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Neovascular glaucoma: Handling in the future

Neovascular glaucoma (NVG), which is refractory to both medical management and surgical intervention, is a disastrous ocular disease for it always ends up with intolerable pain and extinguishing patients' residual visual function. Since insufficient acknowledge of the pathophysiological and molecular mechanisms of NVG, it has been laying a challenging dilemma of managing NVG in clinical practice for a long time. Along with the progression on some new agents and surgical options targeting certain possible roles in the NVG process, there seems having been some new sights but still much unknown and to be revealed.

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 Weathering the Storm of Neovascular Glaucoma

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Articles of Interest

Five Pointers on Neovascular Glaucoma With Active Neovascularization

Neovascular glaucoma (NVG) is a severe form of glaucoma that occurs secondary to vascular proliferation in the anterior chamber of the eye. Like other glaucomatous disease, NVG is characterized by increased IOP, which can lead to optic nerve damage and ultimately loss of vision. Unlike many other forms of glaucoma, NVG can cause rapid damage due to the severe IOP elevation that results.

Reversing the Rubeotic Rampage – Current Approaches in the Management of Neovascular Glaucoma

Neovascular glaucoma is a sight-threatening condition, and can rapidly progress from rubeosis with normal intraocular pressure (IOP), to secondary open-angle glaucoma with raised IOP and finally secondary angle-closure glaucoma with uncontrolled IOP. Early detection and aggressive management with panretinal photocoagulation, intravitreal anti-vascular endothelial growth factor (VEGF), topical aqueous suppressants and valved glaucoma drainage surgery can reduce risk of significant visual loss secondary to neovascular glaucoma.

A paradigm shift in the management of neovascular glaucoma

If medical treatment, PRP and intravitreal Bevacizumab therapy are inadequate, consider the benefits of aqueous tube shunts early.

A Review of Neovascular Glaucoma: Etiology, Pathogenesis, Diagnosis, and Treatment

Neovascular glaucoma (NVG) is a rare, aggressive, blinding secondary glaucoma, which is characterized by neovascularization of the anterior segment of the eye and leading to elevation of the intraocular pressure (IOP). The main etiological factor is retinal ischemia leading to an impaired homeostatic balance between the angiogenic and antiangiogenic factors.

Anti-vascular endothelial growth factor for neovascular glaucoma

Anti-VEGFs as an adjunct to conventional treatment could help reduce IOP in NVG in the short term (four to six weeks), but there is no evidence that this is likely in the longer term. Currently available evidence regarding the short- and long-term effectiveness and safety of anti-VEGFs in achieving control of IOP, visual acuity, and complete regression of new iris vessels in NVG is insufficient.

Improving Outcomes in Neovascular Glaucoma

A core obstacle to neovascular glaucoma (NVG) management and academic discussion is that it is a multidisciplinary problem where the etiology of anterior-segment neovascularization lies in the domain of retina specialists, while the resultant elevated intraocular pressure (IOP) lies in the domain of glaucoma specialists. Diagnosis of NVG is also often delayed, and patients may have already sustained permanent vision loss by the time of presentation. Furthermore, the patients at highest risk of developing NVG are often the most vulnerable in our medical system.

Insights into neovascular glaucoma: Pathogenesis and detection of diabetic retinopathy

The management of NVG focuses on decreasing retinal ischemia through panretinal photocoagulation and the injection of anti-VEGF into the retina to detect retinal ischemia at an early stage.

Literature Review: Predictors of Neovascular Glaucoma in Central Retinal Vein Occlusion

Commonly referred to as 100-day glaucoma, the conversion to NVG after CRVO has been thought to occur within the first 3 months after CRVO onset. This impression is based on CRVO natural history studies conducted before the era of anti-VEGF therapy. Rong and colleagues found the time to NVG onset to be significantly longer than the commonly accepted 100 days, and they found no significant difference in the rate of NVG between patients who received anti-VEGF therapy and those who did not. The researchers concluded that anti-VEGF therapy may reset the clock, so to speak, and delay NVG onset but that therapy does not decrease a patient’s risk of developing NVG.

