Eyeworld

EW GLAUCOMA 42 by Faith A. Hayden EyeWorld Staff Writer Could it be the IOL? Recognizing and treating patients with UGH syndrome "Something just doesn't feel right." T hat's the common com- plaint from post-op cataract patients presenting in an ophthalmologist's office with an achy eye. With symptoms this vague, it's no wonder these patients can be mismanaged for years. Often it's not until the pa- tient is referred to a specialist that the disorder, uveitis-glaucoma-hy- phema (UGH) syndrome caused by a misplaced IOL, is identified. Patients can be asymptomatic early on, causing both the physician and the patient to be oblivious to a problem. Furthermore, the IOL may look totally normal and perfectly centered upon initial examination, so unless the doctor is specifically looking for this condition, the possi- bility of a misplaced IOL might not cross the doctor's mind. "This condition is often over- looked," said Louis B. Cantor, M.D., Jay C. & Lucile L. Kahn Professor of Glaucoma Research & Education, Indiana University School of Medi- cine, Indianapolis. "Because the lens implant is behind the iris and you only see what's right through the pupil, you might not recognize that one of the haptics of the lens is out of position and rubbing on the iris." Misplaced IOLs can wreak havoc in the eye, causing uveitis, second- ary glaucoma, pigment dispersion, an acute rise in intraocular pressure, and even intermittent bleeding in severe cases. "Often by the time I see them, these patients are several months or years out from having had their cataract surgery," said Garry P. Condon, M.D., chairman, Depart- ment of Ophthalmology, Allegheny General Hospital, Pittsburgh. "I've seen patients with a hole in their iris from the lens chafing all the way through over a period of years." But aptly named UGH syn- drome doesn't have to get to this point. Drs. Condon and Cantor agree the key to mitigating damage is catching the condition early. "Unfortunately, if it goes on for a long time and hasn't been recog- nized or fixed, it may cause perma- nent damage to the trabecular mesh- work," said Dr. Cantor. "Then, even if you reposition the lens and fix the problem, the outflow pathway is damaged and the glaucoma will be permanent. If you do recognize it early and fix the lens-related prob- lem, things will settle down." One clue doctors can look for in suspected cases is iris transillumina- tion. Sometimes the lens has chaffed the iris so much that you'll see an area of iris pigment loss in the exact shape of the problem haptic. An- other smoking gun is little bits of pigment floating around in the ante- rior chamber of the eye and deposit- ing in unlikely places. "It's important to dilate the pupil widely and confirm that the lens implant is where you want it and that both haptics are positioned in the capsular bag if that was the intent," said Dr. Cantor. If the patient does have UGH syndrome, Dr. Condon recom- mended physicians do a lens ex- change immediately. Although other treatment options such as ocular hy- potensive and anti-inflammatory medications exist, Dr. Condon pointed out that without a complete lens exchange, UGH patients rarely improve, only getting worse as time goes on. "Over the last several years, we've developed a better under- standing of the natural course of this condition if we leave it alone," said Dr. Condon. "Anyone who is symp- tomatic, anyone who has a condi- tion like chronic inflammation or chronic glaucoma secondary to a malpositioned lens, there is no ques- tion in my mind that these lenses should be exchanged. Too many of these patients are inadequately treated for too long for a condition that is never going to get better." Delaying surgery can result in progressive glaucomatous disc dam- age and permanent glaucoma. Al- though replacing the IOL won't cure the glaucoma that's developed, it can help control it. "The patient may still need drops, and in some cases I've ex- changed the lens and the patient has gone on to need glaucoma sur- gery. The damage is already done," said Dr. Condon. "Some physicians will say, 'Why are you still talking about this? We know this lens can cause problems.' The reason I talk about this is because I still see pa- tients where the underlying condi- tion isn't recognized. I think it's important to keep this on your radar." February 2011 July 2011 If a single-piece IOL is not placed fully within the capsular bag, it may cause UGH syndrome. The diagnosis is straightforward if you know about this syndrome, but it may be elusive if you don't. Garry Condon, M.D., and Lou Cantor, M.D., are glaucoma specialists with impressive expertise in cataract surgery and IOL complications. We are fortunate this month to have their in- sights on the UGH syndrome caused by a misplaced IOL. Within the last month I have seen two patients with single- piece IOLs who had been under treat- ment for months for intractable uveitis and glaucoma. On exam, both patients had one haptic and part of the optic in the sulcus rather than in the bag. The chafing on the iris was causing chronic pigment dispersion but the misplaced IOL had not been recognized. Amputat- ing the haptic in each case relieved the pigment dispersion and the pressure re- turned to normal. Hopefully, this article will increase awareness and help with prompt diagnosis and treatment. Reay Brown, M.D., glaucoma editor Glaucoma editor's corner of the world Extensive iris transillumination due to iris chafing by a single-piece acrylic IOL placed partially in the sulcus several years earlier Source: Garry Condon, M.D. continued on page 43

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