Grand Rounds

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Grand Rounds

• Joseph Reck
• VAMC Wilkes-Barre, PA
• November 3, 2006

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Clinical Presentation

• Seen in Texas six weeks ago GAT- 54
• Current Medications
• Diamox 500mg b.id. ran out 5d ago
• Cosopt b.id.
• Atropine b.id.
• Brimonidine b. id.
• Ocular history
• Cataract extraction without implantation, 1983.
• Anterior chamber IOL implantation, 1987.

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Acuity and Externals

• VA cc O.D. 20/60, PH 20/40
• O.S. 20/20
• Pupils O.D. pharm fixed O.S. RRL APD
• EOM Full and smooth, O.U.
• Confrontation fields Full, O.U.

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Clinical Findings

• Slit Lamp Exam
• 1 injection.
• Diffuse microcysts and SPK.
• 1 AC Reaction.
• Iris atrophy with exposed iris vessels near ACIOL
  haptic foot.

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Tonometry

• O.D. - 52

• O.S.- 13

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Uveitic Glaucoma

• Unilateral, red eye.
• Pain and photosensitivity.
• Corneal edema.
• AC reaction.
• Increased IOP.

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Inflammatory Cells

• Decrease aqueous outflow
• Physically obstruct trabecular meshwork.

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Synechiae
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Inflammation, then Pressure

• Topical steroid.
• Pred Forte q15min then taper.
• Strong cycloplegia.
• Atropine 1 b.id.
• Break synechiae.
• Phenylephrine 10.

• Beta-blocker
• Alpha-agonist
• CAI
• Avoid Prostaglandins.

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Assessment/Plan

• Lotemax q2h
• Atropine t.id.
• Cosopt b.id.
• Diamox 500mg, b.id.
• Follow-up in 1 week.

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One Week Follow-Up

• VA cc O.D. 20/100, PH 20/40
• O.S. 20/20
• GAT O.D. 52, O.S. 12
• 1 AC Reaction

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Updated Treatment Plan

• Continue meds as scheduled.
• Add Alphagan t.id.
• Run full uveitis work-up.
• Follow-up next day.

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Return Visit

• Patient experiencing some pain.
• VA cc O.D. 20/80, ph 20/30
• O.S. 20/20
• GAT O.D. 55, O.S. 11.
• 1 AC reaction.

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Differential

• Unilateral increase in IOP
• Steroid response
• PAS
• Endopthalmitis
• Chronic inflammation
• Retained lens material

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Gonioscopy

• Lens position in iris not angle
• Small areas of synechiae.
• Small areas of bleeding.
• Peripheral rubeosis, superiorly.
• Dilated iris tissue rolled into angle.
• ACIOL haptics appear to have pushed peripheral
  iris directly into angle
• Discontinue Atropine.

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• UVEITIS
• GLAUCOMA
• HYPHEMA

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UGH Syndrome

• Inflammation after anterior chamber IOL
  implantation, caused by the haptics of the IOL.
• Misplaced or misdirected haptics from the
  anterior chamber IOL erode the tissues of the
  angle, causing bleeding and inflammation.

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UGH Syndrome

• Excessive lens movement
• Small size
• Decentration or dislocation
• Poorly manufactured edges
• Iris-clipped IOL
• Rigid, closed loop haptics

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Open v. Closed Loop

• Open Loop IOL
• -good finish/polish
• -easy to size
• -less area of contact

• Closed Loop IOL
• -difficult to fit
• -erosion chaffing
• -large contact zone
• -poorly finished/ sharp edges

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UGH with PCIOLs

• Unstable sulcus fixation
• PCIOL decentration
• zonular weakness
• trauma

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UGH Etiology Uveitis

• Activation of innate immunity.
• Theories
• Cytokine and eicosanoid synthesis triggered by
  mechanical excoriation of the angle or iris by
  the haptics or optic
• Plasma-derived enzymes (especially complement or
  fibrin) activated by the surface of the IOLs
• Adherence of bacteria and leukocytes to the IOL
  surface
• Toxicity caused by contaminants on the IOL
  surface during manufacturing or implantation

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Post-Operative Timing

• UGH Development
• Usually weeks to months.
• Literature suggests 1-8 yrs.
• This patient 1987 to 2006 19 years.

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Clinical Spectrum

• Iris pigment epithelial defects
• Pigment dispersion
• Microhypema
• Macrohyphema I
• Increase in IOP

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Presenting Symptoms

• Intermittant blurring
• Redness to vision
• Eye pain
• Red eye
• Photophobia

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UGH Complications

• Pseudophakic bullous keratopathy
• Corneal staining recurrent hyphema
• Chronic inflammation
• Cystoid macular edema
• Glaucoma

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UGH Management

• Bed rest with elevated head position to encourage
  hyphema settling
• Topical steroid
• Reduce increased IOP
• Ultimately, the lens may have to be repositioned
  or removed.

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UGH Treatment Options

• Observe, treat episodes individually.
• Pharmacologically reposition IOL
• IOL rotation
• IOL explanation /- replacement.

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Patient Returns

• VA cc O.D. 20/50, ph 20/30
• O.S. 20/20
• GAT 22, O.D. 13 O.S.
• 2 AC reaction.
• Patient scheduled for IOL removal.

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STUDYIndications for IOL Explanation (FL)

• The majority of the removed IOLs were anterior
  chamber styles (53.9), followed by iris-fixated
  lenses (33.7)
• The most common indications for surgery included
• Pseudophakic bullous keratopathy, 69
• UGH syndrome, 9
• IOL instability, 7.

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Surgical Timing with ACIOL

• Time between implantation and explanation with
  ACIOL complications
• 1 to 8 years.

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Surgical Outcome

• The poorest visual outcome was seen in patients
  with the UGH syndrome.
• 83 had a final acuity of 20/200 or worse.
• Resolution of pain and inflammation
• Better control of their IOP as a result of the
  surgery.

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1- Day Post-Operative

• Surgery without incident
• VA- 20/400, PH 20/100
• Some corneal edema 3 AC reaction.
• GAT- 13.
• Continue with meds
• Cosopt b.id. - Tobradex ung q.id.
• Alphagan P b.id. - Atropine b.id.
• Diamox 500mg b.id.

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Follow-Ups

• Seen on Day 2, 4, then 1 week, 2 week.
• VA improves to 20/100 with pinhole and 15D lens.
• Cornea improves AC reaction diminishes to grade
  1.
• IOP in mid to low teens.
• Continuing all meds.

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3 Week Follow-Up

• VA- 20/80
• Refracts to 20/30.
• Trace AC reaction.
• GAT- 13.
• SLOW taper off all meds.

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Review Key Points

• Be suspicious of misplaced IOL
• ACIOL with Uveitis
• Gonioscopy

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• THE END