Trabeculectomy with mitomycin C combined with direct cauterization of peripheral iris in the management of neovascular glaucoma

Neovascular Glaucoma Progress and Impact of Therapeutic Intervention in Saudi Arabia

Purpose: This study aimed to present the outcomes of the therapeutic interventions for neovascular glaucoma (NVG) between 2002 and 2012 at a tertiary eye hospital in Saudi Arabia.

Methods: A retrospective chart review of the patients with NVG treated in the last 10 years at King Khaled Eye Specialist Hospital was carried out. The demographics, visual acuity, and intraocular pressure (IOP) at the baseline were compared to that, at last, follow-up. The clinical course of treated eyes and causes for poor vision were reviewed.

Results: Among 597 eyes with NVG, the mean IOP at presentation was 32 mmHg. A total of 335 eyes (56.1%) were treated with pan-retinal photocoagulation (PRP). In 459 (77%) eyes, IOP was controlled with medications or different surgeries. The vision on the last follow-up was 20/20 to 20/40 in 19 (3%) eyes, 20/50 to 20/200 in 67 (11%) eyes, <20/200 to 20/400 in 267 (45%) eyes, and <20/400 in 225 (38%) eyes. Nineteen eyes were soft/enucleated. In 45 (8%, 95% CI 6-10) eyes vision improved. The IOP was reduced to <22 mmHg in 369 (62%, 95% CI 58.2-65.9) eyes, 23-30 mmHg in 69 (12%) eyes and was > 31 mmHg in 102 (17%) eyes. In 26 (3.7%) eyes, ocular hypotony was noted. The causes of poor vision included retinal ischemia (n=75, 13%), optic nerve head cupping (n=104, 17%), retinal detachment (n= 42, 7%) and other (n=17, 3%).

Conclusion: The NVG is a serious ocular ischemic complication. Prompt therapy maintained or improved the vision and controlled IOP in 50% and more cases.

Efficacy and Safety of Combined Surgeries including Intraocular Direct Cyclophotocoagulation with a 532 nm Laser to Treat Advanced Neovascular Glaucoma

Purpose

The purpose of this study was to assess the efficacy and safety of intraocular direct cyclophotocoagulation (IDCP) using a 532 nm laser with combination treatment in reducing intraocular pressure (IOP) for patients with advanced neovascular glaucoma (NVG) with angle closure. In addition, we sought to determine the success rate and frequency of complications and explore an optimized solution to reduce the number of topical medications and the pain of patients.

Methods

A retrospective case note review of all patients undergoing combined treatment including IVR, phaco, PPV, PRP, and IDCP from January 2017 to June 2018.

Results

In total, 24 consecutive patients (25 eyes) were reviewed. The mean IOP was significantly decreased from 42.2 ± 8.5 mmHg preoperatively to 15.56 ± 2.0 mmHg (P < 0.0001), and no neovascularization of the iris (NVI) reoccurred at month 18. The number of medications used was reduced from 2.72 ± 0.45 preoperatively to 0.87 ± 0.40 at month 18 (P < 0.0001).

Conclusions

During 18 months of follow-up, the combined treatments were safe and had a significant IOP-lowering effect. This study provides a new method of performing IDCP with a 532 nm laser, allowing for the use of internal cyclophotocoagulation without extra equipment.

Full Preoperative Panretinal Photocoagulation Improves the Outcome of Trabeculectomy with Mitomycin C for Neovascular Glaucoma

Purpose

To investigate the efficacy of full panretinal photocoagulation (PRP) followed by trabeculectomy with mitomycin C (MMC) in the management of eyes with neovascular glaucoma (NVG).

Methods

This study is based on 30 consecutive eyes of 27 patients with NVG who underwent full PRP followed by trabeculectomy with MMC. NVG was secondary to proliferative diabetic retinopathy (23 eyes) and central retinal vein occlusion (7 eyes). Kaplan-Meier survival analysis of the surgical outcome was performed. Operative success was defined as an intraocular pressure (IOP) of ≤21 mmHg without medical therapy.

