‘Stacked Dex’ for UGH
Authors: Manisha K. Chahal, M.D.; Fred E. Shapiro, M.D.

Institution: Beth Israel Deaconess Medical Center

The Uveitis, Glaucoma, Hyphema Syndrome is an uncommon complication of intra-ocular lens implantation after cataract extraction. We present the judiciously tailored anesthetic cocktail of a patient w/UGH syndrome receiving a vitrectomy and intra-ocular lens removal.

Case Report
A 48 y.o. woman with a history of bilateral cataract surgery had developed smoldering iritis and glaucoma and was noted to have significant iris transillumination and pigment deposition in the inferior angles. The presumptive diagnosis of UGH syndrome was made. Her past medical history was also significant for Fibromyalgia and history of chronic opioid use, COPD and PUD. Her medications were Albuterol, Sertraline and Metformin,as well as, Dorzolamide, Brimonidine and Ketorolac eye drops. Allergies were IVP dye and Latex. Physical exam was remarkable only for obesity.
The patient received monitored anesthesia care for this procedure. During the case, standard ASA monitors were used. The patient lay supine with head near the surgeon. Oxygen support with 3 L/min by nasal cannula was administered continuously throughout the case. In the OR, a total of 3 mg of midazolam, 70 mg of propofol, and 50 micrograms of fentanyl were given to sedate the patient adequately prior to the retrobulbar block. Dexmedetomidine was also given in small increments of 10-20 cc at least 5 minutes
apart for a total of 100 mg during the two-hour case. At the conclusion of the case, the surgeon gave a subconjunctival injection of Cefazolin and Dexamethasone. The patient tolerated the procedure well. It was also decided to discharge the patient on an analgesic regimen, which included dextromethorphan 30 mg po tid, an NMDA antagonist. On postoperative follow up one and two months later, the patient had no complications, was recovering well and pain and discomfort were well controlled.

Discussion
Characteristically, UGH syndrome presents as a temporary, self-limiting gradual misting of vision with incomplete loss of light perception. Pain in the affected eye, resulting from uveitis/iridocyclitis or raised intra-ocular pressure, may also accompany this picture. The pathogenesis of UGH syndrome is due to chafing of the iris by the implanted lens secondary to mal-positioning or poor fit. If symptoms persist despite medical therapy, definite treatment requires surgical removal/replacement of the offending intraocular lens. These surgeries are typically classified as ambulatory due to the minimal noxious surgical stimulus, relatively short duration and lack of need for prolonged post-operative monitoring. Minimal
sedation and analgesia, administered to coordinate with anticipated surgical maneuver, is needed to achieve a spontaneously breathing, calm and compliant patient. It is beneficial to prevent/minimize post-operative nausea/vomiting and excessive drowsiness so that an early discharge of these patients can be achieved. This scenario involved an obese opioid tolerant woman with a mechanically induced inflammatory eye condition. Our plan was to minimize use of opioids, due to the undesirable side effect profile, while meeting the goals of a rapid turnover. For this reason, after convening with the surgeon, we crafted a regimen for intra and post-operative care that involved some innovative uses of three drugs:

1. Dexmedetomidine was chosen due to its effective anxiolytic and sedative properties, and little respiratory depression. The patient’s airway was not readily accessible from the anesthesiologist, an adequate analgesic medication was needed to provide a comfortable operative course for the patient and improved surgical conditions without compromise of spontaneous ventilation and oxygenation.
2. Due to the reactive etiology of this patient’s eye condition, subconjuctival Dexamethasone was injected after operative repair. This is a synthetic adrenalocortical steroid with potent anti-inflammatory and associated analgesic effects used in disorders of many organ systems including the eye & adnexa such as iritis and iridocyclitis.
3. Her history of home narcotic dependence suggested an opioid tolerance as well as lower pain threshold. For this reason, Dextromethorphan (DXM), an N-methyl-D-Aspartate (NMDA) receptor complex antagonist was used to supplement her post-operative analgesia, due to its decreased risk of dependence and analgesic effect. NMDA antagonists competitively inhibit the binding of the pain excitatory
   neurotransmitter glutamate at its NMDA receptor site. Activation of the NMDA receptor by glutamate and aspartate is believed to play a role in the phenomenon known as “wind-up. Clinical studies provide modest evidence that DXM may be an effective treatment in patients with painful peripheral diabetic neuropathy, as well as phantom limb syndrome. In conclusion, this eye case is significant from an anesthesia perspective because it draws attention to the promising analgesic virtues of these drugs.

References:

1. Cates, Carolyn, Newman,Douglas. Transient Monocular visual loss due to UGH syndrome. J Neurol Neurosurg Psychiatry. 1998 Jul;65(1):131-2
2. Sharma, A et al. An unusual case of Uveitis-Glaucoma-Hyphema Syndrome. Am J Ophthalmol. 2003 Apr;135(4):561-3.
3. Aonuma et al. Uveitis-Glaucoma-Hyphema syndrome after posterior chamber intra-ocular lens implantation. Jpn J Ophthalmol. 1997 Mar-Apr;41(2):98-100.

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