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Grand Rounds. Joseph Reck VAMC Wilkes-Barre, PA November 3, 2006. 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:

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grand rounds

Grand Rounds

Joseph Reck

VAMC Wilkes-Barre, PA

November 3, 2006

clinical presentation
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.
acuity and externals
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.
clinical findings
Clinical Findings
  • Slit Lamp Exam:
    • 1+ injection.
    • Diffuse microcysts and SPK.
    • 1+ AC Reaction.
    • Iris atrophy with exposed iris vessels near ACIOL haptic foot.
uveitic glaucoma
Uveitic Glaucoma
  • Unilateral, red eye.
  • Pain and photosensitivity.
  • Corneal edema.
  • AC reaction.
  • Increased IOP.
inflammatory cells
Inflammatory Cells
  • Decrease aqueous outflow
    • Physically obstruct trabecular meshwork.
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.

Inflammation, then Pressure
assessment plan
Assessment/Plan:
  • Lotemax q2h
  • Atropine t.id.
  • Cosopt b.id.
  • Diamox 500mg, b.id.
  • Follow-up in 1 week.
one week follow up
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
updated treatment plan
Updated Treatment Plan
  • Continue meds as scheduled.
    • Add Alphagan t.id.
  • Run full uveitis work-up.
  • Follow-up next day.
return visit
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.
differential
Differential
  • Unilateral increase in IOP
    • Steroid response
    • PAS
    • Endopthalmitis
    • Chronic inflammation
    • Retained lens material
gonioscopy
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.
slide17
UVEITIS
  • GLAUCOMA
  • HYPHEMA
ugh syndrome
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.
ugh syndrome1
UGH Syndrome
  • Excessive lens movement
    • Small size
    • Decentration or dislocation
  • Poorly manufactured edges
  • Iris-clipped IOL
  • Rigid, closed loop haptics
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

Open v. Closed Loop
ugh with pciol s
UGH with PCIOL’s
  • Unstable sulcus fixation
  • PCIOL decentration
    • zonular weakness
    • trauma
ugh etiology uveitis
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
post operative timing
Post-Operative Timing
  • UGH Development
    • Usually weeks to months.
    • Literature suggests 1-8 yrs.
  • This patient; 1987 to 2006 – 19 years.
clinical spectrum
Clinical Spectrum
  • Iris pigment epithelial defects
  • Pigment dispersion
  • Microhypema
  • Macrohyphema I
  • Increase in IOP
presenting symptoms
Presenting Symptoms
  • Intermittant blurring
  • ‘Redness’ to vision
  • Eye pain
  • Red eye
  • Photophobia
ugh complications
UGH Complications
  • Pseudophakic bullous keratopathy
  • Corneal staining; recurrent hyphema
  • Chronic inflammation
  • Cystoid macular edema
  • Glaucoma
ugh management
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.
ugh treatment options
UGH Treatment Options
  • Observe, treat episodes individually.
  • Pharmacologically reposition IOL
  • IOL rotation
  • IOL explanation +/- replacement.
patient returns
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.
study indications for iol explanation fl
STUDY:Indications 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%.
surgical timing with aciol
Surgical Timing with ACIOL
  • Time between implantation and explanation with ACIOL complications:
    • 1 to 8 years.
surgical outcome
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.
1 day post operative
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.
follow ups
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.
3 week follow up
3 Week Follow-Up
  • VA- 20/80
  • Refracts to 20/30.
  • Trace AC reaction.
  • GAT- 13.
  • SLOW taper off all meds.
review key points
Review: Key Points
  • Be suspicious of misplaced IOL
  • ACIOL with Uveitis
  • Gonioscopy