Results

Kaplan-Meier cumulative success rates at the 6-, 12-, and 24-month intervals were 86.5%, 74.7%, and 57.6%, respectively. Pseudophakia was the only identified significant risk factor for failure (p=0.0138; Fisher exact test). Additional surgical procedures were performed in 8 (26.6%) eyes. The mean IOP decreased from 41.0±10.2 mmHg to 18.2±9.2 mmHg (p<0.001; Wilcoxon signed rank test). The number of anti-glaucoma medications was reduced from 3.1±0.5 preoperatively to 0.3±0.7 postoperatively (p<0.001; Wilcoxon signed rank test). Twenty-four (80%) eyes were classified as surgical success after a mean follow-up period of 17.3±22.1 months. Twenty-two (73.3%) eyes had improved vision or retained preoperative vision.

Conclusions

Full PRP followed by trabeculectomy with MMC can effectively reduce the elevated IOP associated with NVG. Presence of pseudophakia is a significant negative predictor of surgical outcome.

Surgical treatment of neovascular glaucoma with Ex-PRESS glaucoma shunt: Case report

RATIONALE

Neovascular glaucoma (NVG) is one of the most aggressive types of glaucoma, and its abnormal fibrovascular tissue growth on the iris and trabecular meshwork may create difficulties to control the intraocular pressure (IOP) and perform the operation such as trabeculectomy.

PATIENT CONCERNS

Ex-PRESS glaucoma shunt has been introduced to serve as one alternative operation for glaucoma, and is thought to have the potential advantage of being less traumatic than traditional trabeculectomy. The purpose of our study is to evaluate the efficacy and safety of primary Ex-PRESS implantation in eyes with NVG.

DIAGNOSES AND INTERVENTIONS

This was a retrospective study of four patients with NVG in whom primary Ex-PRESS implantation was performed between January 2012 and October 2016.

OUTCOMES

After a mean follow-up of 20.8 ± 8.9 months (range, 15-34 months), three of four NVG patients (75.0%) receiving primary Ex-PRESS implantation had postoperative IOP under 21 mmHg without any antiglaucoma medication control at the last follow-up, but shunt reposition had been performed due to failed blebs or recurrent NVG. Besides, the best corrected visual acuity at the last follow-up was stabilized or improved in three of four NVG patients (75.0%), accompanied with the regression of iris neovascularization. Only one patient had self-resolved postoperative hyphema; otherwise, there were no other perioperative complications.

LESSONS

Primary Ex-PRESS implantation might constitute a safe and alternative treatment for patients with NVG. In spite of the possible reoperations, the final outcomes were still shown effective after shunt reposition.

[Results of trabeculectomy with anti-VGEF therapy in the treatment of neovascular glaucoma secondary to retinal vein occlusion (report of 21 cases followed at Bukavu Eye Clinic from January 1 to December 31th, 2015)]

PURPOSE

To evaluate the results of anti-VGEF with trabeculectomy in the treatment of neovascular glaucoma, a severe complication of retinal vein occlusion (RVO).

PATIENTS AND METHODS

This is a prospective case series of consecutive patients with neovascular glaucoma secondary to retinal vein occlusion. All patients underwent panretinal photocoagulation and a mean of 3 anti-VEGF injections prior to trabeculectomy. Ophthalmic parameters were recorded pre- and postoperatively: visual acuity (VA), intraocular pressure (IOP), iris examination, gonioscopy and fundus examination, and as necessary, fluorescein angiography. Minimum follow-up was 9 months.

RESULTS

Twenty-one eyes of 21 patients were included. The mean preoperative intraocular pressure was 38mmHg (31-45mmHg). Postoperatively, the mean IOP was 15mmHg (13-19mmHg). IOP reduction was observed in all eyes after surgery and stayed finally stabilized in nineteen eyes (90.5 %). The rubeosis had definitively disappeared an average of two weeks after injection, but VA decreased in all patients. Nineteen patients (90.5 %) maintained preservation of their eyes. Two eyes underwent evisceration.

CONCLUSION

In most cases, trabeculectomy with anti-VGEF halted anterior segment neovascularization. It allowed for surgery on a quiet, normotensive eye, with good postoperative results. While functional rehabilitation was not achieved, the globe was able to be preserved in 90.5 % of cases.

Hyphema is a risk factor for failure of trabeculectomy in neovascular glaucoma: a retrospective analysis

Background

Several retinal ischemic diseases can cause neovascular glaucoma (NVG). Trabeculectomy with mitomycin C (MMC) is a relatively better treatment modality in the management of eyes with NVG than other glaucoma surgeries. The aim of this study was to investigate the factors that may influence the outcome of trabeculectomy with MMC for NVG.

