Persistent Pupillary Dilation and Irreversible Mydriasis in HLA-B27-Associated Uveitis

Persistent fixed dilated and tonic pupils following an attack of anterior uveitis is an uncommon finding, particularly in patients with a confirmed diagnosis of human leukocyte antigen B27 (HLA-B27)-associated uveitis. The proposed mechanism in this condition is linked to anterior segment ischemia, a phenomenon known as Urrets-Zavalia-like syndrome. We describe a case of a healthy 38-year-old female patient who presented to the neuro-ophthalmology service with persistently dilated pupils in both eyes. She had a past ocular history of recurrent anterior uveitis that was later associated with an HLA-B27 mutation. During the acute attack of anterior uveitis, the patient received topical cyclopentolate 1% drops as part of her management. Later, she presented with worsening photophobia and high ocular pressure, in addition to widely dilated and fixed pupils (atonic pupils) in both eyes. Upon assessment during follow-up visits, the pupils were found to be persistently dilated even after the discontinuation of the mydriatic drops and stabilization of both ocular pressure and inflammation.