J. M. Rouse, M. A. Khaimi Dean McGee Eye Institute, Oklahoma City, OK

1. Endoscopic Management of Displaced IOL Causing Recurrent Hyphema in Patient With Pseudoexfoliation J. M. Rouse, M. A. Khaimi Dean McGee Eye Institute, Oklahoma City, OK The authors have no financial interest in the subject matter of this e-poster.

2. Purpose • To investigate a surgical approach to evaluation and treatment of a patient with a dislocated intraocular lens haptic causing recurrent hyphema (UGH syndrome) using an intraocular endoscope.

3. Introduction • Uveitis-glaucoma-hyphema syndrome has long been a complication of intraocular lens placement since being first described in 19781 • The improvement in phacoemulsification and intraocular lens technology has decreased the episodes of this syndrome, but it is still an important diagnosis to consider in the setting of recurrent hyphema. • Clinical diagnosis of UGH syndrome can be difficult if there is no clear indicator of lens displacement. • Ultrasound biomicroscopy has been advocated as a diagnostic tool to identify displacement of intraocular lens2; however, this may not always be available or definitive in a patient with intraocular heme.

4. Case Report • A 73 year old male with history of pseudoexfoliative glaucoma was referred for 2nd opinion of recurrent, spontaneous hyphemas in his right eye. He had previously undergone phacoemulsification with posterior chamber intraocular lens implantation and trabeculectomy in the eye four years prior to presentation. His follow-up care was uneventful until 2 months prior to presentation when he began developing waxing and waning vision in the right eye secondary to recurrent hyphema. • On physical examination, VA was 20/HM OD and 20/20 OS.

5. Case Report • Intraocular pressure was measured as 28 mmHg OD and 11 mmHg OS. • Slit lamp exam of the right eye revealed post-trabeculectomy changes of the superonasal conjunctiva, posterior chamber IOL with dispersed red blood cells throughout the anterior chamber and a layered hyphema. There was slight iridodenesis noted on exam, but no clear phacodenesis. • Gonioscopy revealed heme within the bleb of the right eye, but no neovascularization or other source of heme. • There was no clear view to the posterior pole on dilated fundus examination. • B-scan ultrasound of the right eye was normal and revealed no significant vitreous hemorrage or retinal detachment.

6. Case Report • Ultrasound biomicroscopy of the right eye did not show any clear displacement of the intraocular lens or other etiology for anterior chamber hyphema.

7. Treatment • Due to an unclear source of recurrent hyphemas and increased intraocular pressure, the decision was made to proceed with surgical exploration using the endoscope handpiece used for endoscopic cyclophotocoagulation and trabeculectomy with Ex-press shunt. • With the use of the endoscope, the inferior haptic of the intraocular lens was noted to be phimosed anterior to the anterior capsule. The end of the haptic was abutted against the ciliary body and posterior iris with a small amount of clotted heme posterior to it.

8. Treatment • With direct visualization provided by the endoscope, retinal microscissors were used to amputate the haptic from the rest of the lens at the optic-haptic junction. Retinal forceps were then used to remove the haptic from the eye. The remaining remnant of the lens settled into the capsular bag. The trabeculectomy portion of the surgery was completed without incident. The lens was centered at the end of the case and remaining heme was washed from the anterior chamber.

9. Results • Post-operatively, VA was 20/40 OD and IOP was 11 mmHg OD. • Slit lamp examination over the first month of follow-up revealed no new anterior chamber heme; however, the intraocular lens did displace inferiorly within the posterior chamber. There was no visual disturbance from this displacement, but the decision was made to remove the posterior chamber lens and place an anterior chamber lens in the eye. • This procedure was completed without incident and there has been no new sequelae of heme or visual trouble in the eye.

10. Discussion • Visualization is often a limiting factor in ophthalmology diagnosis and treatment. Improving endoscopic technology has allowed visualization that was once not possible. • In settings where clinical diagnosis is uncertain, surgical exploration with endoscope allows for a controlled setting for further diagnostic possibility. • In this case report, endoscopic visualization also allowed for safe, controlled removal of the IOL haptic. This surgical maneuver would have been more difficult and precarious in this patient with pseudoexfoliation.

11. Conclusions • The use of an endoscope in this case allowed for identification and safe, controlled treatment of a dislocated intraocular lens in a patient with unstable zonular integrity. The endoscope should be considered in cases where visualization may improve diagnostic and treatment options.

12. References • Ellingson FT. The uveitis-glaucoma-hyphema syndrome associated with the Mark VIII anterior chamber lens implant. J Am Intraocul Implant Soc 1978; 4:50-53 • Piette S et al. Ultrasound biomicroscopy in uveitis-glaucoma-hyphema syndrome. Am J Ophthalmol. 2002 Jun;133(6):839-41.