A novel application of B-ultrasonography at various head positions in the diagnosis of untypical uveitis-glaucoma-hyphema (UGH) syndrome: A case report.

RATIONALE: Uveitis-glaucoma-hyphema (UGH) syndrome could be identified by conventional ultrasound biomicroscopy (UBM) and B-ultrasonography, but failed in some untypical cases. We introduced a novel application of B-ultrasonography in diagnosis of UGH syndrome in a rare case. PATIENT CONCERNS: A 60-year-old woman was referred for distending pain with blurred vision for more than 1 month in the right eye after cataract surgery. DIAGNOSES: B-ultrasound scanner and UBM demonstrated the Intraocular Lens (IOL) was centered in the bag. No chafing in all directions was detected between IOL and iris/ciliary body. The proposed diagnoses were iridocyclitis and secondary glaucoma of the right eye. INTERVENTIONS: The symptoms were not improved after antiinflammation and intraocular pressure (IOP) lowering treatment for 1 month. B-ultrasonography was applied in horizontal, sitting, and head-down positions. The results demonstrated movements of IOLs when position changed. The IOLs were in contact with the iris pigment epithelium in sitting position and head-down positions but not in horizontal position. The dynamic interactions between IOLs and iris/ciliary body implied a diagnosis of UGH syndrome. The IOLs were then extracted. OUTCOMES: Two weeks after the IOLs explantation, the IOP significantly reduced to a normal level in both eyes. Ten-month follow-up showed that the IOP was maintained at a normal level. LESSONS: The chronically intermittent chafing between IOL and iris in specific head positions would also lead to UGH syndrome. Dynamic application of B-ultrasonography in various head positions could be useful in the diagnosis of an untypical UGH syndrome.

Mechanisms for in-the-bag uveitis-glaucoma-hyphema syndrome.

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, pseudophacodonesis 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 configuration 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.

Multidetector CT (MD-CT) in the diagnosis of uncertain open globe injuries.

PURPOSE: To evaluate the significance of multislice CT for the diagnosis of uncertain penetrating globe injuries. MATERIALS AND METHODS: Based on a retrospective chart review between 2002 and 2007, we identified 59 patients presenting with severe ocular trauma with uncertain rupture of the globe due to massive subconjunctival and/or anterior chamber hemorrhage. The IOP (intraocular pressure) was within normal range in all patients. High resolution multidetector CT (MD-CT) scans (16 slice scans) with axial and coronar reconstructions were performed in all patients. The affected eye was examined for signs of penetrating injury such as abnormal eye shape, scleral irregularities, lens dislocation or intravitreal hemorrhages. Four experienced radiologists read the CT scans independently. Beside the diagnosis, the relevant morphological criteria and the optimal plane orientation (axial or coronar) were specified. The sensitivity, specificity, and negative and positive predictive value were calculated. Additionally the interobserver variability was determined by applying the Cohen's kappa test. Surgical sclera inspections were performed in all cases as a standard of reference. The evaluations of the CT examination were compared with the surgery reports. RESULTS: 59 patients were evaluated (42 men, 17 women). The mean age was 29 years (range 7 - 91). In 17 patients a rupture of the globe was diagnosed during surgery. 12 of these 17 penetrating injuries (70.6 %) were classified correctly by MDCT, 5 of the 17 (29.4 %) were not detectable. 42 patients did not have an open globe injury. 41 of these patients were diagnosed correctly negative by MDCT, and one patient was classified false positive. This results in a sensitivity of 70 % with a specificity of 98 %. There was high inter-rater agreement with kappa values between 0.89 - 0.96. Most discrepancies were caused by wrong negative findings. The most frequent morphologic criteria for open globe injury were the deformation (n = 10) and the volume reduction (n = 7) of the globe. These changes were most certain and visible in the axial orientation. CONCLUSION: In about one third of all unclear cases with rupture of the globe due to severe trauma, CT evaluation failed to correctly diagnose the open globe injury, which might lead to a delay in necessary surgical intervention. Thus, surgical sclera inspection is always mandatory in such unclear trauma cases regardless of the MD-CT results.

Three-dimensional high-frequency ultrasonic parameter imaging of anterior segment pathology.

PURPOSE: High-frequency ultrasound allows high-resolution imaging of anterior segment anatomy and pathology. Acoustic echo data, however, contain information relating to the microanatomic structure of the interrogated tissue which is not evident in B-mode images. The aim of this study is to develop imaging techniques to demonstrate and quantify the distribution of acoustic scattering properties in ocular tissues in three dimensions. METHODS: A tumor of the iris and a hyphema were scanned using a 50-MHz ultrasound probe mounted on a computer-controlled two-axis positioning system. Scan data from sequential parallel planes were used to make three-dimensional reconstructions. Digital signal processing and a mathematical model of acoustic backscatter then were used to represent the effective size and acoustic concentration of scattering elements using a false color representation superimposed on B-mode images. RESULTS: Three-dimensional reconstructions improved appreciation of the size and extent of pathology and allowed computation of tissue volumes. Parameter images demonstrated distinctive differences between diffuse and organized blood and allowed quantification of tumor scattering properties. CONCLUSIONS: Three-dimensional imaging of the anterior segment with high-frequency ultrasound allows construction of perspective images, which adds to the already significant clinical use of individual high-resolution B-mode images. Acoustic backscatter properties determined by tissue microstructure can be computed from echo data and represented in false color in three-dimensional reconstructions.

Ultrasound biomicroscopic analysis of haptic position in late-onset, recurrent hyphema after posterior chamber lens implantation.

Late-onset, recurrent hyphema is an uncommon complication of posterior chamber intraocular lens implantation. Pathological studies and indirect clinical evidence, including iris transillumination defects and iris tucking, have implicated haptic-iris contact. The technique of high-resolution ultrasound biomicroscopy developed in our laboratories allows imaging of intraocular lens haptics and their relationship to surrounding structures. Examination of two cases with late-onset, recurrent hyphema revealed that the margins of the superior haptics were sulcus fixated and indenting the peripheral iris. Blood could be traced beneath the peripheral iris in one case. Our findings indicate that haptic-iris contact was the source of bleeding. Capsular fixation should make this complication less likely.

Recurrent microhyphema in the pseudophakic eye.

Although painless transient obscurations of vision are usually attributed to conditions affecting the posterior segment, careful slit-lamp, gonioscopic, and angiographic evaluations may establish an anterior segment origin for these symptoms. Recurrent hyphema, an uncommon late complication following routine cataract extraction, can be caused by spontaneous rupture of incisional vessels. In pseudophakic eyes, the uveitis-glaucoma-hyphema (UGH) syndrome and intermittent visual "white out" are late complications that may necessitate removal of the implant. The authors report five patients with uncomplicated extracapsular cataract extraction and implantation of a Binkhorst biplane, two-loop, capsule-fixated lens who presented with episodes of visual white out on the basis of iris bleeding. Argon laser photocoagulation to sites of iris leakage, at points of lens iris contact, resulted in prompt cessation of bleeding. Laser treatment appears to be a safe and effective alternative to removal of an otherwise satisfactory intraocular lens.

Spontaneous hyphema and vessel anomaly.

We describe a case of spontaneous hyphema, in which results of fluorescein angiography revealed that the condition was caused by anomalous iris vessels. A cavernous hemangloma of the ipsilateral orbit was discovered. We stress the importance of performing fluorescein angiography in all cases of spontaneous hyphema.