CASE REPORT

Mechanisms for in-the-bag

uveitis-glaucoma-hyphema syndrome
Linda Zhang, MD, Christopher T. Hood, MD, Joshua P. Vrabec, MD, Alexis L. Cullen, CDOS,
Elizabeth A. Parrish, CDOS, Sayoko E. Moroi, MD, PhD

We propose 2 mechanisms of uveitis-glaucoma-hyphema (UGH) syndrome in 2 patients with

intracapsular or in-the-bag single-piece acrylic intraocular lenses (IOLs). In the first case, pseu-
dophacodonesis secondary to zonular laxity from pseudoexfoliation syndrome caused chafing
of the posterior iris by the square-edged haptic. In the second case, focal capsular fibrosis around
the square-edged haptics combined with anteriorly rotated ciliary processes in plateau iris config-
uration caused points of chafing. Extensive capsular fibrosis of the haptic in both cases precluded
IOL exchange. In the first case, a capsular tension ring redistributed zonular tension and reduced
symptoms. In the second case, endoscopic cyclophotocoagulation relieved areas of chafing and
resolved symptoms. In-the-bag square-edged haptics of single-piece acrylic IOLs are a potential
source of iridociliary chafing in certain situations. The mechanisms observed here should be
considered to promptly diagnose and treat UGH.
Financial Disclosure: Dr. Moroi receives clinical research funding from Merck & Co., Inc. and book
royalties from Lippincott Williams & Wilkins. No other author has a financial or proprietary interest
in any material or method mentioned.
J Cataract Refract Surg 2014; 40:490492 Q 2014 ASCRS and ESCRS
Online Video

Uveitis-glaucoma-hyphema (UGH) syndrome is a post-
surgical condition caused by mechanical chafing of
anterior segment structures by an intraocular lens
(IOL). It has a wide range of clinical manifestations,
including anterior chamber inflammation and pigment
dispersion, increased intraocular pressure (IOP), hy-
phema or microhyphema, and vitreous hemorrhage.1,2
Iridociliary chafing can also be subtle, and often the
patient's ocular discomfort may be out of proportion
to ocular findings. The syndrome is classically associ-
ated with poorly positioned first-generation anterior
chamber IOLs3; more recently, it has been associated
Submitted: August 23, 2013.
Accepted: September 8, 2013.
From the Department of Ophthalmology and Visual Sciences, W.K.
Kellogg Eye Center, University of Michigan, Ann Arbor, Michigan,
USA.
Presented in part at the ASCRS Symposium on Cataract, IOL and
Refractive Surgery, Chicago, Illinois, USA, April 2012.
Corresponding author: Sayoko E. Moroi, MD, PhD, University of
Michigan, W.K. Kellogg Eye Center, 1000 Wall Street, Ann Arbor,
Michigan 48105, USA. E-mail: smoroi@med.umich.edu.
with single-piece acrylic IOLs placed in the ciliary
sulcus.4,5 Because UGH is not commonly reported
with in-the-bag single-piece acrylic IOLs, it can be chal-
lenging to diagnose and often results in significant
ocular morbidity. We have recently observed a res-
urgence of UGH syndrome associated with single-
piece acrylic IOLs placed in the bag. We describe 2
representative cases and their proposed mechanisms.
CASE REPORTS
Case 1
A 69-year-old man presented with intermittent blurred
vision in his right eye lasting a few days at a time and
reported 15 similar episodes over the prior 3 months. He
was evaluated at 3 institutions and after a thorough systemic
evaluation, including unremarkable carotid ultrasound and
stress echocardiogram, he was given a presumptive diag-
nosis of intermittent iris variceal bleed with secondary
increased IOP and placed on topical pressure-lowering
drops and atropine. The ocular history was significant for
uneventful cataract extraction with placement of a single-
piece acrylic IOL in the bag 4 years previously. The corrected
distance visual acuity (CDVA) was 20/30, and the IOP was
13 mm Hg. Anterior segment examination demonstrated
microhyphema, peripupillary exfoliation material, an iris
transillumination defect nasally, and a centered in-the-bag
IOL without apparent pseudophacodonesis. Gonioscopy

