Uveitis–Glaucoma–Hyphema Syndrome After Uneventful Placement Of A 1-Piece Intraocular Lens Into The Capsular Bag

Uveitis-glaucoma-hyphema (UGH) syndrome is an uncommon but serious complication of cataract surgery, occurring as a result of chafing of the iris by an intraocular lens (IOL). Mechanical disruption of iris tissue leads to pigment dispersion, microhyphema, and release of debris into the anterior chamber, thus increasing intraocular pressure. Initially described as a complication of first-generation IOLs placed in the ciliary sulcus, UGH can also occur with modern IOLs in the sulcus or those in a bag-sulcus tilted position. UGH syndrome with placement of a 1-piece IOL in-the-bag, however, remains exceedingly rare. The purpose of this study is to describe such a case, with UGH syndrome after in-the-bag placement of a modern 1-piece IOL.

This case study was conducted in an academic health sciences centre with requisite human research ethics supervision. Appropriate consent and approval for publication of the case were obtained from the patient and all data were anonymized. 

A 55-year-old man underwent routine cataract surgery on his right eye. Preoperative biometry was unremarkable with an axial length of 24.86mm, anterior chamber depth of 3.83mm, and white-to-white distance of 12.00mm. Intraoperative floppy iris syndrome was encountered, consistent with a history of tamsulosin use, but this was managed without complication. A 1-piece hydrophobic SA60AT 17.5-diopter (D) acrylic IOL was placed in the capsular bag; at the end of the surgery, placement of the IOL with a 360-degree capsular coverage of the optic and haptics was confirmed. Same-day and 1-week postoperative examinations were normal. At the 2-week postoperative visit, slit lamp examination revealed iris transillumination in the shape of IOL haptics and marked iritis, suggestive of UGH. Although the IOL appeared well-centered within the capsular bag, inadequate pupil dilation precluded definitive confirmation. The patient was scheduled for surgery and taken to the operating room the following week. Preoperative ultrasound biomicroscopy (UBM) was not suggestive of a sulcus-placed IOL and we proceeded with surgical exploration. Intraoperatively, the IOL was indeed confirmed in-the-bag with complete capsulorhexis overlap over the optic and both haptics in an intact capsular bag. Given the clinical course, the IOL was exchanged for an MA60AC 17.5 D 3-piece in-the-bag IOL, and wounds were sealed. The postoperative period was unremarkable and sequelae of UGH resolved.

In our case, we postulate that weakened zonular fibers, secondary to a history of head trauma, allowed the otherwise well-positioned IOL to become mobile and chafe the posterior iris intermittently, causing UGH. It is also likely that a component of reverse pupillary block contributed to development of UGH, as intraoperative floppy iris syndrome was encountered, and this can be a predisposing factor. Management of UGH with 1-piece lenses in-the-bag should be focused on addressing the underlying mechanism. As 3-piece IOLs provide improved stability and are vaulted away from the iris, minimizing the potential for chafing, IOL exchange can offer definitive treatment, as observed in our case.