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Current Concepts of the Uveitis-Glaucoma-Hyphema (UGH) Syndrome

Ramakrishnan, Meera S; Wald, Kenneth J
PURPOSE/UNASSIGNED:To discuss the pathophysiology, etiology, and current management strategies of uveitis-glaucoma-hyphema (UGH) syndrome. METHODS/UNASSIGNED:Literature review. RESULTS/UNASSIGNED:The classic UGH syndrome associated with anterior chamber intraocular lenses (ACIOL) have decreased in incidence with the modernization of IOL design and surgical techniques. The current UGH syndrome is increasing in prevalence largely related to a parallel increase in late onset dislocations of intraocular lenses (IOLs) and the developing techniques to remedy that condition. The modern features of UGH can present as cystoid macular edema, intraocular pressure elevation typically not attributed to UGH, and recurrent vitreous hemorrhage, unlike the original description as described by Ellingson in 1978. Medical management to control inflammation, reduce intraocular pressure, and reduced the bleeding diathesis are mainstays of therapy. However, surgery with IOL repositioning or exchange should be reserved for cases that are refractory to or progressing despite medical treatment. CONCLUSIONS/UNASSIGNED:UGH syndrome is an increasingly common, poorly understood, and often subtle, manifestation of an anatomic disturbance post intraocular surgery that persists with continued evolution of intraocular surgical techniques and new imaging modalities to aid in its diagnosis.
PMID: 36476057
ISSN: 1460-2202
CID: 5378702

Presumed retinal pericapillary astrocytic hamartoma: multimodal imaging findings of a novel hamartomatous lesion

Ledesma-Gil, Gerardo; Essilfie, Juliet; Onishi, Alex; Wald, Kenneth J; Fisher, Yale L; Fawzi, Amani A; Shields, Carol L; Freund, K Bailey; Chhablani, Jay
PURPOSE/OBJECTIVE:To describe the multimodal imaging findings of retinal lesions that clinically resemble retinal astrocytic hamartomas (RAHs), but also have unique characteristics that we believe represent a novel variant. METHODS:Observational study. Five eyes in five patients with solitary retinal lesion evaluated at the retina division of three institutions. We describe the multimodal imaging findings including fundus photography, fundus autofluorescence, fluorescein angiography, spectral-domain optical coherence tomography (OCT), swept-source OCT, swept-source OCT angiography and ultrasonography. RESULTS:The retinal lesions described shared similar appearance to RAHs but demonstrated unique features such as glistening granular appearance on fundus photographs with perivascular hyperreflectivity with OCT and OCT angiography. CONCLUSION/CONCLUSIONS:The lesions described herein appear to have unique characteristics that warrant a designation as a novel RAH variant. The name presumed retinal pericapillary astrocytic hamartoma is suggested.
PMID: 32980819
ISSN: 1468-2079
CID: 4616332

Iris suturing for posterior chamber intraocular lens dislocation: A comparison of in-the-bag versus out-of-the-bag dislocations and development of uveitis glaucoma hyphema syndrome [Meeting Abstract]

Pandit, S; Paranjpe, V; Parikh, H A; Wald, K
Purpose : To examine cases of new onset uveitis-glaucoma-hyphema (UGH) syndrome after posterior chamber intraocular lens (PCIOL) repositioning with iris-sutured IOL, differentiating between in-the-bag versus out-of-the-bag dislocations. Methods : Retrospective chart review was performed on 99 patients with a posteriorly dislocated IOL operated upon by a single surgeon from 2018-2020. Patients with previously diagnosed UGH, retained lens fragment, early dislocation, or lost-to-follow-up after one month were excluded. Variables of interest included 1-piece versus 3-piece IOL, in-the-bag versus out-of-the bag dislocation, and history of pxeudoexfoliation. UGH was defined as having at least one of the following: elevated intraocular pressure >25 mmHg, anterior uveitis, hyphema, or post-operative cystoid macular edema (CME). Results : 24 patients were eligible for the study. 18 patients were noted to have in-the-bag dislocations (75%). A total of 12 patients developed UGH (50%). Two of the 12 patients (16.67%) exhibited uveitis, glaucoma, and CME. No patients had hyphema. Among patients with UGH, mean age was 73 years old. 7 of 12 cases were in-the-bag dislocations (58.3%), and 6 of 12 cases (50%) had pre-existing pxeudoexfoliation (PXE). Among in-the-bag dislocations with UGH, 5 out of 7 patients had 1-piece IOLs (71%); whereas among the 5 cases of out-of-the-bag dislocations with UGH, all had 3-piece IOLs. Moreover, none of the patients with out-of-the-bag dislocation had pre-existing PXE. A final logMAR VA of 0.314 for in-the-bag dislocations with UGH (p = 0.832) was not found to be statistically significant compared to out-of-the bag UGH patients. Mean follow-up time was 4.5 months. Patients were treated with topical steroids(9 out of 12, 75% ), topical nonsteroidal antiinflammatory (8 out of 12, 67%), and pressure lowering drops (9 out of 12, 75%). Conclusions : UGH is a notable complication of iris sutured PCIOL repositioning. Preexisting PXE may be a predisposing factor for in-the-bag dislocations. There was a tendency toward UGH with single-piece in-the-bag dislocations, and three-piece out-of-thebag dislocations. Moreover, both in-the-bag and out of-the-bag dislocations appear to have similar visual outcomes. However, a larger sample size with longer follow-up time is necessary to draw more definitive conclusions
ISSN: 1552-5783
CID: 4982282

