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• W2799688917 abstract "Uveitis-glaucoma-hyphema (UGH) syndrome was first named in 1978 by Ellingson.1Ellingson F.T. The uveitis-glaucoma-hyphema syndrome associated with the Mark VIII anterior chamber lens implant.J Am Intraocul Implant Soc. 1978; 4: 50-53Abstract Full Text PDF PubMed Scopus (99) Google Scholar This entity is caused by mechanical chafing of uveal tissue from intraocular lenses (IOL) and implants. Although first described with anterior chamber (AC) IOLs, this condition has been seen with posterior chamber IOLs (both 1-piece and 3-piece),2Percival S.P. Das S.K. UGH syndrome after posterior chamber lens implantation.J Am Intraocul Implant Soc. 1983; 9: 200-201Abstract Full Text PDF PubMed Scopus (31) Google Scholar, 3Uy H.S. Chan P.S. Pigment release and secondary glaucoma after implantation of single-piece acrylic intraocular lenses in the ciliary sulcus.Am J Ophthalmol. 2006; 142: 330-332Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar iris-supported IOLs,4Sinskey R.M. Amin P. Stoppel J.O. Indications for and results of a large series of intraocular lens exchanges.J Cataract Refract Surg. 1993; 19: 68-71Abstract Full Text PDF PubMed Scopus (35) Google Scholar cosmetic iris implants,5Arthur S.N. Wright M.M. Kramarevsky N. Kaufman S.C. Grajewski A.L. Uveitis-glaucoma-hyphema syndrome and corneal decompensation in association with cosmetic iris implants.Am J Ophthalmol. 2009; 148: 790-793Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar and in-the-bag dislocated IOLs.6Zhang L. Hood C.T. Vrabec J.P. Cullen A.L. Parrish E.A. Moroi S.E. Mechanisms for in-the-bag uveitis-glaucoma-hyphema syndrome.J Cataract Refract Surg. 2014; 40: 490-492Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 7Foroozan R. Tabas J.G. Moster M.L. Recurrent microhyphema despite intracapsular fixation of a posterior chamber intraocular lens.J Cataract Refract Surg. 2003; 29: 1632-1635Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 8Boutboul S. Letaief I. Lalloum F. Puech M. Borderie V. Laroche L. Pigmentary glaucoma secondary to in-the-bag intraocular lens implantation.J Cataract Refract Surg. 2008; 34: 1595-1597Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar We describe a unique case of UGH syndrome associated with a Cionni endocapsular tension ring (CTR). A 37-year-old male with a history of trauma OS from a hockey puck requiring a pars plana vitrectomy (for vitreous hemorrhage) 14 months prior was referred for decreased vision. He also had a history of bilateral LASIK 8 years prior. On examination, the pupil OD was 3 mm and reactive while the pupil OS was fixed and dilated at 9 mm. The best-corrected visual acuity (BCVA) was 20/20 OD (plano) and 20/200 OS (−1.00 sphere). Intraocular pressure (IOP) was 14 OD and 19 OS. Anterior segment examination revealed intact LASIK flaps bilaterally, traumatic mydriasis OS, 1 clock-hour iridodialysis temporally OS (from 3:00 to 4:00), and 5–6 clock-hour zonular dialysis temporally (from 12:00 to 5:30) with phacodonesis OS. There was +1 nuclear sclerotic cataract accompanied by dense anterior cortical spoking and posterior subcapsular cataract. Posterior examination was unremarkable OS with a 0.4 cup-to-disc ratio. Two months later, the patient underwent cataract extraction with a scleral-fixated sutured Cionni CTR (type 2C; FCI Ophthalmics Inc, Pembroke, MA) and implantation of a single-piece acrylic IOL (AcrySof IQ SN60WF; Alcon,Fort Worth, TX). The Cionni CTR was inserted with an injector and fixated with 9-0 Prolene (double-armed with CTC-6L needles) to the scleral wall in the centre of the zonular dialysis, 2 mm posterior to the limbus. The surgery and postoperative course were unremarkable, with BCVA 20/30−1 (+0.25 +1.75 × 040) 1 month after surgery; however, the patient reported severe glare due to the traumatic mydriasis. After failing a trial of an opaque contact lens, he underwent suture repair of the iridodialysis and pupillary cerclage for mydriasis with 10-0 Prolene sutures. The pupil was fixed at 4 mm. No iris transillumination defects (TIDs) were noted at that time. The patient did well until 3 years later when his IOP was elevated to 30 mm Hg OS. Topical latanoprost 0.005% controlled his IOP for 2 years, when it was switched to bimatoprost 0.03% for an IOP 24 mm Hg. Over this period, Humphrey visual fields, optical coherence tomography, and optic nerve evaluation remained unremarkable. Six years after cataract extraction, the in-the-bag IOL and Cionni CTR were dislocated nasally, and the fixation suture for the Cionni ring was broken. Visual field testing revealed an early inferior arcuate visual field defect. Two years later, the patient experienced an episode of iritis and elevated IOP, which responded well to topical prednisolone acetate 1% and brimonidine tartrate/timolol maleate (0.2%/0.5%). BCVA was 20/80, and iris TIDs were noted, directly overlying the fixation element of the dislocated Cionni CTR (Fig. 1). There were no significant TIDs elsewhere (Fig. 2). As contact between the Cionni CTR and iris could be observed by slit lamp, no further imaging (i.e., ultrasound biomicroscopy) was pursued. UGH syndrome was diagnosed, and the patient underwent IOL repositioning and scleral fixation. During the case, an endocyclophotocoagulation probe directly visualized the broken suture and the iris, confirming its contact with the subluxed Cionni segment. A 9-0 Prolene suture, double armed with CTC-6L