(UGH) Syndrome

L. Jay Katz


BASICS


DESCRIPTION


A secondary glaucoma resulting from elevated intraocular pressure (IOP) due to intraocular lens (IOL)–associated chronic inflammation and recurrent hyphemas


EPIDEMIOLOGY


Incidence


Uncommon


Prevalence


Unknown


RISK FACTORS


• Most common with iris-supported or closed-loop anterior chamber lOLs


• Malpositioned haptics of posterior chamber IOLs


• Subluxed IOLs


GENERAL PREVENTION


• Avoid using closed-loop anterior chamber IOLs


• Meticulous placement of posterior chamber lenses in the bag and appropriate lenses in the sulcus to avoid poorly positioned haptics.


PATHOPHYSIOLOGY


IOL-induced iris trauma leads to chronic intraocular inflammation and hemorrhage.


ETIOLOGY


A poorly positioned IOL causes iris chaffing and leads to inflammation and hemorrhage, resulting in elevated IOP.


COMMONLY ASSOCIATED CONDITIONS


Pseudoexfoliation


DIAGNOSIS


HISTORY


• History of cataract surgery with placement of an iris-sutured anterior chamber or a malpositioned posterior chamber IOL


• Transient blurring of vision


• Anticoagulation may exacerbate hemorrhage associated with IOL-induced iris chaffing (1)[C].


PHYSICAL EXAM


• Elevated IOP


• Anterior chamber IOL


• Poorly positioned or subluxed posterior chamber IOL


• Iritis


• Hyphema or microhyphema


• Iris transillumination defects


• Posterior synechiae


• Gonioscopy may be helpful in identifying malpositioned IOL haptics.


• Also perform gonioscopy to rule out neovascularization/peripheral anterior synechiae of the angle.


DIAGNOSTIC TESTS & INTERPRETATION


Lab


Consider checking the PT/INR in patients on anticoagulants to rule out supratherapeutic levels.


Imaging


Initial approach

• Ultrasound biomicroscopy (2)[C] may be used to identify IOL malpositioning and facilitate planning for surgical intervention.


• Optic disc photography or imaging (confocal scanning laser ophthalmoscopy, optical coherence tomography, scanning laser polarimetry)


Follow-up & special considerations

Repeat optic nerve photography or imaging periodically.


Diagnostic Procedures/Other


Visual fields


Pathological Findings


• Sterile anterior segment inflammation and hemorrhage


• Iris melanosomes on IOL haptics


DIFFERENTIAL DIAGNOSIS


• Trauma


• Neovascular glaucoma


• Uveitic glaucoma


• Swan syndrome (elevated IOP and recurrent hyphema associated with neovascularization of the corneoscleral surgical wound)


• Fuchs’ heterochromic iridocyclitis


• Ghost cell glaucoma


• Intraocular tumors (such as malignant melanomas) resulting in recurrent hyphemas


• Juvenile xanthogranuloma


TREATMENT


MEDICATION


First Line


• Atropine 1%


• Topical steroids (e.g., prednisolone acetate)


• Topical beta-blockers (e.g., timolol, betaxolol), alpha-2 agonists (e.g., brimonidine), and/or carbonic anhydrase inhibitors (e.g., dorzolamide, brinzolamide)


• Prostaglandin analogues (e.g., travoprost, latanoprost, bimatoprost) may be used if other topical medications fail to provide adequate IOP control.


Second Line


• Oral or intravenous carbonic anhydrase inhibitors (e.g., acetazolamide)


• Intravenous hyperosmotics (e.g., mannitol)


ADDITIONAL TREATMENT


Issues for Referral


Consider referral to an experienced anterior segment surgeon if surgical intervention is warranted.


SURGERY/OTHER PROCEDURES


• Argon laser ablation of an isolated area of bleeding vessels may be attempted (3)[C].


• Lens exchange or repositioning and/or anterior chamber washout is often required (4)[C].


• Trabeculectomy or tube shunt if IOP remains uncontrolled


IN-PATIENT CONSIDERATIONS


Initial Stabilization

Control the IOP using the medications described previously.


Admission Criteria


Admission is rarely indicated. Consider admission if the IOP remains significantly elevated despite topical and oral medications.


Discharge Criteria


• Reasonable IOP


• Controlled eye pain


ONGOING CARE


FOLLOW-UP RECOMMENDATIONS


Timing of follow-up is dependent on IOP control.


Patient Monitoring


Periodically monitor IOP, optic nerve appearance, and visual fields.


PROGNOSIS


• Variable depending on:


– Time to diagnosis and treatment


– Preexisting optic nerve damage


COMPLICATIONS


• Glaucomatous visual field loss


• Decreased acuity related to IOL position, glaucomatous optic neuropathy, or both



REFERENCES


1. Schiff FS. Coumadin related spontaneous hyphemas in patients with iris-fixated pseudophakos. Ophthalmic Surg 1985;16:172–173.


2. Piette S, Canlas OA, Tran HV, et al. Ultrasound biomicroscopy in uveitis-glaucoma-hyphema syndrome. Am J Ophthalmol 2002;133:839–841.


3. Magaragal LE, Goldberg RE, Uram M, et al. Recurrent microhyphema in the pseudophakic eye. Ophthalmology 1983;90:1231–1234.


4. Carlson AN, Steward WC, Tso PC. Intraocular lens complications requiring removal or exchange. Surv Ophthalmol 1998;42:417–440.

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Nov 9, 2016 | Posted by in OPHTHALMOLOGY | Comments Off on (UGH) Syndrome

Full access? Get Clinical Tree

Get Clinical Tree app for offline access