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Fixed Pupil Following Keratoplasty
FIXED P U P I L FOLLOWING KERATOPLASTY EVALUATION OF SIX CASES L. Ε. URIBE,
M.D.
New York Spontaneous mydriasis following corneal transplantation, originally observed by Castroviejo, 3 has been reported during the past few years by several authors. 4 " 7 This dilatation of the pupil after surgery is most distressing. Sometimes it can be noted 24 hours after the operation; or it may pro gress gradually over a period of several days. I n this condition, the pupils usually do not respond to miotics. T h e consequences of this severe mydriasis, which can be perma nent, may include atrophy of the iris, secon dary glaucoma, haziness of the graft and a more or less permanent degree of photopho bia related to the size of the pupil. T h e purpose of this paper is to report six cases of keratoconus in which the phenome non of irreversible mydriasis developed fol lowing a partial penetrating keratoplasty. I n two of them, acetylcholine was injected into the anterior chamber three to four weeks after the operation. C A S E REPORTS
TABLE 1 COMPLICATIONS OF FIXED PUPILS
(Six eyes)
Peripheral anterior synechiae Slight iris atrophy Haziness of the graft Glaucoma Poor visual acuity Photophobia No complications
Eyes
Figures
2 3 2 2 1 2 2
1 and 2 1, 2 and 4 2, 3 and 4 1 and 2 2 1 and 3 5 and 6
one drop of adrenalin 1:1000. Méthylène blue 1:500 was instilled to visualize the outline made on the donor cornea with the trephine. Normal physiologic saline solution was used to irrigate the anterior chamber. Two small peripheral iridectomies were performed at the 10- and 12-o'clock positions. The graft was sutured with 7-0 silk. Air (0.2 cc) was injected into the ante rior chamber with a 30-gauge needle. Neosporin ointment and a monocular dressing were applied. Twenty-four hours later a pronounced mydri asis of about 9.0 mm was noticed. There was a small air bubble in the anterior chamber which reabsorbed two days later, leaving a chamber of normal depth. The patient was placed on Phospholine Iodide 0.25% drops twice a day for three weeks with no appreciable change in the size of
CASE 1
Mrs. J. M., aged 23 years, a white woman, had been affected with keratoconus since the age of 19 years. She had had measles at the age of three years and a tonsillectomy at eight years. The pa tient had a tendency to obesity and had twice been treated for hypothyroidism. The keratoconus was more advanced in the left eye. Contact lenses were tried upon four occasions but the patient could not tolerate them. Vision was: R.E., with correction, 20/SO; L.E., 20/400, no improvement. On September 18, 1964, the patient had a par tial penetrating keratoplasty with a circular 8.5-mm graft in the left eye. One hour before surgery she was given 1.5 gr of Nembutal. Neosporin solution was instilled twice in each eye fol lowing admission to the hospital. Akinesia of the facial nerve was effected with 15 cc of Carbocaine 1%; retrobulbar injection by 1.0 cc of Carbocaine 2%. Surface akinesia was induced by sev eral instillations of pontocaine 0.5%, followed by
Fig. 1 (Uribe). Case 1. Three years after an From the Department of Ophthalmology, St. 8.5-mm partial penetrating circular keratoplasty. Fixed pupil 9.0 mm. Vincent's Hospital and Medical Center. 1682
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1683
the pupil. She was comfortable with no ocular pain. The intraocular pressure appeared normal to fingers. The sutures were removed without loss of the anterior chamber on the 22nd postoperative day, under local anesthesia and akinesia of the facial nerve. After removal of the last suture an opening was made through the cornea into the anterior chamber near the limbus, using a Wheeler knife 0.5-mm wide and 15-mm long. The anterior chamber was irrigated through the same opening with acetylcholine 1% with a 30-gauge needle, without noticing any immediate or delayed miosis. The patient was examined two years after the operation. At that time there was a mydriasis of about 8.0 mm and the graft was clear. Vision in the left eye was 20/50 with a —1.5D sph C —2.0D cyl ax 135°. The intraocular pressure and facili ty of outflow have remained within normal limits. Gonioscopy shows an open angle and, under the slitlamp, the peripheral rolls of the iris appear agglutinated one to the other. The patient com plained of moderate photophobia. CASE 2