Methods

Forty-nine NVG eyes from 43 patients (26 males and 17 females) underwent primary trabeculectomy with MMC. The mean follow-up period was 16.8 ± 8.1 months (range, 6 to 34 months). Twenty-one eyes of 21 patients received intravitreal bevacizumab (IVB) 3.6 ± 1.8 days before trabeculectomy with MMC. A Kaplan-Meier survival-curve analysis was used to summarize the cumulative probability of success. We examined the relationship between the surgical outcome and the following surgical factors: gender, age, history of panretinal photocoagulation, history of cataract surgery, history of vitrectomy, preoperative IVB, NVG in the fellow eye, and postoperative complications (hyphema, choroidal detachment, and formation of fibrin) by multivariate analysis.

Results

The survival rate was 83.7% after 6 months, 70.9% after 12 months, and 60.8% after 24 months. The Kaplan-Meier survival curves showed no significant difference in the survival rate between the eyes with preoperative IVB (n = 21) and the eyes without preoperative IVB (n = 28) (p = 0.14). The multiple logistic regression analysis showed that postoperative hyphema (odds ratio, 6.54; 95% confidence interval, 1.41 to 35.97) was significantly associated with the surgical outcome (p = 0.02).

Conclusions

Postoperative hyphema was significantly correlated with the outcome of trabeculectomy for NVG. There was no significant association between preoperative IVB and postoperative hyphema or the results of trabeculectomy.

Anterior segment uses of bevacizumab

PURPOSE OF REVIEW

A significant recent advancement in the treatment of neovascularization of the anterior segment of the eye is the development of antivascular endothelial growth factor (anti-VEGF) therapeutic agents.We present a review of the current knowledge on anti-VEGF therapy with bevacizumab for anterior segment neovascularization.

RECENT FINDINGS

A review of the recent peer-reviewed literature reveals an increasing number of experimental and clinical studies on the use of Avastin in both human and animal eye models. Although the numbers are still relatively small, the evidence suggests that bevacizumab may be effective in the treatment of corneal and iris neovascularization. Its effect on primary and recurrent pterygium is more controversial. In general, achievement of vessels regression is usually partial, and recurrence may occur after cessation of treatment. Response to treatment is affected by the chronicity of vessels, their extent, the cause for blood vessels formation, and the route of administration.

SUMMARY

Effective short-term response together with high patient tolerance to local bevacizumab therapy offer encouraging results for the management of anterior segment neovascular disorders. Although statistically significant regression of vessels has been documented in many studies, the clinical significance of this finding is still a subject of debate.

Silicone Ahmed glaucoma valve with and without intravitreal triamcinolone acetonide for neovascular glaucoma: randomized clinical trial

PURPOSE

To compare the effect on intraocular pressure (IOP) of the silicone Ahmed glaucoma valve with and without an intravitreal injection of triamcinolone acetonide.

PATIENTS AND METHODS

Forty-nine patients with clinically uncontrolled neovascular glaucoma were included in the study; 22 were randomly assigned to the study group (silicone Ahmed glaucoma valve implant with intravitreal triamcinolone acetonide) and 27 to the control group (silicone Ahmed glaucoma valve). IOP was the primary outcome measure in this study. The secondary outcome measure was success, defined by IOP lower than 22 mm Hg and higher than 5 mm Hg, and no serious complications. Success rates in both the groups were compared using Kaplan-Meier survival curves and the log-rank test. IOP levels were compared using mixed linear model analysis to correct for repeated measures correlation.

RESULTS

Forty-three patients, 18 in the study group and 25 in the control group, completed the study (follow-up of 12 mo). The mean IOP was significantly lower after 1 year in both the groups (P<0.001). The mean IOP in the first month of follow-up was lower in the study group (control; 20.4±9.7, study; 13.6±6.5, P<0.01). The success rate at 1 year was 78% for the study group and 76% for the control group (P=0.82). Complication rates were not different between the groups.

CONCLUSIONS

Intravitreal injection of triamcinolone acetonide in neovascular glaucoma did not affect the intermediate-term success of the silicone Ahmed valve nor reduce the incidence of complications. The mean IOP spike in the first month was lower in the triamcinolone group.

A new manner of reporting pressure results after glaucoma surgery

Purpose

To evaluate to what extent contemporary glaucoma abstracts offer complete information and to suggest a new manner of pressure results reporting.

