Transcript Uveitic Glaucoma

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:
– Cataract extraction without implantation, 1983.
– Anterior chamber IOL implantation, 1987.
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

Slit Lamp Exam:
– 1+ injection.
– Diffuse microcysts and SPK.
– 1+ AC Reaction.
– Iris atrophy with exposed iris vessels near
ACIOL haptic foot.
Tonometry
 O.D.
- 52
 O.S.-
13
Uveitic Glaucoma

Unilateral, red eye.
 Pain and photosensitivity.
 Corneal edema.
 AC reaction.
 Increased IOP.
Inflammatory Cells

Decrease aqueous outflow
– Physically obstruct trabecular meshwork.
Synechiae
Inflammation, then Pressure

Topical steroid.

Beta-blocker

Alpha-agonist

CAI

Avoid Prostaglandins.
– Pred Forte q15min;
then taper.

Strong cycloplegia.
– Atropine 1% b.id.

Break synechiae.
– Phenylephrine 10%.
Assessment/Plan:

Lotemax q2h
 Atropine t.id.
 Cosopt b.id.
 Diamox 500mg, b.id.

Follow-up in 1 week.
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

Continue meds as scheduled.
– Add Alphagan t.id.

Run full uveitis work-up.

Follow-up next day.
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

Unilateral increase in IOP
 Steroid response
 PAS
 Endopthalmitis
 Chronic inflammation
 Retained lens material
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.
UVEITIS
GLAUCOMA
HYPHEMA
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 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
UGH with PCIOL’s

Unstable sulcus fixation
 PCIOL decentration
– zonular weakness
– trauma
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

UGH Development
– Usually weeks to months.
– Literature suggests 1-8 yrs.

This patient; 1987 to 2006 – 19 years.
Clinical Spectrum

Iris pigment epithelial defects
 Pigment dispersion
 Microhypema
 Macrohyphema I
 Increase in IOP
Presenting Symptoms

Intermittant blurring
 ‘Redness’ to vision
 Eye pain
 Red eye
 Photophobia
UGH Complications

Pseudophakic bullous keratopathy
 Corneal staining; recurrent hyphema
 Chronic inflammation
 Cystoid macular edema
 Glaucoma
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

Observe, treat episodes individually.
 Pharmacologically reposition IOL
 IOL rotation
 IOL explanation +/- replacement.
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)
 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

Time between implantation and explanation
with ACIOL complications:
– 1 to 8 years.
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

Surgery without incident
 VA- 20/400, PH 20/100
 Some corneal edema; 3+ AC reaction.
 GAT- 13.
 Continue with meds:
– Cosopt b.id.
– Alphagan P b.id.
– Diamox 500mg b.id.
- Tobradex ung q.id.
- Atropine b.id.
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

VA- 20/80
 Refracts to 20/30.
 Trace AC reaction.
 GAT- 13.

SLOW taper off all meds.
Review: Key Points

Be suspicious of misplaced IOL

ACIOL with Uveitis

Gonioscopy
THE END