Mr. R. C, aged 23 years, a white man, had bi lateral keratoconus diagnosed at the age of IS years. He wore corneal contact lenses at first and then corneoscleral contact lenses until he could no longer tolerate them in the right eye. The kerato conus was more advanced in the right eye with dense corneal scars in the pupillary area, the se quelae of recurrent episodes of acute hydrops. Vi sion was: R.E., with correction, counting fingers at 10 feet, L.E., 20/70. On April 15, 1963, a partial penetrating kera toplasty with a 7.0-mm square graft was per formed. Preoperative preparation and local anes thesia were the same as described for the pre vious patient. Méthylène blue 1: 500 was used to visualize the outline of the graft made on the re cipient cornea with the Castroviejo square mark er. A small peripheral iridectomy was performed at the 12-o'clock position. The anterior chamber was irrigated with a balanced saline solution and the same type 7-0 silk sutures were used. The an terior chamber was reformed by the injection of 0.2 cc of air. When the eye was dressed the follow ing day, the pupil was dilated about 9.0 mm. The anterior chamber, which appeared to be of normal depth under slitlamp examination, had a small air bubble. Instillations of Phospholine Iodide 0.25% were started twice daily for two weeks with no discernible change in the size of the pupil. The intraocular pressure appeared normal to fingers. The sutures were removed uneventfully at three weeks. Four days later the patient was returned to the operating room and acetylcholine 1% was injected into the anterior chamber, using the same operative technique as described for Case 1. During postoperative recovery, the increased in traocular pressure was controlled with miotics. The patient was last seen three years after the operation. At that time, the graft remained slightly hazy. Vision in the right eye was 20/70
FIG. 2 (Uribe). Case 2. A 7.0-mm partial pene trating square keratoplasty. Fixed pupil 7.0 mm. with correction; mydriasis was about 7.0 mm. In traocular pressure was controlled with pilocarpine 2% twice daily. By gonioscopy the angle showed small peripheral anterior synechiae. Reoperation was suggested. CASE 3
Mr. A. G., aged 26 years, a white man, had been affected with keratoconus since the age of 15 years. The keratoconus was markedly ad vanced in the left eye. He had tried contact lenses unsuccessfully. Vision was : R.E., 20/200
Fig. 3 (Uribe). Case 3. A 7.5-mm partial pene trating square keratoplasty. Fixed pupil 7.5 mm.
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four days. Two and one-half years later the pupil remained dilated 7.0 mm and slight atrophie changes in the iris were noticeable. Vision in the left eye with a —1.5D sph C —1.5D cyl ax 165° was 20/20. Gonioscopy revealed no synechiae. CASE 5
Miss N. W., aged 41 years, a white woman, had been affected with advanced keratoconus in the right eye for as long as she can remember. The left eye showed an incipient keratoconus. Vision was: R.E., with correction, 20/400; L.E., with correction, 20/20. A penetrating keratoplasty with a 7.25-mm square graft was performed in the right eye. Preoperative care and the surgical technique were the same as in Cases 3 and 4. Two days after the
Fig. 4 (Uribe). Case 4. A 7.0-mm partial pene trating square keratoplasty. Slight atrophie changes in the iris. Fixed pupil 7.0 mm. corrected to 20/40 ; L.E., counting fingers at 10 feet, not correctible. The patient had a partial penetrating keratoplasty with a 7.5-mm square graft in the left eye. Preoperative care and the surgical procedure were the same as described for Case 2, except a peripheral iridectomy was not performed. Eighteen hours after surgery the pupil appeared in slight mydriasis and a large air bubble was present in the anterior chamber. Neosporin ointment was applied. Two days later the mydriasis was very pronounced, the air bubble had disappeared, there was no pain and finger tension was normal. Pilocarpine 2% was instilled twice daily for the next six weeks. The sutures were uneventfully removed 33 days after the op eration. One year later the pupil was dilated about 7.5 mm. Vision in the right eye with a +1.5D sph Z -3.25D cyl ax 125°, 20/20-3. Gonioscopy showed no synechiae. The patient complained of slight photophobia.