Materials, methods, and results

Most of the 36 relevant surgical glaucoma abstracts found in one issue of International Glaucoma Review contain insufficient data-supported statements. Such abstracts cannot offer a clear picture of the study essence if economic, linguistic, or political barriers prevent access to the full text. In order to enrich abstract content and to avoid typographic space waste, a formula is suggested to provide, in one single line of symbols and figures, all the necessary data for statistical interpretation at two evolution moments: the first significative control (6 months) and the final one.

Conclusion

The current manner of results reporting in surgical glaucoma abstracts is subject to too little standardization, allowing insufficiently data-supported statements. Abstracts, especially those printed in small-circulation language journals, should be conceived and standardized in such a manner that any abstract review reader is capable of grasping the essence of the study at first glance. The suggested manner of reporting results would bring satisfaction to all areas of the process. Publishers would save typographic space, readers would find all the necessary data for statistical analysis and comparison with other studies, and authors would be convinced that the essence of their work would penetrate in spite of any economic, linguistic, or political barriers.

Intravitreal bevacizumab with or without mitomycin C trabeculectomy in the treatment of neovascular glaucoma

Purpose:

To demonstrate the role of intravitreal bevacizumab in regression of iris neovascularization, and intraocular pressure (IOP) control in neovascular glaucoma.

Methods:

A retrospective random case series study was performed. Twenty eyes of 20 patients who presented with neovascular glaucoma were treated with intravitreal bevacizumab 2.5 mg in 0.1 mL. Retinal photocoagulation was performed for all cases as soon as possible after intravitreal injection and subscleral trabeculectomy with mitomycin C 0.4 mg/mL for 3 minutes for cases having peripheral anterior synechiae. Cases were followed up for 12 months when regression of iris neovessels, IOP control, improvement in visual acuity, and success of filtering surgery were recorded.

Results:

All cases showed complete regression of iris neovessels at 2 months after injection; recurrence of iris neovessels was observed in 4 cases (20%) at 4 months and in 14 cases (70%) at 8 months follow-up. The mean IOP dropped from 41.45 ± 5.89 mmHg preoperatively, to 19.3 ± 5.5 mmHg and 17.75 ± 3.74 mmHg at 6 months and 12 months postoperatively, respectively. The success rate of subscleral trabeculectomy with mitomycin C after intravitreal bevacizumab was 77.8%. Visual acuity was improved in 17 cases (85%) from preoperative 0.12 ± 0.11 to 0.26 ± 0.2 postoperative.

Conclusion:

Intravitreal bevacizumab has a role in regression of iris neovessels and IOP control in neovascular glaucoma cases and also in increasing the success rate of subscleral trabeculectomy with mitomycin C; however this role has a limited time and reinjection is needed to maintain this effect.

Trabeculectomy versus Ahmed Glaucoma Valve implantation in neovascular glaucoma

Purpose:

To compare surgical outcomes in neovascular glaucoma patients who underwent trabeculectomy with mitomycin C versus Ahmed Glaucoma Valve implantation.

Patients and methods:

This was a retrospective comparative case series. We reviewed 40 eyes of 39 patients with underlying diagnosis of neovascular glaucoma, divided into two groups: Ahmed Glaucoma Valve (N = 20) and trabeculectomy with mitomycin C (N = 20). Surgical success was defined as 6 mm Hg ≤ intraocular pressure ≤21 mm Hg, with or without the use of glaucoma medications, with no further glaucoma surgery, and light perception or better vision. Early postoperative hypotony was defined as intraocular pressure <5 mm Hg during the first postoperative week.

Results:

The average follow-up was 31 months (range 6–87 months) for the Ahmed Glaucoma Valve group and 25 months (6–77 months) for the trabeculectomy group. Although the mean number of postoperative intraocular pressure-lowering medications was significantly higher in the trabeculectomy group compared with the Ahmed Glaucoma Valve group at 3 and 6 month time points, there was no statistically significant difference at any other time point. There was no statistically significant difference between both groups in postoperative visual acuity and intraocular pressure. Success was 70% and 65% at 1 year and 60% and 55% at 2 years after Ahmed Glaucoma Valve and trabeculectomy, respectively. Kaplan–Meier survival curve analysis showed no significant difference in success between the two groups (P = 0.815). Hyphema was the most common complication in both groups.

Conclusion:

We found similar results after trabeculectomy with mitomycin C and Ahmed Glaucoma Valve implantation in eyes with neovascular glaucoma.