Hyperbaric oxygen therapy in ophthalmic practice: an expert opinion

Lin, Lawrence J.; Chen, Tiffany X.; Wald, Kenneth J.; Tooley, Andrea A.; Lisman, Richard D.; Chiu, Ernest S.
Introduction: There has been a growing interest in hyperbaric oxygen therapy (HBOT) in recent years across multiple disciplines. In the field of ophthalmology, the implications of increased HBOT use may include expanded applications in treating ocular vascular pathologies as well as a greater incidence of HBOT-induced visual complications. Areas covered: The authors review recent studies on HBOT usage in the treatment of ocular conditions. In addition to providing updates on the ophthalmic indications of HBOT, adverse visual effects of HBOT are also investigated. Expert opinion: Further evidence substantiating HBOT as an effective treatment modality for ocular vascular pathologies, such as central retinal artery occlusion and diabetic retinopathy, have been published in recent years. With the identification of more prognostic factors, increased success in HBOT has been reported. However, studies also show that adverse ocular effects associated with hyperbaric oxygen exposure include myopia and cataracts. It is important to recognize the risks of iatrogenic changes in visual acuity when considering patients for HBOT.
ISSN: 1746-9899
CID: 4394472

Characterization of outcomes for re-operation in macular hole surgery using inner retinal brushing [Meeting Abstract]

Parikh, H A; Liebenthal, R; Gupta, A; Tseng, J; Wald, K
Purpose : To characterize outcomes for patients with re-operated macular holes using a novel technique after failed closure in the initial surgery Methods : A retrospective chart review was conducted on 401 eyes that had undergone macular hole surgery in a private retina practice from 2013 to 2018. Those patients that underwent re-operation for persistently open macular hole were then identified. The initial macular hole surgery was done using pars plana vitrectomy (PPV), hyaloid elevation, internal limiting membrane (ILM) peeling with indocyanine green staining (ICG) with wide removal to the arcades, SF6 gas, and prone positioning for 6 days. For those patients that underwent a successive operation, 25-gauge PPV and a Tano diamond-dusted membrane scraper or Finesse flex loop was used to brush the retina in an outside-in manner in attempts to reduce the hole diameter. No attempt was made to restain the ILM, and C3F8 gas was used for re-operation. Age, race, gender, lens status, initial visual acuities before initial surgery, time to reoperation, and final visual outcomes were recorded. The optical coherence tomography (OCT) images of the initial hole and re-operated hole were analyzed. Results : Eight eyes were re-operated from 2013 2018. Visual outcomes improved by at least 3 lines from the initial prior to surgery to the most recent following re-operation in 7 (87.5%) patients, with all 8 (100%) eyes having macular hole closure. The re-operated eyes had larger hole diameters of >500 microns compared to eyes with successful primary macular hole operation. Conclusions : Previous studies have reported few techniques for re-operation include wider ILM peel/rexis and intraoperative macular hole fluid drainage. In this study, we utilized a technique of brushing the retina in an outside-in manner to help facilitate anatomic closure of the hole. Inner retinal brushing with hole diameter reduction and long-acting gas appears to be a successful treatment for persistent macular holes or possibly as initial surgery for large macular holes
ISSN: 1552-5783
CID: 4586042