Long-term outcomes of neovascular glaucoma treated with and without intravitreal bevacizumab

Although bevacizumab delayed the need for glaucoma surgery, PRP was the most important factor that reduced the need for surgery. Vision and IOP in eyes with NVG treated with bevacizumab showed no long-term differences when compared with eyes that were not treated with bevacizumab. Thus, intravitreal bevacizumab serves as an effective temporizing treatment, but is not a replacement for close monitoring and definitive treatment of NVG.

Managing Neovascular Glaucoma

Patients with NVG typically present with a chronically red, painful eye, which often has significant vision loss. The majority of patients’ presenting acuity will be below 20/200. They often have significant concurrent vascular disease, such as diabetes, hypertension or giant cell arteritis (GCA)— diabetes is the most common precipitating cause of NVG. Patients are also likely to have an antecedent history of a retinal vessel occlusion, carotid artery disease, chronic retinal detachment or advanced DR.

Neovascular Glaucoma

The abnormal blood vessels in NVG grow inside the eye as a result of poor retinal blood supply. There are many conditions that cause abnormal blood supply to the retina. They include diabetic retinopathy, retinal vein occlusion, retinal artery occlusion, ocular ischemic syndrome, retinal detachment, and inflammation. In these conditions the blood supply to the retina is impaired, so the retina sends out chemical messages that it needs more blood supply. As a result, new blood vessels begin to grow inside the eye. Unfortunately, these new blood vessels may grow into the drain (trabecular meshwork) where they cause harm.

Neovascular Glaucoma Stages

Neovascular glaucoma (NVG) is a secondary glaucoma that is considered an advanced complication of ischemic retinal vascular disease. NVG accounts for 3.9% of all glaucoma cases.

Neovascular Glaucoma: Etiology, Diagnosis and Prognosis

Neovascular glaucoma (NVG) is a severe form of glaucoma with devastating visual outcome attributed to new blood vessels obstructing aqueous humor outflow, usually secondary to widespread posterior segment ischemia. Invasion of the anterior chamber by a fibrovascular membrane initially obstructs aqueous outflow in an open-angle fashion and later contracts to produce secondary synechial angle-closure glaucoma. The full blown picture of NVG is characteristized by iris neovascularization, a closed anterior chamber angle, and extremely high intraocular pressure (IOP) with severe ocular pain and usually poor vision.

Pathology and Management of Neovascular Glaucoma

Around three-quarters of cases of NVG are due to proliferative diabetic retinopathy (PDR), ischemic central retinal vein occlusion (CRVO), or ocular ischemic syndrome (OIS). Although classically termed “90-day glaucoma,” eyes can develop NVG anytime between 2 weeks to 2 years after the onset of CRVO.

Preserving Vision in Neovascular Glaucoma

Neovascular glaucoma is a secondary glaucoma usually associated with severe retinal hypoxia. Most eyes suffering from this condition have ischemic changes, although about 3 percent of cases are associated with inflammation without ischemia.1 How we treat these patients depends on the cause of the ischemia, the stage of the disease and the individual’s visual potential.

The convoluted condition of neovascular glaucoma

“To control the IOP, topical and oral medications are used initially. If medical therapy is not enough, which is usually the case, or if patients need to be placed on oral carbonic anhydrase inhibitors, laser or surgical treatments should be offered,” she said. “These traditionally include cyclophotocoagulation (CPC), aqueous shunts, or trabeculectomy.”

The mechanism and therapeutic strategies for neovascular glaucoma secondary to diabetic retinopathy

Neovascular glaucoma (NVG) is a devastating secondary glaucoma characterized by the appearance of neovascular over the iris and the proliferation of fibrovascular tissue in the anterior chamber angle. Proliferative diabetic retinopathy (PDR) is one of the leading causes of NVG. Currently increasing diabetes population drive the prevalence rate of NVG into a fast-rising lane. The pathogenesis underlying NVG makes it refractory to routine management for other types of glaucoma in clinical practice.

Resources

Glaucoma Research Foundation

Symptoms of NVG can include pain or discomfort, eye redness, and vision loss. This type of glaucoma never occurs on its own and is always associated with other abnormalities, such as retinal vein occlusion and diabetes.