Uveitis-Glaucoma-Hyphema syndrome following sutureless scleral fixated intraocular lens: A case report

Manavi D Sindal; Kanika Chhabra; Ayushi Sinha

doi:10.4103/ijo.IJO_731_21

CASE REPORT

Year : 2022 | Volume : 2 | Issue : 2 | Page : 402-403

Uveitis-Glaucoma-Hyphema syndrome following sutureless scleral fixated intraocular lens: A case report

Manavi D Sindal, Kanika Chhabra, Ayushi Sinha
Vitreoretina Services, Aravind Eye Hospital and Postgraduate Institute of Ophthalmology, Pondicherry, India

Date of Submission	01-Apr-2021
Date of Acceptance	06-Oct-2021
Date of Web Publication	13-Apr-2022

Correspondence Address:
Manavi D Sindal
Vitreoretina Services, Aravind Eye Hospital, Thavalakuppam, Cuddalore Main Road, Pondicherry - 605 007
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijo.IJO_731_21

Abstract

Uveitis-glaucoma-hyphema (UGH) syndrome is a rare complication usually seen with anterior chamber intraocular lens. We report the occurrence of sudden-onset blurred vision and pain 1 year after an uneventful sutureless scleral fixated intraocular lens (SFIOL) implantation. Despite initial conservative management, the symptoms persisted. A recurrence of VH, uncontrolled IOP, and an irritable painful eye led to the diagnosis of UGH syndrome, and the SFIOL was explanted. We postulate a floppy iris secondary to previous trauma with resultant iris chaffing as the cause for the occurrence of UGH syndrome.

Keywords: Increased IOP, IOL explantation, SFIOL, UGH syndrome, vitreous hemorrhage

How to cite this article:
Sindal MD, Chhabra K, Sinha A. Uveitis-Glaucoma-Hyphema syndrome following sutureless scleral fixated intraocular lens: A case report. Indian J Ophthalmol Case Rep 2022;2:402-3

How to cite this URL:
Sindal MD, Chhabra K, Sinha A. Uveitis-Glaucoma-Hyphema syndrome following sutureless scleral fixated intraocular lens: A case report. Indian J Ophthalmol Case Rep [serial online] 2022 [cited 2023 Jun 2];2:402-3. Available from: https://www.ijoreports.in/text.asp?2022/2/2/402/343000

Uveitis-glaucoma-hyphema UGH syndrome is a rare complication caused by repetitive mechanical trauma to uveal tissue by a malpositioned or subluxated IOL. While it has been historically reported with anterior chamber lenses, some cases are caused by posterior chamber lenses as well. The spectrum of clinical manifestations includes anterior chamber inflammation, micro-hyphema, pigment dispersion, elevated intraocular pressure, and blurred vision.^[1] Here we report a case of UGH syndrome after sutureless scleral fixated intraocular lens implantation (SFIOL).

Case Report

A 55-year-old gentleman with zonular dialysis and phacodonesis following blunt trauma to the right eye was initially evaluated in December 2005. In February 2006, he was scheduled for extraction of the traumatic cataract with intraocular lens (IOL) implantation. Intraoperatively, due to significant zonular dialysis, an IOL could not be implanted. He underwent pars plana vitrectomy along with sutureless scleral fixated intraocular lens (SFIOL) implantation (MA60AC, AcrySof IOL, Alcon) in April 2019. Postoperative BCVA was 6/9 with a stable SFIOL and thin epiretinal membrane (ERM).

In March 2020, he presented with sudden-onset blurred vision, redness, floaters, and pain in the right eye for 5 days. His vision had reduced to perception of light with an intraocular pressure (IOP) of 44 mm Hg. Slit-lamp examination revealed a 1-mm hyphema with blood-tinged aqueous obscuring the details of posterior structures. [Figure 1]a and [Figure 2]a Ultrasonography was suggestive of vitreous hemorrhage (VH). [Figure 3]a His left eye was within normal limits, with early cataract changes and a normal fundus. The patient was initiated on topical anti-glaucoma medications (AGM), steroids, and cycloplegics. On review, IOP was controlled but VH persisted, and a vitreous lavage was performed in April 2020. Intraoperatively, his fundus was normal, except for the ERM, with no obvious cause for VH. The haptics of IOL were well secured and stable. He had a recurrence of VH on post-op day 10 with increased IOP. Gonioscopy showed open angles with increased pigmentation in the right eye. Left eye gonioscopy showed open angles. There was no concave iris configuration in either eye. He underwent a detailed systemic evaluation and hematological workup, which was normal. He was re-initiated on topical and systemic AGMs. Despite conservative management, IOP remained 30 mm Hg with persistence of VH. The patient had ciliary tenderness with symptoms that were out of proportion to signs. Considering his recurrent VH, increased IOP, and ciliary tenderness, a diagnosis of UGH syndrome was made. He underwent IOL explantation with vitreous lavage in the right eye in June 2020. Postoperative visual acuity was 6/18 with aphakic correction. The eye was quiet, symptoms relieved, and IOP controlled without medications till the last review, which was 6 months postoperatively. [Figure 1]b, [Figure 2]b, and [Figure 3]b