Results of combined cyclectomy/trabeculectomy procedure compared with ahmed glaucoma valve implant in neovascular glaucoma cases

Purpose. Cyclectomy/trabeculectomy and Ahmed glaucoma valve implant are operations suggested for refractory glaucomas. In this study, we have evaluated the outcomes that we observed with these two techniques in neovascular glaucoma patients. Material and Methods. Thirty-five eyes with neovascular glaucomas were included in this study. Ahmed Glaucoma valve (group A) was applied to ten eyes, while cyclectomy/trabeculectomy was applied to 25 eyes (group C/T). Vision, intraocular pressure and complications were evaluated at the end of the first week and after 6 and 12 months. Results. Vision preservations were 80% and 92%, and success rates in reducing intraocular pressure were 50% and 72% for Ahmed glaucoma valve and cyclectomy/trabeculectomy groups, respectively. None of the differences in complication rates was found to be statistically significant. Conclusions. In the surgical management of neovascular glaucoma, cyclectomy/trabeculectomy was shown to be an alternative to Ahmed glaucoma valve operation.

Adjunctive intravitreal bevacizumab-combined trabeculectomy versus trabeculectomy alone in the treatment of neovascular glaucoma

PURPOSE

To evaluate the effect of adjunctive intravitreal bevacizumab (ivBe) with trabeculectomy versus trabeculectomy alone in the management of patients with neovascular glaucoma (NVG).

METHODS

Retrospective, consecutive, interventional case series. NVG patients were divided into groups by treatment: with adjunctive ivBe and trabeculectomy (ivBe group, n = 14 eyes) and with trabeculectomy only (control group, n = 28 eyes). The main outcome measure was visual acuity. Regression of iris neovascularization (NVI), change(s) in intraocular pressure (IOP), NVI recurrence, additional glaucoma surgeries required, eyes of leading to total blindness, intraoperative and postoperative complications, and number of topical medications required after trabeculectomy were regarded as second outcome measures. In the ivBe group, intravitreal injections of 2.5 mg bevacizumab were delivered using a sharp 27-gauge needle through the inferotemporal quadrant.

RESULTS

Of 42 eyes of 42 patients identified, change in IOP, additional glaucoma surgeries required, and number of IOP-lowering topical medications required after trabeculectomy did not differ significantly between groups (P > 0.05 for all). However, the ivBe group had significantly higher frequency and rapidity of iris neovascular regression, improved visual acuity in the logarithm of minimum angle of resolution (logMAR), leading to total blindness in fewer eyes and intraoperative and postoperative complications in others than in the control group (P = 0.015, 0.002, 0.007, 0.023, and 0.008, respectively). The follow-up duration (mean +/- SD) from trabeculectomy surgery was 179 +/- 97 days (range, 93-315 days) and 196 +/- 108 days (range, 92-370 days) in the ivBe and control group (P = 0.324).

CONCLUSIONS

Intravitreal bevacizumab might be a useful adjunctive therapy in addition to trabeculectomy in the management of NVG. Large controlled randomized studies for treatment of bevacizumab on NVG are warranted.

Beneficial effects of preoperative intravitreal bevacizumab on trabeculectomy outcomes in neovascular glaucoma

PURPOSE

This study aimed to investigate the effects of preoperative intravitreal bevacizumab (IVB) on outcomes in trabeculectomy for neovascular glaucoma (NVG).

METHODS

Charts for 52 NVG eyes of 52 consecutive patients who received primary trabeculectomy with mitomycin C (MMC) were reviewed. Postoperative follow-up periods for all patients were > or = 4 months. Thirty-two consecutive eyes were treated without IVB (control group) and 20 consecutive eyes received IVB (1.25 mg) 10 +/- 11 days before trabeculectomy (IVB group). The main outcome measures were postoperative intraocular pressure (IOP) and incidence of postoperative complications. Surgical success was defined as IOP< 21 mmHg with or without medication (qualified or complete success, respectively). Failure was defined as IOP exceeding these criteria, phthisis bulbi, loss of light perception or additional glaucoma surgeries. Kaplan-Meier survival analysis with the log-rank test was performed to compare surgical success rates between the two groups.

