CASE PRESENTATION

A 61-year-old woman is referred by her optometrist for elevated IOP (40s mm Hg) and uveitic glaucoma in her right eye. The patient’s ocular history is significant for high myopia, age-related macular degeneration, and cataract surgery in each eye and retinal detachment surgery in the right eye in 2007.

On presentation, her BCVA is hand motions OD and 20/200 OS. IOP measures 24 mm Hg OD and 20 mm Hg OS with Goldmann applanation tonometry. The patient’s current medical regimen for the right eye consists of a fixed combination of timolol and brimonidine administered twice daily, bimatoprost instilled at bedtime, and ketorolac and prednisolone acetate dosed four times daily.

A slit-lamp examination reveals diffuse corneal endothelial pigment in the right eye and no significant findings in the left eye. The anterior chamber of the right eye has 2+ pigmented cells. Iris transillumination defects are present nasally in the right eye, corresponding to an IOL haptic. Gonioscopy reveals a grade 4 open angle in each eye with 4+ and 1+ pigmented trabecular meshwork in the right and left eyes, respectively.

A dilated examination of the right eye finds a mildly subluxated one-piece acrylic IOL in the sulcus and an open posterior capsule. No vitreous is visible in the anterior chamber.

Each eye has a tilted optic nerve and myopic dysplasia. The macula of each eye is atrophic and scarred from severe myopic degeneration. The peripheral retina exhibits large areas of scarring from laser treatment and atrophy.

How would you manage the patient?

—Case prepared by Steven R. Sarkisian Jr, MD

ANALISA AROSEMENA, MD

The patient has developed secondary pigment dispersion glaucoma from chafing of the iris by the IOL, which released pigment and overwhelmed the trabecular meshwork. Therapy with atropine would be initiated to prevent further chafing, and the steroid dose would be decreased.

An IOL exchange is mandatory. Because the lens was implanted years ago, there may be some fibrosis around the haptics. Care should be taken to avoid tearing the capsule so that it can support a three-piece IOL.

The haptics would be loosened with an OVD and Sinskey hooks placed through a paracentesis. The IOL would be rotated and brought into the anterior chamber, where it would be bisected with microscissors and removed through a clear corneal incision. A secondary three-piece IOL would be placed in the sulcus, and reverse optic capture would be performed if possible. My preference would be to orient the haptics 90º away from the areas of iris transillumination.

The patient is a great candidate for MIGS. After performing canaloplasty and viscodilation, I would remove the pigment occluding the trabecular meshwork using either the Omni Surgical System (Sight Sciences) or a Kahook Dual Blade (New World Medical) combined with viscodilation using a Rivero cannula (Aurora Surgical).

J. MATTHEW ROUSE, MD

The most likely source of the patient’s disease process is uveitis-glaucoma-hyphema syndrome precipitated by iris chafing from the one-piece acrylic IOL in the sulcus. The transillumination defects and the location of the IOL in the sulcus are consistent with this hypothesis. Ultrasound biomicroscopy could be used to analyze the position of the IOL in relation to other ocular structures as further confirmation.1

Treatment must include removing the inciting cause of inflammation. My preference would be to exchange the current IOL for a three-piece IOL placed in the sulcus. I would consider performing an anterior vitrectomy, given the open posterior capsule, and I would carefully position the haptics of the three-piece IOL.

Reducing IOP is also important given the likely damage to the outflow system from chronic inflammation. Filtration surgery would be appropriate in conjunction with the IOL exchange because of the high IOP, but the patient’s history of retinal surgery could limit her surgical options. Is a buckle present from the retinal repair? Is there significant conjunctival scarring? My typical choice for filtration surgery is to place a Xen 45 or 63 Gel Stent (Allergan)2,3 or a tube shunt4 depending on the other clinical parameters present.

ZARMEENA VENDAL, MD

The one-piece acrylic IOL in the sulcus is chafing the iris and causing pigment dispersion. I would address the IOL first rather than continue to treat refractory bouts of iritis with long-term steroid therapy. The IOL would be exchanged for a three-piece sulcus-fixated IOL, and the steroid dosage would be reduced. Another option would be to leave the eye aphakic for some time to allow the pigment dispersion to settle. Given the patient’s current visual potential, this would not significantly affect her ability to function.

If uveitis remains a problem in the long term, I would work with my retina and rheumatology colleagues to determine the etiology and if nonsteroidal forms of immunotherapy could be used to reduce steroid-induced IOP elevation. My suspicion, however, is that the inflammation is completely due to the IOL. I therefore anticipate that the uveitis and pigment dispersion will subside after the current IOL is replaced.

The patient would also benefit from MIGS at the time of the IOL exchange. Two options are canaloplasty with the Omni Surgical System and a goniotomy with the Sion (Sight Sciences).

WHAT I DID: STEVEN R. SARKISIAN JR, MD

The patient had glaucoma secondary to iris chafing from the one-piece IOL captured in the sulcus. I removed the IOL and replaced it with a three-piece IOL in the sulcus, with the haptics oriented at the 12 and 6 clock positions because the original lens implant had subluxated nasally. I also performed a partial goniotomy using a bent cystotome to address the pigment clogging the trabecular meshwork.

Postoperatively, the patient's glaucoma resolved completely, and the unmedicated IOP was in the midteens. One month after surgery, however, the IOL had subluxated, this time almost completely. The IOP was still controlled. An IOL exchange was performed, and the subluxated IOL was replaced with an anterior chamber IOL.

Six months after surgery, the patient’s vision remains stable, IOP control has been maintained, and there is no evidence of pigment dispersion.

1. Piette S, Canlas OA, Tran HV, Ishikawa H, Liebmann JM, Ritch R. Ultrasound biomicroscopy in uveitis-glaucoma-hyphema syndrome. Am J Ophthalmol. 2002;133(6):839-841.

2. Qureshi A, Jones NP, Au L. Urgent management of secondary glaucoma in uveitis using the Xen-45 Gel Stent. J Glaucoma. 2019;28(12):1061-1066.

3. Serrar Y, Rezkallah A, Kodjikian L, Poli M, Mathis T, Denis P. Xen 63 Gel Stent to treat a refractory uveitic glaucoma: a case report. Eur J Ophthalmol. Published online June 16, 2022. doi:10.1177/11206721221109199

4. Bettis DI, Morshedi RG, Chaya C, Goldsmith J, Crandall A, Zabriskie N. Trabeculectomy with mitomycin C or Ahmed valve implantation in eyes with uveitic glaucoma. J Glaucoma. 2015;24(8):591-599.