Main

Sir,

Uveitis–Glaucoma–Hyphaema (UGH) syndrome is more commonly associated with anterior chamber intraocular lenses (IOLs),1 and less commonly with posterior chamber IOLs.2, 3, 4 We report a case of UGH syndrome in a patient with posterior chamber IOL who was on treatment with warfarin.

Case report

An 83-year-old male initially presented to eye casualty with an embolic left inferotemporal branch retinal occlusion. He had undergone bilateral extracapsular cataract surgery with posterior chamber IOLs 18 years previously. Both IOLs were noted to have subluxed inferiorly (Figure 1a), with iris atrophy superiorly in the left eye and a mild anterior uveitis. He had suffered a pulmonary embolus 1 month prior to his attendance and was on warfarin. His International Normalized Ratio (INR) was 1.7 (therapeutic range 2.0–3.0).

Figure 1
figure 1

(a) The IOL is seen subluxed inferiorly; (b) 70% hyphaema in the same eye.

Full size image

After 10 days, he reattended with loss of vision to perception of light in his left eye. Examination revealed a total hyphaema with an intraocular pressure (IOP) of 30 mmHg (Figure 1b). The INR was elevated at 3.8. He was commenced on topical and systemic ocular hypotensives. After 2 days, his hyphaema remained unchanged but the IOP had normalized. The hyphaema resolved over 6 weeks and acuity improved to 6/9. IOP remained normal off treatment, but a residual anterior uveitis required topical corticosteroids. At review 3 months after the initial presentation, his INR was 2.1, the uveitis had virtually resolved and topical steroids were gradually stopped. His warfarin was stopped 1 month later and no further problems relating to UGH syndrome occurred. The patient was discharged from regular review 18 months following initial presentation.

Discussion

Systemic anticoagulation rarely causes spontaneous intraocular haemorrhaging and does not require cessation prior to intraocular surgery.5

UGH syndrome appears to arise from repetitive mechanical iris trauma by a malpositioned or subluxed IOL.6, 7, 8 In our case, superior iris transillumination was noted and was likely due to chafing by a displaced haptic. Iris melanosomes have previously been isolated from haptic tips in this condition.9

The British Society for Haematology recommends an INR of 2.5–3.5 for patients with prosthetic heart valves.10 Such patients remain at risk of spontaneous hyphaema where IOL malposition has occurred. Small incision phacoemulsification and a correctly positioned IOL will reduce this risk considerably.