New onset uveitis-glaucoma-hyphema syndrome after iris suturing for posterior chamber intraocular lens dislocation [Meeting Abstract]

Shah, P; Dempsey, K; Parikh, H A; Karl, M; Tseng, J; Wald, K
Purpose : We primarily aim to determine the incidence of uveitis-glaucoma-hyphema (UGH) after surgical repair of late, in-the-bag posterior chamber intraocular lens (PCIOL) dislocations treated by PCIOL-capsular complex repositioning and iris-suture fixation technique. Secondarily, we aim to characterize the outcomes of patients with this complication. Methods : We retrospectively reviewed the course of 212 patients with a lens repositioning surgical procedure by a single-surgeon in a four-year period, from 2014-2018. 68 patients with a posteriorly dislocated, in the capsular bag, PCIOL treated with iris-sutured lens repositioning with a follow-up duration of at least 3 months were included. Patients with pre-existing UGH, early dislocation within three months of cataracts extraction, or with retained lens material were excluded. UGH was defined as iritis or a combination of hyphema, high intraocular pressure, or vitreous hemorrhage. Results : After a median follow-up of 8.0 months, six (8.8% of 68) patients developed UGH at a median onset of 82.5 days from surgery. Baseline characteristics of these patients were the following: mean age of 70, initial intraocular pressure (IOP) of 18 +/- 4, initial logarithm of the minimum angle of resolution visual acuity (logMAR VA) of 0.64 +/- 0.56, and 1-piece IOL dislocation (83.3%). UGH was treated with topical corticosteroids in 5 patients (83.3%) and pressure lowering drops in 4 patients (66.7%). No patient required reoperation, nor had diminished vision. At a median follow-up of 8.0 months within this cohort with UGH, the final logMAR VA was 0.22 +/- 0.06 (versus baseline, p=0.104), and the final IOP was 23 +/- 10 (versus baseline, p=0.193). Conclusions : UGH is a rare but notable complication of iris sutured PCIOL repositioning. Patients who develop UGH can be effectively treated with medical therapy without surgical intervention and achieve good final visual acuity outcomes. A syndrome combining signs of iritis, VH, hyphema, and sustained IOP elevation particularly with single piece PCIOLs should prompt consideration of a UGH diagnosis and early treatment intervention to optimize patient outcomes. Future prospective clinical trials are needed to compare overall complication rates and outcomes of in-the-bag lens repositioning surgery with scleral versus iris sutured fixation technique
ISSN: 1552-5783
CID: 4586092

Augmented Posterior Hyaloid Adhesion Associated With Retinal Detachment After Macular Hole Repair

Lo, Danielle M; Chua, Michael R; Larochelle, Ryan D; Wald, Kenneth J
BACKGROUND AND OBJECTIVE/OBJECTIVE:There remains a low but intractable risk of rhegmatogenous retinal detachment (RRD) after surgical repair of macular holes (MHs). The purpose of this study is to identify potential causes for RRDs after MH surgery. PATIENTS AND METHODS/METHODS:The authors retrospectively examined a single surgeon series of stage 3 MH repair surgeries during a 5-year period. Clinical data, including preoperative, intraoperative, and postoperative evaluations, were reviewed to determine potential causes of RRD. RESULTS:Of the 332 eyes that received MH surgery, 12 (3.6%) developed postoperative RRD. Seven RRD cases exhibited no evident precursor pathology; however, augmented posterior hyaloid adhesions (APHAs) were found intraoperatively and postoperatively. CONCLUSIONS:In MH surgery, APHA increases risk for RRD. During PPV, the vitreous typically separates to the peripheral vitreous base. Some eyes have APHAs near the equator that cannot be elevated, consistent with strong adhesion. The authors believe the high postoperative RRD rate is due to continued hyaloid elevation after surgery. [Ophthalmic Surg Lasers Imaging Retina. 2019;50:635-638.].
PMID: 31671196
ISSN: 2325-8179
CID: 4220672

Outcomes of subretinal high-dose tissue plasminogen activator injection in massive submacular hemorrhage [Meeting Abstract]

Kally, Peter; Chua, Michael; Lo, Danielle; Brodie, Scott E.; Wald, Kenneth
ISSN: 0146-0404
CID: 4154502