Fig. 5 (Uribe). Case 5. A 7.5-mm partial pene trating square keratoplasty. Fixed irregular pupil 9.5 mm.
CASE 4
Mr. R. J., aged 34 years, a white man, had had bilateral keratoconus since the age of 16 years. He had to stop wearing contact lenses. Kerato conus was slightly more advanced -in the left eye. Vision was: R.E., with correction, 20/25; L.E., with correction, 20/100. A penetrating kera toplasty with a 7.0-mm square graft was per formed in the left eye. Preoperative care and op erative technique were the same as described for Case 2. Seventeen hours after surgery the pupil appeared in moderate mydriasis, the anterior chambe: was deep and no air was present. Phospholine Iodide 0.06% once daily was started. The sutures were removed 26 days later. The anterior chamber was partially lost but it reformed in
Fig. 6 (Uribe). Case 6. A 7.5-mm partial pene trating square keratoplasty. Fixed pupil 7.5 mm.
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operation the pupil was dilated. Pilocarpine 2% was started twice daily, with no change in the size of the pupil. Five years after the operation mydriasis of approximately nine mm remained un changed, the anterior chamber was deep with no peripheral synechiae. Intraocular pressure was within normal limits. Vision in the right eye with a -4.5D cyl ax 45° was 20/20. CASE 6
Miss A. M., aged 48 years, a white woman, had been affected with bilateral keratoconus for many years. She could not tolerate contact lenses. Vision was : R.E., with correction, 20/400 ; L.E., correctible to 20/80 and with the addition of +1.5D sph, Jl. A partial penetrating keratoplasty, with a 7.5 mm square graft was performed first. A year later the left eye was operated unevent fully. The mydriasis in the right eye appeared three days after surgery and was treated with pi locarpine 2% two or three times daily, with no pupillary response. Three years later the pupil re mained unchanged. Vision in the right eye with a +1.5D sph C -3.25D cyl ax 70° was 20/20. There were no peripheral synechiae. DISCUSSION
Irreversible postoperative mydriasis may appear in patients undergoing penetrating keratoplasty, usually in those affected with keratoconus. F o r the past two years Castroviejo 3 has cautioned against the indiscriminate use of mydriatics and cycloplegics during the post operative recovery period after penetrating keratoplasty. T h e r e seems to be no doubt that the use of mydriatic agents makes the occurrence of mydriasis more likely. T h a t the syndrome may appear without the use of these drugs is, however, proved by these six cases and by those of Castroviejo, 3 Rodri guez Barrios 5 and Urrets-Zavalia. 7 ' 8 T h e possibility that the condition is caused by peripheral synechiae forming d u r ing chemical or physiologic pupillary dilata tion was suggested by Urrets-Zavalia 7 ' 8 who pointed out that this complication had not been reported in eyes in which peripheral iridectomy had been performed at the time of keratoplasty. However, peripheral iridec tomy had been performed in two of the six cases of fixed pupil presented here, as in an other two mentioned in later publications. 5 · 8 Besides, gonioscopy showed open and clear
1685
angles in four eyes and the anterior cham ber was always of normal depth. Trapping of air in the posterior chamber has also been suggested as a cause, a condition pres ent in none of these eyes. I n my opinion, the iris atrophy, to which a good deal of attention has been given, is a consequence and not a cause of the disease. T h e condition can be present for a long time and the iris degeneration very slight, as four of my cases show. T h e failure of two eyes to respond to acetylcholine injected into the anterior chamber three to four weeks after the corneal transplantation is an interesting observation. Probably, this failure is not due to atrophy of the iris muscle, since this was not clinically apparent and the pupils did not respond to anticholinesterase agents in the early stages of the disease when the iris was normal. T h i s directs attention to the possibility that the cause is at the level of the nervous system. Since it is hard to imagine a n y damage to the central or axonal zones of the nerves themselves as a result of this surgical procedure, and since the pupils do not respond to local instillations of acetyl choline, it may be that the site of the patho logic process, most probably of neurochemical origin, is in the nerve ending where it may be as a response to the liberation of acetylcholine by the stimulated nerves. Recently, pilocarpine 2 % has been in stilled routinely preoperatively in the eyes of patients undergoing a partial penetrating keratoplasty, a peripheral iridectomy is per formed at the 12-o'clock position and, when the pupil shows a tendency to dilatation, acetylcholine 1 % is injected into the ante rior chamber at the time of the operation. D u r i n g the three years since these precau tionary measures were established, I have had no more cases of irreversible mydriasis. SUMMARY
