Surgical Management of UGH Syndrome

Speaker 1 (00:00): This is Ike Ahmed. And I'm Arsham Sheybani. And we want to welcome you to GT: The Podcast. We're bringing this to you together with BMC and Glaucoma Today. To offer audible insights into current topics in glaucoma care. Presented by the authors of our latest, most-read GT articles. Check it out.

Speaker 2 (00:21): Welcome to GT: The Podcast. In this episode, glaucoma specialists share insights into treating uveitis-glaucoma-hyphema or UGH syndrome as featured in the January/February 2026 issue of Glaucoma Today. Dr. Roya Garakani recaps her article, surgical decision-making in patients with UGH Syndrome in which she outlines options for patients with UGH syndrome who require glaucoma surgery in addition to an IOL procedure. She explains that management of these cases calls for a nuanced approach that balances the need for further IOP reduction with the risks of performing surgery on an inflamed eye. Then Dr. Mahsaw Mansoor recaps her article, selecting an IOL and fixation technique for patients with UGH syndrome, which was written with Dr. Nicole Fram. Dr. Mansoor presents a case of the in-the-bag UGH syndrome secondary to dead bag syndrome, highlights key points to help guide the surgical management of these complex cases, and stresses that durable resolution of UGH syndrome often depends on choosing an appropriate IOL and fixation strategy.

(01:35): First, we hear from Dr. Garakani.

Speaker 3 (01:43): During the acute phase of uveitis-glaucoma-hyphema syndrome, elevated IOP from the mechanical rubbing of an IOL or capsule on the iris and ciliary body can lead to obstruction of the trabecular meshwork by debris. Repositioning or exchanging the IOL is the definitive treatment to relieve the chafing. Medical therapy may be used as a bridge to manage IOP and inflammation until surgery can be performed. The efficacy of conservative medical therapy alone, however, is significantly worse than when it is combined with IOL surgery, which has been shown to improve both visual and IOP outcomes. Medical therapy is primarily a temporizing measure and not a definitive solution in this patient population. A unique challenge is that many of these individuals require glaucoma therapy after UGH syndrome has been resolved with IOL repositioning or exchange. A review by Armonaite and Behndig analyzed 71 patients with UGH syndrome and found that 51% of those without preexisting glaucoma subsequently required ongoing glaucoma treatment after the resolution of UGH syndrome.

(02:47): Patients with an IOP of 22 mm Hg or higher during their first hyphema episode were at an increased risk of needing long-term glaucoma therapy. Permanent damage to the aqueous outflow pathways that may occur during active UGH episodes can result in elevated IOP, even after the mechanical chafing has resolved. The decision of whether to proceed with glaucoma surgery in patients with UGH syndrome requires carefully balancing the need for further IOP reduction with the risks of performing surgery on an inflamed eye. Performing the lens procedure first is often beneficial for inflammation control. The success of glaucoma surgery in an eye that has not undergone IOL surgery is often compromised by ongoing inflammation. If a patient with UGH syndrome requires glaucoma surgery in addition to an IOL procedure, various approaches may be utilized. Laser peripheral iridotomy can successfully reduce elevated IOP in eyes with UGH syndrome that results from reverse pupillary block.

(03:45): In a case series of six eyes, LPI resolved UGH syndrome in all of them, and the mean IOP decreased from 30.5 to 15.5 mm Hg postoperatively. Although LPI is an excellent approach to reverse pupillary block, the procedure does not have a role in eyes where the chafing of iris and ciliary body tissue occurs by a different mechanism. This highlights the importance of a careful examination, anterior segment OCT, and ultrasound biomicroscopy to guide the surgical approach to patients with UGH syndrome. There's a lack of published literature on MIGS outcomes in patients with UGH syndrome. Hypothetically, however, MIGS may have a role in such cases because it would spare the conjunctiva in patients who are at high risk of requiring multiple glaucoma interventions in their lifetime. Gonioscopy-assisted transluminal trabeculotomy in particular has been shown to be effective for IOP management in eyes with uveitic glaucoma, which has an underlying mechanism similar to the chronic IOP elevation observed with UGH syndrome.

(04:42): This procedure was reported to achieve surgical success in 71.8% of eyes with uveitic glaucoma and the mean IOP decreased from 31.4 to 13.8 mm Hg at one year in one study. Glaucoma drainage devices may be considered as well for patients with UGH syndrome who have extremely high IOP that is refractory to medical therapy. Compared with trabeculectomy, tube shunt surgery is less susceptible to failure due to inflammation. In patients with uveitic glaucoma, a recurrence of inflammation caused lower rates of surgical failure in a tube shunt group when compared with a trabeculectomy group in one study. Additionally, valve tube shunts may mitigate the risk of hypotony after the resolution of inflammation related to UGH syndrome. Trabeculectomy may have a role, however, in eyes that have been quiescent for many months. Cyclodestructive procedures such as transscleral or endoscopic cyclophotocoagulation can be effective for the management of UGH syndrome.

(05:38): In a case report of transscleral cyclophotocoagulation in a patient with UGH syndrome, no contact between the IOL and posterior iris was observed after treatment indicating that the TSCPC might have relieved areas of mechanical chafing by inducing contraction of the ciliary body. In another case report, a patient with UGH syndrome who could not undergo an IOL exchange owing to extensive capsular fibrosis received endoscopic cyclophotocoagulation after which their symptoms resolved. Although the benefits of CPC must be weighed against its known risks like hypotony, worsening of inflammation, vision loss, cyclodestructive procedures may serve a dual purpose in terms of lowering IOP and improving the anatomic relationship between the iris lens and ciliary body. The management of glaucoma in patients with UGH syndrome requires a nuanced approach. Careful patient selection, the identification of specific anatomic problems, and the timing of lens and glaucoma treatment are critical.