490 Q 2014 ASCRS and ESCRS 0886-3350/$ - see front matter

Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jcrs.2013.12.002
 CASE REPORT: IN-THE-BAG UGH SYNDROME
revealed a densely pigmented open angle without iris vessel
abnormalities. Fundoscopic examination showed mild
anterior vitreous hemorrhage. The left eye was notable for
a stable posterior chamber IOL and exfoliation material.
Ultrasound biomicroscopy (UBM) revealed an in-the-bag
single-piece acrylic IOL, with the nasal haptic in close
apposition to the iris. Intraoperative endoscopy showed
dynamic zonular laxity; exfoliation material frosting the
zonular fibers; intermittent forward displacement of the
hapticcapsule complex against the iris, with a zone of
contact causing focal whitening of the iris; and blood in the
equator of the capsule (Video 1, available at http://jcrsjour-
nal.org). Because of extensive fibrosis of the capsule to the
haptic, the surgeon (S.E.M.) was unable to perform an IOL
exchange so a capsular tension ring (CTR) (Reform, Alcon
Surgical, Inc.) was placed to redistribute the force in the
capsular bag.
In the first 3 months postoperatively, the patient experi-
enced 2 episodes of vitreous hemorrhage and hyphema. In
1 episode, the IOP increased to 42 mm Hg and required
oral acetazolamide and an anterior chamber paracentesis.
Repeat UBM did not reveal contact between the single-
piece acrylic IOL haptic and any anterior segment structure
or displacement of the CTR. The option of IOL removal
was offered, but the patient elected conservative manage-
ment and was started on a daily cycloplegic agent. He has
experienced 1 additional episode of UGH in 16 months of
follow-up.
Case 2
A 71-year-old woman with open-angle glaucoma had
uneventful cataract surgery in her right eye with placement
of an Alcon SN60WF single-piece acrylic IOL in the bag.
She developed blurred vision, redness, and eye pain with
elevated IOP on postoperative day 1. The symptoms and
examination improved on topical corticosteroid and
additional glaucoma therapy, but each time the corticoste-
roid was tapered, the symptoms recurred. After 5 months,
she was referred with a CDVA of 20/25 and an IOP of
29 mm Hg. Anterior segment examination was significant
for rare cells. Fundoscopic examination revealed mild
cystoid macular edema (CME). Gonioscopy showed plateau
iris configuration, which was confirmed by UBM. The UBM
also showed 1 haptic opposed to and distorting the infero-
nasal ciliary processes (Figure 1).
Intraoperative endoscopy confirmed in-the-bag posi-
tioning of both haptics; however, there was extensive
capsule fibrosis surrounding the nasal haptic with the square
edge of the haptic abutting the nasal ciliary processes (Video
2, available at http://jcrsjournal.org). An IOL exchange or
placement of a CTR was considered but deemed risky due
to extensive capsule fibrosis. Instead, focal endoscopic
cyclophotocoagulation of the involved ciliary processes
was performed to retract them from the area of haptic
impingement. Within 2 months, the presenting symptoms,
anterior chamber inflammation, and CME had resolved
and the IOP returned to preoperative levels.
DISCUSSION
Although single-piece acrylic IOLs placed in-the-bag
rarely cause UGH, we report 2 mechanisms of in-the-
bag UGH. In pseudoexfoliation syndrome (Case 1), zon-
ular instability led to subclinical pseudophacodonesis of
J CATARACT REFRACT SURG - VOL 40, MARCH 2014
491
the hapticcapsule complex, resulting in secondary
chafing of the posterior iris by the intracapsular-
contained square-edged haptic of the single-piece
acrylic IOL. In plateau iris configuration (Case 2), the
anteriorly positioned ciliary processes were prone to
chafing when focal capsule fibrosis around the square-
edged haptic created points of pseudoherniation with
mechanical contact to adjacent ciliary processes.
There are 2 reports of UGH-spectrum syndrome
with in-the-bag placement of single-piece acrylic
IOLs.1,6 One case occurred because of anterior bowing
of a haptic within the capsular bag, related to IOL
deformation during loading.6 In the second, an irido-
ciliary cyst displaced the IOL optic, which chafed the
pupillary margin.1 In contrast to these reported mech-
anisms of in-the-bag UGH, we propose that the sharp
square haptic edges can cause iridociliary irritation
when combined with zonular instability (Case 1) or
plateau iris configuration (Case 2). In these settings,
a multipiece acrylic IOL with round polypropylene
(Prolene) haptics may be preferable because the
rounded polypropylene haptics do not have sharp
edges as a potential source of mechanical chafing
and help to stabilize the capsular bag and zonule.
In our other recent cases of in-the-bag UGH, onset of
symptoms ranged from 1 day to 6 years after cataract
surgery, time to diagnosis ranged from 3 to 43 months
after onset of symptoms, and patients underwent
extensive systemic evaluations, multiple trips to the
emergency department for eye pain, and even vitrec-
tomy for evacuation of vitreous hemorrhage prior to
diagnosis (data not presented). We found UBM to be
useful for identifying haptic placement and iridocili-
ary chafing.7 Intraoperative endoscopy was instru-
mental in visualizing hapticoptic malposition for
diagnosis and treatment. For treatment, we prefer
IOL exchange with placement of a multipiece IOL
with polypropylene haptics in the bag, but this is not
always possible because of extensive hapticcapsule
fibrosis. In such cases, endoscopic cyclophotocoagula-
tion to retract affected ciliary processes away from the
herniated hapticcapsular complex or placement of a
CTR to redistribute zonular tension at the capsular
equator has been successful.
Given the prevalence of implanting single-piece
acrylic IOLs at the time of cataract surgery in the
United States,4 it is important to recognize single-
piece acrylic IOL-related in-the-bag UGH, which is
uncommon but can cause serious morbidity in patients
who often report vague symptoms and have subtle
findings after uneventful cataract surgery. Clinicians
should be aware that square-edged haptics are a
potential source of iridociliary chafing, particularly
in patients with zonular laxity or with plateau iris
configuration. It is important to consider these
492 CASE REPORT: IN-THE-BAG UGH SYNDROME
mechanisms to promptly diagnose and treat UGH to
reduce ocular morbidity and avoid unnecessary
procedures.
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Intra-Ocular Implant Soc J 1978; 4(2):5053
J CATARACT REFRACT SURG - VOL 40, MARCH 2014
Figure 1. A: Axial cut on UBM showing
plateau iris configuration. B: Axial cut
on UBM showing haptic touch to
the adjacent ciliary processes (dashed
arrow). C: Transverse cut on UBM
showing a row of ciliary processes,
some of which are being compressed
by the haptic (solid arrow).
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Mamalis N, Oetting TA, Packer M; for the ASCRS Cataract
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