S i x cases of irreversible mydriasis fol lowing a partial penetrating keratoplasty for keratoconus are presented. T h e fixed pupil did not respond to instillation of strong
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miotics, nor to acetylcholine 1% injected into the anterior chamber three to four weeks after the operation. Visual results were excellent in five cases but two of the patients still complained of photophobia two years after the operation. These cases differ from others reported in that mydriatics had not been instilled, gonioscopy did not disclose any synechiae and peripheral iridectomies had been per formed at the time of surgery in two of the patients. Paralysis of the local parasympathetic nervous system by disturbance of the acetyl choline mechanism is postulated as a cause of the pathologic process. 9 East 91st Street (10028)
JUNE, 1967
REFERENCES
1. Barraquer, M., J. I.: Acetylcholine as a miotic agent for use in surgery. Am. J. Ophth. 57:406, 1964. 2. : La acetil colina corno miotico per operatorio. Soc. Am. Of tal. Optom. 4:283, 1963. 3. Castroviejo, R. : Atlas of Keratectomy and Keratoplasty. Philadelphia, Saunders, 1966. 4. Picetti, B. and Fine, M. : Keratoplasty in children. Am. J. Ophth. 61:782, 1966. 5. Rodriquez Barrios, R. : Personal communica tion. 6. Ruedemann, A. D., Jr.: Keratoplasty. South. M.J. 57:1075,1964. 7. Urrets-Zavalia, A., Jr. : Fixed, dilated pupil, iris atrophy and secondary glaucoma. Distinct clini cal entity following penetrating keratoplasty in keratoconus. Am. J. Ophth. 56 :257, 1963. 8. : Iris atrophy after penetrating kera toplasty. In King, J. H., Jr. and McTigue, J. W. (eds.) : The Cornea: World Congress. Washington, Butterworth, 1964, p. 700.
RESTORATION O F T H E A N T E R I O R CHAMBER W I T H GLYCEROL 50% AND MYDRIASIS CHARLES R. LEONE, JR., M.D.,
AND ALSTON CALLAHAN,
M.D.
Birmingham, Alabama
Delayed restoration of the anterior cham ber following intraocular surgery is nearly always disconcerting. In a report by Fine, 1 the incidence of flat chamber following cata ract surgery ranged from 10.3% to 15.1% when two sutures were used, and decreased to 6.1% to 11.2% when three sutures were used. In fistulizing operations, Kronfeld2 found the frequency of delayed chamber restoration to be approximately 20% follow ing various types of corneosclerectomies and less frequent following iridencleises. Taylor 3 believes that the flat-chamber syndrome following cataract extraction is due entirely to wound dehiscence. Weisel and Swan4 agree but attribute a different pathogenesis to the later decrease in depth of a previously formed chamber. However, only one of their 14 cases showed a demon strable wound leak. In our experience, demonstrable wound dehiscence rarely ocFrom the Eye Foundation Hospital.
curs, although, frequently, hypotony and choroidal detachment are associated findings. In fistulizing operations an intentional gap is made at the limbus and a leak is de sired. However, the episcleral tissues will usually provide enough resistance to allow the aqueous to maintain a chamber. Gross leaking of the wound would suggest a defect in the flap or in the reunited conjunctival edges.2 Empirical medical therapy, including acetazolamide,1 mydriasis4 and miotics5 is frequently used for this condition. When these agents have proved ineffective, the next step usually consists of air injection alone or combined with posterior sclerotomy to avoid the formation of peripheral ante rior synechiae. If the chamber fails to re form after seven to 10 days following a filtering procedure, Becker and Shaffer6 in ject air with or without sclerotomy. They also recommend that this be done even be fore the seventh day if the eye is irritated
M.D.
