UVEITIS GLAUCOMA HYPHEMA (UGH) SYNDROME

Uveitis-Glaucoma-Hyphema (UGH) Syndrome or Ellingson syndrome is a complication of intraocular lens (IOL) and MIGS implants, caused by mechanical irritation of intraocular structures.

The term UGH Syndrome was first coined by Ellingson in 1978. He noticed that certain styles of anterior chamber intraocular lenses (ACIOL) had warped footplates leading to a rocking motion of the lens and mechanical irritation of adjacent anterior chamber angle structures. 

Usually seen with ACIOLs, it is also seen with posterior chamber IOLs placed in the sulcus, causing posterior iris chafing by the loop or the optic. The syndrome occurs more commonly with planar loop design than with angulated loops. There is a report with scleral fixated lens also.

Repetitive mechanical trauma and chaffing of intraocular structures leads to a spectrum of iris transillumination defects and pigmentary dispersion to microhyphemas and hyphemas with elevated intraocular pressure (IOP).

It is characterized by chronic inflammation, cystoid macular edema (CME), secondary iris neovascularization, recurrent hyphemas, and glaucomatous optic neuropathy leading to a loss of vision. 

Inflammatory changes in the anterior chamber affect the aqueous outflow out of the eye, causing IOP to rise and cause glaucoma.

Hyphema complicates matters since blood in the anterior chamber may obstruct outflow channels and exacerbate inflammation.

The best treatment for a specific case of UGH syndrome depends on the exact underlying cause of the condition, and as such is variable.

Advances in IOL material and design as well as surgical technique have reduced the incidence of UGH syndrome from 3% to between 0.4% and 1.2%, but it remains a relevant clinical entity, particularly in eyes with a malpositioned IOL optic or haptics, zonular instability, and plateau iris configuration.

Chief complaints include intermittent blurry vision, “white out” vision, photophobia, hyperemia, and ocular pain or discomfort that may be out of proportion with examination findings.

Slitlamp examination can reveal the anterior chamber flare and cells. Usually it is mild but can occasionally lead to hypopyon formation. Slitlamp examination and gonioscopy can show microhyphema and hyphema. 

Ultrasound biomicroscopy (UBM) is the best technique for evaluation of such cases. UBM can confirm the proper location of an IOL’s haptics and optic, a tilted optic, or the haptic of a one-piece IOL improperly placed in the ciliary sulcus.

Management of UGH depends upon the situation. In mild cases pharmacological methods might be attempted. However, in most cases explantation of IOL is required.