Prevention of UGH syndrome is the main reason for the decreased incidence of the disease. During routine cataract surgery, a 1 piece lens and haptics should be placed within the lens capsule. If this is not possible due to intraoperative complications, then there are other lens types and techniques that should be undertaken to prevent uveal disruption from the intraocular lens.
A 1 piece lens should not be placed in the sulcus. Additionally, reverse optic capture of the lens can be attempted by placing the edges under the anterior capsulorhexis. If there is inadequate capsular support then a 3 piece sulcus lens can be fixated via scleral fixation. Upside-down lens syndrome [8] is characterized by 'chronic iritis, cystoid macular edema, pupil capture, iris adhesions, and corneal decompensation' due to inverted placement of the Kelman multiflex anterior chamber IOL.
There is an increased risk of corneal decompensation with an ACIOL which can create further complications. The diagnosis of UGH Syndrome is clinical, based on history, physical exam, and supplemented by imaging. Patients often present with intermittent decreased or blurred vision, intermittent white-out of vision, photophobia, redness, and ocular pain in the involved eye. The examination can reveal a variety of physical exam findings. The ophthalmologist should look for the following signs on slit-lamp microscopy: raised IOP, microhyphema or hyphema, anterior chamber cells, and flare or hypopyon, iris neovascularization, iris-lens contact, iris transillumination defects, dislocated or malpositioned IOL, misplaced haptic, vitreous hemorrhage if the posterior capsule is not intact, and or CME.
Examples of these can be seen in the figures to the right. Additionally, gonioscopy should be performed to look for blood within the angle, increased pigmentation of the trabecular meshwork, signs of mechanical erosion.
Gonioscopy can also be used to aid in finding the haptic location that may be the cause of anterior chamber structure erosion. The UBM probe should be used to confirm the position of haptics and optics and their relationships to surrounding ocular structures.
This can help the clinician in reconfirming the clinical suspicion of UGH syndrome and aid in treatment decision-making. Unlike these previously reported eyes with UGH syndrome after in-the-bag implantation of an IOL, our patient had a sclera-fixed two-haptic IOL and a history of multiple previous eye surgeries. At the time of presentation, these had caused multiple tissue lesions and made the structure fragile. Because the eye was also highly myopic, the stability of the capsular bag and the support it provided to the IOL were further impaired, which might have been responsible for the initial displacement of the IOL.
In the first of several episodes of blurred vision, floaters, eye pain, and redness, the patient was only given symptomatic treatment to relieve the inflammation and reduce her IOP, with no clear diagnosis of the etiology or pathogenesis of her eye disease. This temporarily mitigated the complaint, but recurrent episodes followed. Delayed-onset postoperative endophthalmitis was first considered when the patient attended our hospital, based on the typical complaints of blurred vision, redness, and pain.
Reduced media clarity and poor fundus visualization are among the major clinical signs of endophthalmitis [ 5 ]. The recurrent episodes and remission after medication also suggested infection with hypovirulent bacteria. However, this did not fully explain the elevated IOP and bleeding. Although rare, UGH syndrome produces symptoms and signs that were observed in our patient. Under such circumstance, gonioscopy and particularly UBM allow the direct evaluation of the anterior chamber and the chamber angle, and provide essential clues to clarify the etiology [ 6 ].
IOL explantation successfully eliminated the cause of chafing and the symptoms did not recur. Bacterial culture of the IOL was negative, excluding the possibility of endophthalmitis. The electron microscopic findings for the explanted IOL were similar to those reported by Asaria et al. Doctors should be cautious in making this decision in such circumstances, considering the multiple tissue lesions induced by previous surgery and the invasive manipulation involved in IOL scleral fixation.
Therefore, at our hospital, the eye was managed by removing the cause of the mechanical irritation of the iris i. Although transscleral fixation of the IOL is safe and usually has favorable visual outcomes in aphakic eyes [ 8 ], doctors should be careful in the selection of the IOL for highly myopic eyes because the eyeballs of these patients are larger compared with emmetropic eyes. However, the symptoms might not be completely resolved if there is no clear diagnosis and the mechanical stimulation persists.
In most cases, surgical intervention may ultimately be necessary [ 1 ]. In summary, doctors should be cautious in the choice of sclera-fixed IOL in patients with a history of multiple eye operations. It is important to use gonioscopy, together with UBM, to identify evidence of iris irritation in UGH syndrome and to understand its possible etiology.
A differential diagnosis of postoperative endophthalmitis is also necessary. Zemba M, Camburu G. Uveitis-Glaucoma-Hyphaema syndrome. General review. Rom J Ophthalmol. Article Google Scholar. Recurrent microhyphema despite intracapsular fixation of a posterior chamber intraocular lens. J Cataract Refract Surg.
Uveitis-glaucoma-hyphaema syndrome with in-the-bag placement of intraocular lens. BMJ Case Rep. Mechanisms for in-the-bag uveitis-glaucoma-hyphema syndrome. Current approach to postoperative endophthalmitis. Br J Ophthalmol. Ultrasound biomicroscopy in uveitis-glaucoma-hyphema syndrome.
Definitive treatment is to secure or exchange the IOL or iris implant. Web Privacy Policy Nondiscrimination Statement. References Ellingson FT. J Am Intraocul Implant Soc ;4 2 Uveitis-glaucoma-hyphema syndrome caused by posterior chamber intraocular lens--a rare complication in pediatric cataract surgery. Ann Ophthalmol Skokie ;40 Complications of sulcus placement of single-piece acrylic intraocular lenses: recommendations for backup IOL implantation following posterior capsule rupture.
J Cataract Refract Surg ;35 8 Uveitis-glaucoma-hyphema syndrome and corneal decompensation in association with cosmetic iris implants. Am J Ophthalmol ; 5 Laser iridotomy to treat uveitis-glaucoma-hyphema syndrome secondary to reverse pupillary block in sulcus-placed intraocular lenses: Case series. J Cataract Refract Surg ;41 10 Mechanisms for in-the-bag uveitis-glaucoma-hyphema syndrome. J Cataract Refract Surg ;40 3 Intraocular lens exchange surgery at a tertiary referral center: Indications, complications, and visual outcomes.
J Cataract Refract Surg ;42 9 Serial intracameral bevacizumab for uveitis-glaucoma-hyphema syndrome: a case report. Recent: How pediatric glaucoma can have impact beyond clinical effects. Eyes with anterior chamber lenses were much more likely to develop glaucoma or macular edema than the other groups. That group also had the longest time to diagnosis and saw the greatest number of ophthalmologists before a confirmed diagnosis. Related: Laser therapy addresses bilateral glaucoma in single treatment.
There was a considerable delay for all groups from the time of cataract surgery until diagnosis, despite being evaluated by several surgeons, Dr. Cheung said, with the anterior chamber group having a mean of 1, before diagnosis compared with days for the one- and three-piece groups. The one- and three-piece IOLs had higher rates of TIDs than the anterior chamber lenses, he said, but those groups also fared better visually after repositioning or exchange.
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