New York Spontaneous mydriasis following corneal transplantation, originally observed by Castroviejo, 3 has been reported during the past few years by several authors. 4 " 7 This dilatation of the pupil after surgery is most distressing. Sometimes it can be noted 24 hours after the operation; or it may pro gress gradually over a period of several days. I n this condition, the pupils usually do not respond to miotics. T h e consequences of this severe mydriasis, which can be perma nent, may include atrophy of the iris, secon dary glaucoma, haziness of the graft and a more or less permanent degree of photopho bia related to the size of the pupil. T h e purpose of this paper is to report six cases of keratoconus in which the phenome non of irreversible mydriasis developed fol lowing a partial penetrating keratoplasty. I n two of them, acetylcholine was injected into the anterior chamber three to four weeks after the operation. C A S E REPORTS
TABLE 1 COMPLICATIONS OF FIXED PUPILS
(Six eyes)
Peripheral anterior synechiae Slight iris atrophy Haziness of the graft Glaucoma Poor visual acuity Photophobia No complications
Eyes
Figures
2 3 2 2 1 2 2
1 and 2 1, 2 and 4 2, 3 and 4 1 and 2 2 1 and 3 5 and 6
one drop of adrenalin 1:1000. Méthylène blue 1:500 was instilled to visualize the outline made on the donor cornea with the trephine. Normal physiologic saline solution was used to irrigate the anterior chamber. Two small peripheral iridectomies were performed at the 10- and 12-o'clock positions. The graft was sutured with 7-0 silk. Air (0.2 cc) was injected into the ante rior chamber with a 30-gauge needle. Neosporin ointment and a monocular dressing were applied. Twenty-four hours later a pronounced mydri asis of about 9.0 mm was noticed. There was a small air bubble in the anterior chamber which reabsorbed two days later, leaving a chamber of normal depth. The patient was placed on Phospholine Iodide 0.25% drops twice a day for three weeks with no appreciable change in the size of
CASE 1
Mrs. J. M., aged 23 years, a white woman, had been affected with keratoconus since the age of 19 years. She had had measles at the age of three years and a tonsillectomy at eight years. The pa tient had a tendency to obesity and had twice been treated for hypothyroidism. The keratoconus was more advanced in the left eye. Contact lenses were tried upon four occasions but the patient could not tolerate them. Vision was: R.E., with correction, 20/SO; L.E., 20/400, no improvement. On September 18, 1964, the patient had a par tial penetrating keratoplasty with a circular 8.5-mm graft in the left eye. One hour before surgery she was given 1.5 gr of Nembutal. Neosporin solution was instilled twice in each eye fol lowing admission to the hospital. Akinesia of the facial nerve was effected with 15 cc of Carbocaine 1%; retrobulbar injection by 1.0 cc of Carbocaine 2%. Surface akinesia was induced by sev eral instillations of pontocaine 0.5%, followed by
Fig. 1 (Uribe). Case 1. Three years after an From the Department of Ophthalmology, St. 8.5-mm partial penetrating circular keratoplasty. Fixed pupil 9.0 mm. Vincent's Hospital and Medical Center. 1682
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FIXED PUPIL AFTER KERATOPLASTY
1683
the pupil. She was comfortable with no ocular pain. The intraocular pressure appeared normal to fingers. The sutures were removed without loss of the anterior chamber on the 22nd postoperative day, under local anesthesia and akinesia of the facial nerve. After removal of the last suture an opening was made through the cornea into the anterior chamber near the limbus, using a Wheeler knife 0.5-mm wide and 15-mm long. The anterior chamber was irrigated through the same opening with acetylcholine 1% with a 30-gauge needle, without noticing any immediate or delayed miosis. The patient was examined two years after the operation. At that time there was a mydriasis of about 8.0 mm and the graft was clear. Vision in the left eye was 20/50 with a —1.5D sph C —2.0D cyl ax 135°. The intraocular pressure and facili ty of outflow have remained within normal limits. Gonioscopy shows an open angle and, under the slitlamp, the peripheral rolls of the iris appear agglutinated one to the other. The patient com plained of moderate photophobia. CASE 2