RESULTS

Complete and qualified success rates at 6 months were 95% versus 50% and 95% versus 75% in the IVB and control groups, respectively. The IVB group achieved significantly better surgical success rates than the control group (complete success, p < 0.001; qualified success, p = 0.026). Postoperative hyphaema on day 1 or hyphaema with a duration of > 1 week occurred significantly less frequently in the IVB group than in the control group (p = 0.009, p = 0.014, respectively). The incidence of serious complications such as endophthalmitis, phthisis bulbi and a marked decrease in visual acuity did not increase in the IVB group.

CONCLUSIONS

This retrospective study showed that preoperative IVB decreased postoperative hyphaema and increased surgical success rates, and thus may be an effective adjunct to trabeculectomy in NVG.

The effect of different doses of intracameral bevacizumab on surgical outcomes of trabeculectomy for neovascular glaucoma

PURPOSE

To prospectively evaluate the effect of 1.25 mg and 2.5 mg intracameral bevacizumab on surgical outcomes of trabeculectomy for neovascular glaucoma (NVG), with primary outcome measures being the regression of neovascularization of iris (NVI) and reduction of intraocular pressure (IOP).

METHODS

Consecutive patients with neovascular glaucoma from December 2006 to March 2007 were randomized into two cohorts assigned to receive 1.25 mg (Group 1) or 2.5 mg (Group 2) intracameral bevacizumab prior to undergoing mitomycin C (MMC) trabeculectomy. Surgical outcome measures were evaluated following initial injection and during follow-up post-surgery.

RESULTS

The most common causes for iris neovascularization were central retinal vein occlusion (47.3%) and proliferative diabetic retinopathy (36.8%). Following intracameral bevacizumab, there was a reduction in IOP compared to baseline in both treatment groups (Group 1, n=9: -10.4+/-4.5 mmHg, p=0.57; Group 2, n=10: -12.1+/-5.5 mmHg, p=0.1). The reduction in IOP was not statistically significant between the two groups (p=0.55). None of the eyes underwent further retinal ablation post trabeculectomy. Reappearance of NVI was seen in three eyes (Group 1, n=2; Group 2, n=1) after 3 months. There was no statistically significant difference in regression of NVI grade between the treatment groups (p=0.1).

CONCLUSIONS

The efficacy of an intracameral dose of 2.5 mg of bevacizumab prior to trabeculectomy for eyes with NVG is not significantly different from a 1.25 mg dose. Intracameral bevacizumab followed by trabeculectomy results in good surgical outcomes. Longer follow-up would be needed to evaluate differences in recurrence rates of iris neovascularization using different dosages.

Trabeculectomy with mitomycin C for neovascular glaucoma: prognostic factors for surgical failure

PURPOSE

To evaluate the prognostic factors for surgical outcomes of trabeculectomy with mitomycin C (MMC) for neovascular glaucoma (NVG).

DESIGN

Retrospective cohort study.

METHODS

We reviewed the medical records of 101 patients (101 eyes) with NVG treated at Kumamoto University Hospital. The primary endpoint was persistent intraocular pressure > or = 22 mm Hg, deterioration of visual acuity to no light perception, and additional glaucoma procedures. Multivariate analysis was performed using the Cox proportional hazards model.

RESULTS

The mean follow-up period was 29.3 months (range, 0.5 to 142.3 months). The probability of success 1, 2, and 5 years after trabeculectomy was 62.6%, 58.2%, and 51.7%, respectively. The multivariate model showed that younger age (relative risk [RR], 0.96/year; P = .0007) and previous vitrectomy (RR, 1.62; P = .02) were prognostic factors for surgical failure among all NVG patients. Additionally, an eye with unremoved proliferative membrane and/or unrepaired retinal detachment (RD) after vitrectomy (RR, 1.59; P = .05) was a probable prognostic factor in a subgroup of 66 eyes with previous vitrectomy, and having a fellow eye with NVG (RR, 1.73; P = .003) was a significant prognostic factor in 82 eyes with NVG attributable to diabetic retinopathy.

CONCLUSIONS

The prognostic factors for surgical failure of trabeculectomy with MMC for NVG were younger age and previous vitrectomy in all NVG patients, and having a fellow eye with NVG in patients with disease caused by diabetic retinopathy. Persistent proliferative membrane and/or RD after vitrectomy might contribute to poorer outcomes of trabeculectomy.

Intravitreal bevacizumab to treat iris neovascularization and neovascular glaucoma secondary to ischemic retinal diseases in 41 consecutive cases

PURPOSE

To evaluate the biologic efficacy of intravitreal bevacizumab (IVB) for iris neovascularization (INV) or neovascular glaucoma (NVG) in patients with ischemic retinal disorders.