Speaker 2 (06:41): Here is Dr. Mansoor with more insight into the surgical management of UGH syndrome.

Speaker 4 (06:50): Uveitis-glaucoma-hyphema syndrome can present a unique surgical challenge in pseudophakic eyes. Diagnosis and glaucoma management receive much of the attention in the situation, but really, the durable resolution of UGH syndrome frequently hinges on choosing an appropriate IOL and fixation strategy. Although IOL induced UGH syndrome is classically associated with sulcus fixated one piece acrylic IOLs, subluxated IOLs and malpositioned IOLs, the complication may also occur when the lens implant is fully within the capsular bag, often called in-the-bag UGH syndrome. Proposed mechanisms for the development of this latter scenario include iris chafing in the setting of severe pseudoexfoliative pseudophacodonesis and asymmetric capsular fibrosis with a calcific Soemmering ring, which creates focal points of iris contact. We have recently encountered cases of in-the-bag UGH syndrome resulting from subtle pseudophacodonesis in patients presenting with dead bag syndrome. First described by Dr. Samuel Masket, dead bag syndrome is characterized by late IOL dislocation due to capsular bags that lack sufficient structural integrity to provide long-term support.

(08:07): In eyes with DBS, the diaphanous, floppy, and sometimes floating capsule may result in zonulopathy and pseudophacodonesis. Peripheral dislocation of the IOL haptics through the equator of the capsule may also occur particularly if the bag splits spontaneously. Preoperatively, ultrasound biomicroscopy can be a critical step in assessing bag integrity, IOL position, tilt, and even if there is a calcific Soemmering ring as possible etiologies of UGH syndrome. This article presents a case of in-the-bag UGH syndrome secondary to dead bag syndrome and highlights key points that can help guide the surgical management of these complex cases. A 75-year-old pseudophakic patient was referred for an evaluation of recurrent vitreous hemorrhage of unknown etiology. The patient had previously undergone uncomplicated cataract extraction with placement of a posterior chamber, one-piece acrylic IOL nearly 20 years prior. Prior careful retinal evaluations had identified no definitive source of vitreous hemorrhage. On examination, the IOL was in the capsular bag, which exhibited minimal to no fibrosis.

(09:17): Retro-illumination at the slit lamp revealed peripheral iris transillumination defects at the two and eight o'clock positions, raising clinical suspicion that the one piece acrylic IOL was in the sulcus or UGH syndrome had developed. UBM later confirmed that the IOL was in the bag without visible tilt or evidence of prominent iris chafing induced by capsular fibrosis or asymmetric Soemmering ring material.

(09:43): The surgical management of UGH syndrome in pseudophakic eyes begins with a critical assessment of whether the existing IOL can safely be salvaged. This determination depends on the integrity of the capsular bag, the feasibility of achieving durable posterior fixation, and the likelihood that repositioning itself will definitively eliminate iris contact. If the capsular bag seems to be intact, lasso fixation or repositioning may be considered. Any attempt at IOL preservation, however, should ensure full capsular overlap of the haptics and posterior fixation of the lens to avoid sulcus fixation of a one piece IOL. In addition, asymmetric fixation causing tilt and/or ciliary body compromise may increase the risk of persistent or recurrent UGH syndrome. Adequate capsular fibrosis and minimal perioperative tilt should be confirmed when repositioning a one piece acrylic IOL. In the case briefly mentioned earlier, an initial attempt was made to reposition the IOL using the lasso technique while preserving the capsular bag.

(10:50): During manipulation, tension split the capsular bag, causing the suture to slip along the haptic, which is a common occurrence in patients with dead bag syndrome. This confirmed, unfortunately, the bag's non-viability. At that point, the decision was made to remove the entire capsular bag IOL complex and proceed with secondary IOL placement via scleral suture fixation. In our practice, we have learned from the cases such as this one to resist the temptation to reposition a dead bag. Early recognition and decisive IOL removal can reduce operative morbidity. After explantation of the original IOL, an enVista Toric MX60ET IOL selected to address the patient's high corneal astigmatism was implanted using pars plana fixation. There are case reports of UGH syndrome with this lens platform and approach, but we do suspect the incidents of this are due to overly anterior suture fixation of the IOL. In our experience, a stable posteriorly fixated optic that avoids such contact is a key determinant of success in these eyes.

(11:55): Sutureless intrascleral haptic fixation, such as the well-known Yamane technique, are viable alternatives in select cases, but the approach can be very unforgiving. Even subtle IOL tilt or decentration may result in postoperative iris chafing and recurrent inflammation. An intrascleral haptic fixation does not permit the correction of greater than two diopters of corneal astigmatism. When performing intrascleral haptic fixation in eyes with UGH syndrome, meticulous attention to haptic externalization, tunnel construction, and symmetry is essential. Surgeons should have a very low threshold for intraoperatively reassessing IOL centration and iris clearance. In the setting of scleral fixation, a surgical peripheral iridotomy is routinely performed in our practice. Creating a peripheral iridotomy facilitates a collaboration of the anterior and posterior chambers and may reduce dynamic iris movement or iridodonesis that can contribute to pupillary capture and iris chafing, particularly in eyes that have a history of pars plana vitrectomy. Dead bag syndrome is an underrecognized cause of in-the-bag UGH syndrome.

(13:06): Successful management depends on recognizing when the capsular bag is not viable, avoiding futile repositioning attempts, and prioritizing stable posterior fixation of the IOL. When these principles are followed, durable resolution of UGH syndrome can be achieved.

Speaker 2 (13:23): Thank you for tuning in to this episode of GT: The Podcast. If you have any feedback or topic suggestions, find us on Instagram, LinkedIn, Facebook, or Twitter and stay tuned for more hot topics in glaucoma care on GT: The Podcast.