Mr. R. C, aged 23 years, a white man, had bi lateral keratoconus diagnosed at the age of IS years. He wore corneal contact lenses at first and then corneoscleral contact lenses until he could no longer tolerate them in the right eye. The kerato conus was more advanced in the right eye with dense corneal scars in the pupillary area, the se quelae of recurrent episodes of acute hydrops. Vi sion was: R.E., with correction, counting fingers at 10 feet, L.E., 20/70. On April 15, 1963, a partial penetrating kera toplasty with a 7.0-mm square graft was per formed. Preoperative preparation and local anes thesia were the same as described for the pre vious patient. Méthylène blue 1: 500 was used to visualize the outline of the graft made on the re cipient cornea with the Castroviejo square mark er. A small peripheral iridectomy was performed at the 12-o'clock position. The anterior chamber was irrigated with a balanced saline solution and the same type 7-0 silk sutures were used. The an terior chamber was reformed by the injection of 0.2 cc of air. When the eye was dressed the follow ing day, the pupil was dilated about 9.0 mm. The anterior chamber, which appeared to be of normal depth under slitlamp examination, had a small air bubble. Instillations of Phospholine Iodide 0.25% were started twice daily for two weeks with no discernible change in the size of the pupil. The intraocular pressure appeared normal to fingers. The sutures were removed uneventfully at three weeks. Four days later the patient was returned to the operating room and acetylcholine 1% was injected into the anterior chamber, using the same operative technique as described for Case 1. During postoperative recovery, the increased in traocular pressure was controlled with miotics. The patient was last seen three years after the operation. At that time, the graft remained slightly hazy. Vision in the right eye was 20/70
FIG. 2 (Uribe). Case 2. A 7.0-mm partial pene trating square keratoplasty. Fixed pupil 7.0 mm. with correction; mydriasis was about 7.0 mm. In traocular pressure was controlled with pilocarpine 2% twice daily. By gonioscopy the angle showed small peripheral anterior synechiae. Reoperation was suggested. CASE 3
Mr. A. G., aged 26 years, a white man, had been affected with keratoconus since the age of 15 years. The keratoconus was markedly ad vanced in the left eye. He had tried contact lenses unsuccessfully. Vision was : R.E., 20/200
Fig. 3 (Uribe). Case 3. A 7.5-mm partial pene trating square keratoplasty. Fixed pupil 7.5 mm.
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four days. Two and one-half years later the pupil remained dilated 7.0 mm and slight atrophie changes in the iris were noticeable. Vision in the left eye with a —1.5D sph C —1.5D cyl ax 165° was 20/20. Gonioscopy revealed no synechiae. CASE 5
Miss N. W., aged 41 years, a white woman, had been affected with advanced keratoconus in the right eye for as long as she can remember. The left eye showed an incipient keratoconus. Vision was: R.E., with correction, 20/400; L.E., with correction, 20/20. A penetrating keratoplasty with a 7.25-mm square graft was performed in the right eye. Preoperative care and the surgical technique were the same as in Cases 3 and 4. Two days after the
Fig. 4 (Uribe). Case 4. A 7.0-mm partial pene trating square keratoplasty. Slight atrophie changes in the iris. Fixed pupil 7.0 mm. corrected to 20/40 ; L.E., counting fingers at 10 feet, not correctible. The patient had a partial penetrating keratoplasty with a 7.5-mm square graft in the left eye. Preoperative care and the surgical procedure were the same as described for Case 2, except a peripheral iridectomy was not performed. Eighteen hours after surgery the pupil appeared in slight mydriasis and a large air bubble was present in the anterior chamber. Neosporin ointment was applied. Two days later the mydriasis was very pronounced, the air bubble had disappeared, there was no pain and finger tension was normal. Pilocarpine 2% was instilled twice daily for the next six weeks. The sutures were uneventfully removed 33 days after the op eration. One year later the pupil was dilated about 7.5 mm. Vision in the right eye with a +1.5D sph Z -3.25D cyl ax 125°, 20/20-3. Gonioscopy showed no synechiae. The patient complained of slight photophobia.
Fig. 5 (Uribe). Case 5. A 7.5-mm partial pene trating square keratoplasty. Fixed irregular pupil 9.5 mm.