Increased Inner Retinal Layer Reflectivity in Eyes With Acute CRVO Correlates With Worse Visual Outcomes at 12 Months

Mehta, Nitish; Lavinsky, Fabio; Gattoussi, Sarra; Seiler, Michael; Wald, Kenneth J; Ishikawa, Hiroshi; Wollstein, Gadi; Schuman, Joel; Freund, K Bailey; Singh, Rishi; Modi, Yasha
Purpose/UNASSIGNED:To determine if inner retinal layer reflectivity in eyes with acute central retinal vein occlusion (CRVO) correlates with visual acuity at 12 months. Methods/UNASSIGNED:Macular optical coherence tomography (OCT) scans were obtained from 22 eyes of 22 patients with acute CRVO. Optical intensity ratios (OIRs), defined as the mean OCT reflectivity of the inner retinal layers normalized to the mean reflectivity of the RPE, were measured from the presenting and 1-month OCT image by both manual measurements of grayscale B-scans and custom algorithmic measurement of raw OCT volume data. OIRs were assessed for association with final visual outcome. Cohort subgroup division for analysis was determined statistically. Results/UNASSIGNED:Eyes with poorer final visual acuity (≥20/70) at 1 year were more likely to have a higher ganglion cell layer OIR than eyes with better final visual acuity (<20/70) at 1 month (manually: 0.591 to 0.735, P = 0.006, algorithmically: 0.663 to 0.799, P = 0.014). At 1 month, eyes with a poorer final visual acuity demonstrated a higher variance of OIR measurements (algorithmically: 0.087 vs. 0.160, P = 0.002) per scan than eyes with better final visual acuity. Conclusions/UNASSIGNED:In acute CRVO, ganglion cell layer changes at 1 month, including increased reflectivity and increased heterogeneity of reflectivity signal as expressed as OIR and OIR variance, were associated with a poorer visual prognosis at 1 year. Technique calibration with larger sample sizes and automated integration into OCT platforms will be necessary to determine if OIR can be a clinically useful prognostic tool.
PMID: 30025093
ISSN: 1552-5783
CID: 3201002

Augmented posterior hyaloid adhesion associated with retinal detachment after macular hole repair [Meeting Abstract]

Lo, D M; Chua, M R; Wald, K J
Purpose: Despite advances in vitreoretinal surgery to improve closure rate and visual acuity for idiopathic macular holes (MH), there remains a low but intractable rate of rhegmatogenous retinal detachment (RRD) in the postoperative period. The purpose of this retrospective observational clinical study is to identify potential causes for RRDs after MH surgery.
Method(s): We retrospectively examined a single surgeon series of 332 stage III macular hole surgeries over a 5-year period (2012-2017). All patients underwent uniform surgical approach with pars plana vitrectomy (PPV), elevation of the posterior hyaloid face, internal limiting membrane peeling, and use of 20% SF6 gas. In all eyes, intraoperative scleral indentation and laser treatment to any pathology was performed. The charts of patients with postoperative RRD were analyzed for potential causes.
Result(s): Of the 332 eyes that received MH surgery, 12 (3.6%) developed postoperative RRD. Mean postoperative time to RRD was 55.2 days (SD 62.5). Mean improvement in visual acuity in patients with postoperative RRD was 1.4 lines (SD 2.1). 4 eyes had preexisting pathology such as lattice that was treated with preoperative and intraoperative laser. A retinal break was found superiorly in 2 eyes and inferiorly in 10 eyes. 7 eyes had equatorial type retinal breaks with no evident precursor pathology. These 7 cases were observed intraoperatively and post-operatively to have an augmented posterior hyaloid adhesion (APHA). (Fig.1)
Conclusion(s): A primary surgical objective of MH surgery is separation of the posterior hyaloid face, thereby producing an inherent risk factor for RRD. When PPV is performed, the vitreous typically separates to the peripheral vitreous base. During this process, breaks can be detected and treated. Some eyes, however, have APHA near the equator that cannot be elevated-this may be related to the strong vitreomacular adhesion that is a hallmark of MHs. We believe that these cases have a high rate of postoperative RRD as ongoing elevation of the hyaloid occurs in the postoperative period. The presence of gas may further increase vitreoretinal tractional forces especially at the inferior areas. We do not have a specific recommendation on the management of such cases, though one can consider prophylactic laser treatment along this zone. (Figure Presented)
ISSN: 1552-5783
CID: 4004492