needles, re-fixated the Cionni CTR to the scleral wall (at 3:00) and BCVA improved to 20/30 with normal IOP 3 months postoperatively. The patient was tapered off corticosteroids but continued the bimatoprost and brimonidine tartrate/timolol maleate given the prior visual field changes.Fig. 2Slit-lamp photograph with retroillumination demonstrating marked iris trans-illumination defects (TIDs) localized over the Cionni endocapsular tension ring fixation element without significant TIDs elsewhere.View Large Image Figure ViewerDownload Hi-res image Download (PPT) UGH syndrome was originally described as a late complication of intraocular chafing from AC IOLs.1Ellingson F.T. The uveitis-glaucoma-hyphema syndrome associated with the Mark VIII anterior chamber lens implant.J Am Intraocul Implant Soc. 1978; 4: 50-53Abstract Full Text PDF PubMed Scopus (99) Google Scholar While more commonly associated when an IOL or haptic is malpositioned outside of the capsular bag, there have been reports of UGH syndrome from iris trauma associated with an IOL that is still in-the-bag. Prior reports have been seen in the setting of pseudoexfoliation syndrome with stretched zonules allowing anterior dislocation toward the iris,6Zhang L. Hood C.T. Vrabec J.P. Cullen A.L. Parrish E.A. Moroi S.E. Mechanisms for in-the-bag uveitis-glaucoma-hyphema syndrome.J Cataract Refract Surg. 2014; 40: 490-492Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar plateau iris configuration with anteriorly positioned ciliary processes,6Zhang L. Hood C.T. Vrabec J.P. Cullen A.L. Parrish E.A. Moroi S.E. Mechanisms for in-the-bag uveitis-glaucoma-hyphema syndrome.J Cataract Refract Surg. 2014; 40: 490-492Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar iridociliary cyst causing displacement of the IOL optic,7Foroozan R. Tabas J.G. Moster M.L. Recurrent microhyphema despite intracapsular fixation of a posterior chamber intraocular lens.J Cataract Refract Surg. 2003; 29: 1632-1635Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar and anterior bowing of the haptic related to IOL deformation during loading.8Boutboul S. Letaief I. Lalloum F. Puech M. Borderie V. Laroche L. Pigmentary glaucoma secondary to in-the-bag intraocular lens implantation.J Cataract Refract Surg. 2008; 34: 1595-1597Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar In all these cases, the iris and IOL–capsule complex were brought into closer contact than would normally occur. We present a unique case where a single-piece acrylic IOL was placed in-the-bag with a Cionni CTR after a traumatic cataract that was accompanied by extensive zonular dehiscence (~6 clock-hours). The patient also had a complete traumatic mydriasis that was repaired with a pupillary cerclage suture. The patient did well for over half a decade until the combination of zonular weakness and a broken scleral-fixation suture holding the Cionni ring allowed the in-the-bag IOL–Cionni CTR complex to dislocate anteriorly. This permitted repeated iris trauma from the anteriorly displaced Cionni ring fixation eyelet, causing the formation of iris TIDs, which led to both glaucoma and subsequent iritis. A unique feature of this case is the complete traumatic mydriasis. Because the iris was atonic, only movement of the dislocated in-the-bag IOL–Cionni CTR complex was responsible for the iris TIDs, which were localized over the Cionni CTR fixation element. 9-0 Prolene (recommended suture by the CTR manufacturer) was used for the repair as there have been reports of late suture breakage with 10-0 Prolene.9FCI Ophthalmics. Cionni CTR product information, 〈fci-ophthalmics.com/products/cionni-ctr〉; 2018 [accessed 10 February 2018].Google Scholar, 10Price M.O. Price Jr, F.W. Werner L. Berlie C. Mamalis N. Late dislocation of scleral-sutured posterior chamber intraocular lenses.J Cataract Refract Surg. 2005; 31: 1320-1326Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar, 11Vote B.J. Tranos P. Bunce C. Charteris D.G. Da Cruz L. Long-term outcome of combined pars plana vitrectomy and scleral fixated sutured posterior chamber intraocular lens implantation.Am J Ophthalmol. 2006; 141: 308-312Abstract Full Text Full Text PDF PubMed Scopus (232) Google Scholar Some surgeons have advocated for the use of Gore-Tex CV-8 suture, although this is currently off-label for use in ocular surgery by the U.S. Food and Drug Administration. Although rare, UGH syndrome is an important diagnosis to bear in mind. The ophthalmologist needs to actively assess for signs of UGH, especially the development of iris TIDs overlying any portion of an implanted device, to make a timely diagnosis. Although not used in this case, ultrasound biomicroscopy is a noninvasive way to diagnose iris–IOL touch preoperatively.6Zhang L. Hood C.T. Vrabec J.P. Cullen A.L. Parrish E.A. Moroi S.E. Mechanisms for in-the-bag uveitis-glaucoma-hyphema syndrome.J Cataract Refract Surg. 2014; 40: 490-492Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar Early diagnosis will help to decrease morbidity from this potentially sight-threatening complication of intraocular surgery. The authors have no proprietary or commercial interest in any materials discussed in this article. A.Y.C. has received a grant from the Eye Bank Association of America." @default.
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• W2799688917 title "Uveitis-glaucoma-hyphema syndrome caused by dislocated Cionni endocapsular tension ring" @default.
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