CASE 4
Mr. R. J., aged 34 years, a white man, had had bilateral keratoconus since the age of 16 years. He had to stop wearing contact lenses. Kerato conus was slightly more advanced -in the left eye. Vision was: R.E., with correction, 20/25; L.E., with correction, 20/100. A penetrating kera toplasty with a 7.0-mm square graft was per formed in the left eye. Preoperative care and op erative technique were the same as described for Case 2. Seventeen hours after surgery the pupil appeared in moderate mydriasis, the anterior chambe: was deep and no air was present. Phospholine Iodide 0.06% once daily was started. The sutures were removed 26 days later. The anterior chamber was partially lost but it reformed in
Fig. 6 (Uribe). Case 6. A 7.5-mm partial pene trating square keratoplasty. Fixed pupil 7.5 mm.
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FIXED PUPIL AFTER KERATOPLASTY
operation the pupil was dilated. Pilocarpine 2% was started twice daily, with no change in the size of the pupil. Five years after the operation mydriasis of approximately nine mm remained un changed, the anterior chamber was deep with no peripheral synechiae. Intraocular pressure was within normal limits. Vision in the right eye with a -4.5D cyl ax 45° was 20/20. CASE 6
Miss A. M., aged 48 years, a white woman, had been affected with bilateral keratoconus for many years. She could not tolerate contact lenses. Vision was : R.E., with correction, 20/400 ; L.E., correctible to 20/80 and with the addition of +1.5D sph, Jl. A partial penetrating keratoplasty, with a 7.5 mm square graft was performed first. A year later the left eye was operated unevent fully. The mydriasis in the right eye appeared three days after surgery and was treated with pi locarpine 2% two or three times daily, with no pupillary response. Three years later the pupil re mained unchanged. Vision in the right eye with a +1.5D sph C -3.25D cyl ax 70° was 20/20. There were no peripheral synechiae. DISCUSSION
Irreversible postoperative mydriasis may appear in patients undergoing penetrating keratoplasty, usually in those affected with keratoconus. F o r the past two years Castroviejo 3 has cautioned against the indiscriminate use of mydriatics and cycloplegics during the post operative recovery period after penetrating keratoplasty. T h e r e seems to be no doubt that the use of mydriatic agents makes the occurrence of mydriasis more likely. T h a t the syndrome may appear without the use of these drugs is, however, proved by these six cases and by those of Castroviejo, 3 Rodri guez Barrios 5 and Urrets-Zavalia. 7 ' 8 T h e possibility that the condition is caused by peripheral synechiae forming d u r ing chemical or physiologic pupillary dilata tion was suggested by Urrets-Zavalia 7 ' 8 who pointed out that this complication had not been reported in eyes in which peripheral iridectomy had been performed at the time of keratoplasty. However, peripheral iridec tomy had been performed in two of the six cases of fixed pupil presented here, as in an other two mentioned in later publications. 5 · 8 Besides, gonioscopy showed open and clear
1685
angles in four eyes and the anterior cham ber was always of normal depth. Trapping of air in the posterior chamber has also been suggested as a cause, a condition pres ent in none of these eyes. I n my opinion, the iris atrophy, to which a good deal of attention has been given, is a consequence and not a cause of the disease. T h e condition can be present for a long time and the iris degeneration very slight, as four of my cases show. T h e failure of two eyes to respond to acetylcholine injected into the anterior chamber three to four weeks after the corneal transplantation is an interesting observation. Probably, this failure is not due to atrophy of the iris muscle, since this was not clinically apparent and the pupils did not respond to anticholinesterase agents in the early stages of the disease when the iris was normal. T h i s directs attention to the possibility that the cause is at the level of the nervous system. Since it is hard to imagine a n y damage to the central or axonal zones of the nerves themselves as a result of this surgical procedure, and since the pupils do not respond to local instillations of acetyl choline, it may be that the site of the patho logic process, most probably of neurochemical origin, is in the nerve ending where it may be as a response to the liberation of acetylcholine by the stimulated nerves. Recently, pilocarpine 2 % has been in stilled routinely preoperatively in the eyes of patients undergoing a partial penetrating keratoplasty, a peripheral iridectomy is per formed at the 12-o'clock position and, when the pupil shows a tendency to dilatation, acetylcholine 1 % is injected into the ante rior chamber at the time of the operation. D u r i n g the three years since these precau tionary measures were established, I have had no more cases of irreversible mydriasis. SUMMARY