Figure 1: (a) Preoperative slit-lamp photograph showing corneal edema and diffuse hyphema with a scleral fixated intraocular lens in situ. (b) Postoperative picture with clear cornea, no hyphema, and aphakia

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Figure 2: (a) Preoperative fundus image with dispersed vitreous hemorrhage obscuring fundus view. (b) Postoperative fundus image with no vitreous hemorrhage and a normal fundus

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Figure 3: (a) Preoperative ultrasonography of right eye showing multiple low reflective dot echoes suggestive of dispersed vitreous hemorrhage in a previously vitrectomised eye. (b) Postoperative ultrasonography showing an anechoic vitreous cavity

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Discussion

We report a case of UGH syndrome that occurred a year after successful SFIOL implantation. The patient had nonresolving vitreous hemorrhage with increased IOP, which was transiently controlled by a vitreous lavage. Along with poor IOP control and persistent VH, the patient also had severe photophobia with ciliary tenderness. Increased angle pigmentation was suggestive of iris chaffing. Considering these clinical findings and the symptomatology, we decided to explant the SFIOL. Following the procedure, the patient was asymptomatic with controlled IOP. As there was no access to ultrasound biomicroscopy (UBM) at our institution, we were unable to image the haptic-iris position. We postulate that the patient had a floppy iris secondary to previous trauma with increased iris chaffing by the IOL or its haptics. Malpositioned haptics causing trauma or irritation of ciliary processes possibly resulted in VH and ciliary tenderness. Both these factors may have played a role in the occurrence of UGH syndrome in this patient.

Zhang et al.^[2] described the occurrence of UGH in two cases with anterior square edge IOLs placed in the bag. One case had lax iris due to pseudoexfoliation and another had plateau iris configuration. In a retrospective series of 112 eyes with sutureless SFIOL, Kansal et al.^[3] encountered UGH syndrome in 13 eyes (11.6%). Though they managed their cases medically, intervention was required in the form of IOL explantation in two eyes, ACIOL implantation in one eye, iris synechiolysis in one eye, and a laser iridotomy in five eyes. A floppy iris-lens diaphragm from causes such as trauma, high myopia, or previous retinal detachment surgery predisposed to UGH syndrome in this series. They suggested that a peripheral iridectomy can help by moving the iris away from the lens. Du et al.^[4] reported a case of UGH syndrome in a highly myopic eye with SFIOL. UBM demonstrated a malpositioned haptic causing forward push to iris root with resultant iris chaffing. The IOL was explanted with resolution of symptoms. UGH has also been reported with in-the-bag IOL placement due to the proximity of the edge of the IOL optic to an iridociliary body cyst near the inferior pupillary margin,^[5] and by a displaced haptic through a tear in the equatorial part of the bag.^[6]

Management for UGH syndrome is primarily medical with topical and systemic medication to reduce the IOP, control the anterior segment inflammation, and bring symptomatic relief.^[1] Cases with pseudophakodonesis can benefit by implanting a capsular tension ring to stretch the bag.^[2] Some cases require explantation of the IOL.^[3],[4] Cyclophotocoagulation of ciliary processes in the area of haptic fixation may also relieve symptoms by causing the shrinking of ciliary processes.^[2],[7] In a case of iris chaffing by IOL, laser iridoplasty to iris on sides of haptic led to resolution of symptoms.^[8]

Conclusion

To conclude, UGH syndrome can be a rare complication of sutureless scleral fixated IOL. A high index of suspicion in a patient presenting with increased IOP, VH, and inflammation can help in diagnosis. Where conservative management fails, IOL explantation may be needed for symptomatic relief.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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