In this case of repeated occurrence of anterior chamber bleeding causing transient IOP spikes and blurry vision in the presence of a subluxated sulcus-fixated open-loop IOL, my diagnosis is uveitis-glaucoma-hyphema (UGH) syndrome.
The lower haptic of the inferiorly decentered posterior chamber IOL (PC IOL) seems to have eroded some of the supporting zonular fibers, and this haptic is fixated somewhere behind the plane of the zonular ring. This could be verified by high-resolution UBM.
When the patient bends and bows her head, the upper haptic is encouraged to freely move, like a loose windshield wiper, inducing hemorrhage and presumably some pigment dispersion from abraded uveal tissue. This recurrent bleeding is the cause of the repeated transient IOP spikes and consequent blurry vision.
I envision 2 surgical strategies to resolve this situation. The first is to explant the sulcus-fixated IOL and replace it with an iris-supported anterior chamber IOL (AC IOL). The second is to fixate the unstable PC IOL by suturing the haptics to the iris. I would prefer the second option because the patient is 79 years old. To remove the 3-piece PMMA optic PC IOL, one would have to create a 7.0 mm sclerocorneal wound, which would have to be sutured to reduce the risk for induced astigmatism. Also, there is a risk for expulsive intraoperative hemorrhage and postoperative endophthalmitis. This surgery would have to be performed using peribulbar or general anesthesia. Because the CDVA is 0.9 in this eye and the patient has little astigmatism, I would avoid such an incision and intraocular manipulation and instead simply fixate the PC IOL with iris sutures rather than remove it.
After constricting the pupil with topical pilocarpine drops, I would introduce an iris spatula through a 1.0 mm clear corneal wound at 12 o’clock, through the iridectomy, and under the IOL optic. By lifting the optic from behind through the pupil into the anterior chamber with the spatula and thus capturing it within the pupil, the IOL could be well centered and the contour of the haptics seen through the iris. In this position, the 2 haptics could be fixated to the iris with 10-0 polypropylene McCannel sutures. The needle and suture would pass through the clear cornea and iris, under the haptic, and then out through the iris and clear cornea again. After the needle is cut off, the suture ends would be pulled out through the incision at 12 o’clock with a hook and then tied. Peripheral placement of the haptic sutures is preferred to avoid postoperative pupil ovalization. Once suturing is completed, the optic is gently pushed backward behind the iris. With this suture technique described by McCannel in 1976, one can center and stabilize the subluxated IOL through a small incision, avoiding the risk for induced astigmatism and other complications associated with more invasive surgery.
The patient’s problem will be solved by this surgery, which can be performed under topical or intracameral anesthesia.