S i x cases of irreversible mydriasis fol lowing a partial penetrating keratoplasty for keratoconus are presented. T h e fixed pupil did not respond to instillation of strong
1686
AMERICAN JOURNAL OF OPHTHALMOLOGY
miotics, nor to acetylcholine 1% injected into the anterior chamber three to four weeks after the operation. Visual results were excellent in five cases but two of the patients still complained of photophobia two years after the operation. These cases differ from others reported in that mydriatics had not been instilled, gonioscopy did not disclose any synechiae and peripheral iridectomies had been per formed at the time of surgery in two of the patients. Paralysis of the local parasympathetic nervous system by disturbance of the acetyl choline mechanism is postulated as a cause of the pathologic process. 9 East 91st Street (10028)
JUNE, 1967
REFERENCES
1. Barraquer, M., J. I.: Acetylcholine as a miotic agent for use in surgery. Am. J. Ophth. 57:406, 1964. 2. : La acetil colina corno miotico per operatorio. Soc. Am. Of tal. Optom. 4:283, 1963. 3. Castroviejo, R. : Atlas of Keratectomy and Keratoplasty. Philadelphia, Saunders, 1966. 4. Picetti, B. and Fine, M. : Keratoplasty in children. Am. J. Ophth. 61:782, 1966. 5. Rodriquez Barrios, R. : Personal communica tion. 6. Ruedemann, A. D., Jr.: Keratoplasty. South. M.J. 57:1075,1964. 7. Urrets-Zavalia, A., Jr. : Fixed, dilated pupil, iris atrophy and secondary glaucoma. Distinct clini cal entity following penetrating keratoplasty in keratoconus. Am. J. Ophth. 56 :257, 1963. 8. : Iris atrophy after penetrating kera toplasty. In King, J. H., Jr. and McTigue, J. W. (eds.) : The Cornea: World Congress. Washington, Butterworth, 1964, p. 700.
RESTORATION O F T H E A N T E R I O R CHAMBER W I T H GLYCEROL 50% AND MYDRIASIS CHARLES R. LEONE, JR., M.D.,
AND ALSTON CALLAHAN,
M.D.
Birmingham, Alabama
Delayed restoration of the anterior cham ber following intraocular surgery is nearly always disconcerting. In a report by Fine, 1 the incidence of flat chamber following cata ract surgery ranged from 10.3% to 15.1% when two sutures were used, and decreased to 6.1% to 11.2% when three sutures were used. In fistulizing operations, Kronfeld2 found the frequency of delayed chamber restoration to be approximately 20% follow ing various types of corneosclerectomies and less frequent following iridencleises. Taylor 3 believes that the flat-chamber syndrome following cataract extraction is due entirely to wound dehiscence. Weisel and Swan4 agree but attribute a different pathogenesis to the later decrease in depth of a previously formed chamber. However, only one of their 14 cases showed a demon strable wound leak. In our experience, demonstrable wound dehiscence rarely ocFrom the Eye Foundation Hospital.
curs, although, frequently, hypotony and choroidal detachment are associated findings. In fistulizing operations an intentional gap is made at the limbus and a leak is de sired. However, the episcleral tissues will usually provide enough resistance to allow the aqueous to maintain a chamber. Gross leaking of the wound would suggest a defect in the flap or in the reunited conjunctival edges.2 Empirical medical therapy, including acetazolamide,1 mydriasis4 and miotics5 is frequently used for this condition. When these agents have proved ineffective, the next step usually consists of air injection alone or combined with posterior sclerotomy to avoid the formation of peripheral ante rior synechiae. If the chamber fails to re form after seven to 10 days following a filtering procedure, Becker and Shaffer6 in ject air with or without sclerotomy. They also recommend that this be done even be fore the seventh day if the eye is irritated