DESIGN

Retrospective, consecutive, interventional case series.

PARTICIPANTS

Thirty patients (41 eyes) with INV or NVG secondary to ischemic retinal disorders.

METHODS

Patients received IVB (1 mg) as the initial treatment for INV or NVG and were followed up for at least 6 months. Ophthalmic evaluations included measurement of visual acuity and intraocular pressure (IOP), a complete ophthalmic examination, and fluorescein angiography. Patients were divided into 3 subgroups: INV without elevated IOP (INV group), NVG with an open angle (O-NVG group), and NVG with angle closure (C-NVG group) for outcomes analysis.

MAIN OUTCOME MEASURES

The controllability of IOP by IVB, incidence of recurrence, and requirement for surgery to treat NVG.

RESULTS

No significant ocular or systemic adverse events developed during follow-up (range, 6-22 months; mean, 13.3 months). The mean IOP levels were 14.7, 31.2, and 44.9 mmHg at baseline in the INV, O-NVG, and C-NVG groups, respectively. In the INV group (9 eyes), the INV regressed or resolved after 1 injection. Iris neovascularization recurred in 4 eyes by 6 months and stabilized after repeated injections without IOP elevation. In the O-NVG group (17 eyes), rapid neovascular regression with successful IOP normalization (<or=21 mmHg) occurred in 12 eyes (71%) within 1 week after 1 injection. Five (29%) of the 17 eyes required surgery by 6 months despite repeated IVB injections, and a total of 7 eyes (41%) underwent surgery during follow-up. In the C-NVG group (15 eyes), IVB caused INV resolution but failed to lower the IOP. Fourteen (93%) of 15 eyes required surgery by 2 months after initial IVB and achieved IOP stabilization. The mean interval between IVB and surgery was significantly shorter in the C-NVG group than in the O-NVG group (P<0.001).

CONCLUSIONS

Intravitreal bevacizumab is well tolerated, effectively stabilized INV activity, and controlled IOP in patients with INV alone and early-stage NVG without angle closure. In advanced NVG, IVB cannot control IOP but may be used adjunctively to improve subsequent surgical results. Further evaluation in controlled randomized studies is warranted.

Role of Intravitreal Bevacizumab in Neovascular Glaucoma

We report on the effect of intravitreal bevacizumab (IVB) for the treatment of neovascular glaucoma (NVG). A retrospective chart review of 6 consecutive cases of NVG was performed. The follow-up period was 3-19 months (average, 9.7 months). All patients received 1.25 mg (0.05 cc) of IVB followed by panretinal photocoagulation (PRP) approximately 1 week later. In all cases, there was a complete regression of iris and anterior chamber angle neovascularization. However, 2 eyes showed a recurrence of neovascularization; in 1 case, it recurred after 3 months, and in the second, after 5 months. These patients received another IVB injection followed by additional PRP, which resulted in the resolution of the recurrent neovascularization. Glaucoma was controlled with topical eye drops alone in patients who had iris and angle neovascularization without peripheral anterior synechiae (PAS). However, patients with PAS at the time of presentation needed subsequent glaucoma surgery. Our study suggests that IVB may be a valuable addition in the treatment of NVG by hastening the resolution of anterior segment neovascularization, improving the results of glaucoma surgeries, and appears to give long-term control when used in combination with PRP.

Neovascular glaucoma

Neovascular glaucoma (NVG) is a severely blinding, intractable disease. The objective of this review is to provide detailed information on its basic and clinical aspects, to enable us to manage it logically. Therefore, its causes, pathogenesis and pathology, methods of early diagnosis and management are discussed. To prevent or reduce the extent of visual loss caused by NVG, the first essential is to have a high index of suspicion of its development. The most common diseases responsible for development of NVG are ischemic central retinal vein occlusion (CRVO), diabetic retinopathy and ocular ischemic syndrome. In the management strategy, the first priority should be to try to prevent its development by appropriate management of the causative diseases. If NVG develops, early diagnosis is crucial to reduce the extent of visual loss. Management of NVG primarily consists of controlling the high IOP by medical and/or surgical means to minimize the visual loss. Currently, we still do not have a satisfactory means of treating NVG and preventing visual loss in the majority, in spite of multiple modes of medical and surgical options advocated over the years and claims made. This review discusses the pros and cons for the various advocated treatments.