthalmic viscosurgical device HPMC (hydroxypropyl methylcellulose), was used and ICL was implanted in the sulcus. The right eye received a 12.6 mm lens with postoperative vault of 271µm and vision 20/20. To achieve higher vault, the left eye received 13.2 mm lens. The surgery was uneventful. On POD-1,vision and vault of left eye was 20/30 and 568µm respectively. On POD-2,the patient presented with severe pain and redness. On examination, left eye showed eyelid edema, diffuse 360° subconjunctival hemorrhage, chemosis and corneal edema. Left eye IOP was 70 mmHg on RBT.Aggressive IOP control was initiated with IV mannitol,oral and topical anti-glaucoma medications. Topical anti-inflammatory and a combination antibiotic-steroid preparation was initiated. Slow decompression was done and IOP decreased to 21 mmHg.  Surgical video of left eye was reviewed and confirmed that adequate visco wash was done. Despite medical therapy and AC decompression, IOP raised again to 50 mmHg on POD-3,necessitating AC washout along with surgical peripheral iridectomy and ICL footplate reposition was done. IOP at 1 week, 2 week and 1 month was 21, 14 and 16 mmHg respectively. Antiglaucoma medication was gradually stopped.

Post-operative right eye vision and vault remained stable. Following IOP stabilization, left eye corneal edema subsided gradually. At day 7,left eye vision was 20/70, vault 263 µm. At week 3, left eye vision was 20/60 (pinhole 20/30), vault 226 µm and the pupil remained fixed and mid-dilated with minimal pupil reaction to light, indicative of UZS. At 3^rd year and 5^th year follow up, right eye vision remained stable at 20/20 and left eye vision also remained stable at -1.5D sphere/-0.5D cylinder@74° to 20/30. 

This case highlights that early recognition of pressure spikes & prompt surgical intervention are critical to prevent irreversible iris ischemia. Additionally, retained visco material appears to be a possible contributory factor in the pathogenesis. This case exhibited the importance of intraoperative viscoelastic removal, vigilant post-operative monitoring and awareness of UZS among refractive surgeons.