UGH rare, but potentially devastating complication

New Orleans-Patients who have uveitis-glaucoma-hyphema (UGH) syndrome caused by the complications after implantation of an anterior chamber IOL fared worse with final visual outcomes than patients who also develop UGH but have other lenses implanted, said Albert Cheung, MD.

Speaking at ASCRS 2016, Dr. Cheung said UGH is a complication of intraocular chafing from IOL implants that can lead to a host of defects characterized by chronic inflammation, cystoid macular edema, secondary iris neovascularization, recurrent hyphema, and glaucomatous optic neuropathy.

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This mechanical iris trauma can develop immediately after cataract surgery or can develop over the course of years. Reports in the literature note UGH was first discovered as a result of excessive lens movement, and poorly manufactured lens edges may have been an initial primary cause, as might iris-clipped IOLs or rigid closed-loop haptics.

This complication was first reported in anterior chamber IOLs, but has also been reported in one-piece and three-piece posterior chamberIOLs, iris-supported IOLs, and in-the-bag dislocated IOLs.

Surgery is commonly the only treatment to repair the damage done. Although a severe complication of cataract surgery, it is also fairly rare. But that also means it is often difficult to diagnose.

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In this 10-year (2005-2015) retrospective chart review, Dr. Cheung analyzed 249 patients who had been referred for evaluation for IOL reposition or exchange. Of those initial 249 patients, 56 eyes (53 patients) were determined to have UGH at presentation. All eyes underwent repositioning or exchange by a single surgeon.

Eyes were then sorted into groups based on IOL type and IOL position. Outcomes of one-piece, three-piece, and anterior chamber IOLs were then compared for initial/final visual acuity, time from initial cataract surgery to diagnosis of UGH, number of physicians seen prior to the UGH diagnosis, and development of glaucoma, uveitis/cystoid macular edema, transillumination defects (TIDs), and hyphema/vitreous hemorrhage.

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“In these cases, we were defining UGH to include evidence of a malpositioned optic or haptic either on examination or by ultrasound biomicroscopy,” Dr. Cheung said.

Study findings

Study findings

There were 29 eyes with a one-piece IOL, 17 eyes with a three-piece IOL, and 10 eyes with an anterior chamber IOL, Dr. Cheung said.

“If you look at uveitis and CME, there was no significant difference among the groups,” Dr. Cheung said. “Only when we considered CME alone was there a difference.

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There was a significant association (p < 0.0001) between IOL group and CME as well as presence of TIDs (p = 0.0091), but not for the other outcome measures. Eyes with anterior chamber lenses were much more likely to develop glaucoma or macular edema than the other groups. That group also had the longest time to diagnosis and saw the greatest number of ophthalmologists before a confirmed diagnosis.

Conversely, eyes with one-piece IOLs were diagnosed with UGH earlier than any other group, and eyes with either one- or three-piece IOLs had similar initial and final visual acuities as well as similar rates of development of glaucoma and uveitis/macular edema.

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There was a considerable delay for all groups from the time of cataract surgery until diagnosis, despite being evaluated by several surgeons, Dr. Cheung said, with the anterior chamber group having a mean of 1,970 before diagnosis compared with 753 days for the one- and three-piece groups.

“When we evaluated the different components, we found more than 10% of the eyes had none of the classic signs of UGH, just TIDs,” he said.

Conversely, fewer than 10% had all three classic signs of UGH.

The one- and three-piece IOLs had higher rates of TIDs than the anterior chamber lenses, he said, but those groups also fared better visually after repositioning or exchange.

“It’s important that ophthalmologists recognize the signs of UGH earlier to decrease morbidity from this complication,” he said. “We also believe UGH may be a misnomer, and propose the term ‘pseudophakic iris trauma syndrome.’ ”

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Dr. Cheung reported no financial complications.