Widefield swept-source optical coherence tomography angiography metrics associated with neovascular glaucoma in patients with proliferative diabetic retinopathy

PURPOSE

To explore the association between widefield swept-source optical coherence tomography angiography (WF SS-OCTA) metrics, including nonperfusion area (NPA) and neovascularization (NV), and presence of neovascular glaucoma (NVG) in patients with proliferative diabetic retinopathy (PDR).

METHODS

A prospective, cross-sectional study was conducted from November 2018 to February 2020. A total of 85 eyes of 60 PDR patients without NVG and 9 eyes of 8 PDR patients with NVG were included. Retinal ischemic parameters (NPA; ischemia index [NPA/total retinal area]) and NV features (NV number; NV area; NV vessel density) were evaluated. Foveal avascular zone (FAZ), macular thickness/volume, and choroidal thickness/volume were obtained using the Zeiss ARI Network. WF SS-OCTA retinal and choroidal metrics, systemic, and ocular parameters were screened using Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression for variable selection. Firth's bias-reduced logistic regression (outcome: presence of NVG) was subsequently used to identify parameters associated with NVG.

RESULTS

After LASSO variable selection, 8 variables were significantly associated with the presence of NVG: DM duration (years), insulin (yes/no), best-corrected visual acuity (BCVA) (logMAR), IOP, ischemia index, skeletonized vessel density, macular thickness (inner inferior, outer temporal regions). Firth's bias-reduced logistic regression showed ischemia index (odds ratio [OR]=13.2, 95% confidence interval [CI]:5.3-30.7, P<0.001) and BCVA (OR=5.8, 95%CI:1.2-28.8, P<0.05) were associated with the presence of NVG. NV metrics, FAZ, and choroidal parameters were not related to NVG.

CONCLUSIONS

Retinal ischemia but not NV was associated with the presence of NVG in patients with PDR using WF SS-OCTA. Larger, longitudinal studies are needed to validate imaging biomarkers associated with diabetic NVG.

Trabeculectomy with concurrent intravitreal bevacizumab in neovascular glaucoma

PURPOSE

To evaluate the clinical efficacy of concurrent intravitreal bevacizumab (IVB) injection with trabeculectomy with mitomycin-C (MMC) in neovascular glaucoma (NVG).

METHODS

Patients with NVG who underwent trabeculectomy with concurrent IVB (group 1) and those who underwent IVB sequentially, followed by trabeculectomy with MMC (group 2) in 1-2 weeks between January 2021 and August 2022, were included in this retrospective hospital-based study. The need for medications for intraocular pressure (IOP) control at 6 months in the two groups was the primary outcome measured and compared between the groups. The association of the need for medications postoperatively with clinical variables was assessed using stepwise multivariate regression statistics.

RESULTS

We finally included 40 patients ( n = 12 in group 1, n = 28 in group 2) with no significant differences in presenting age between groups. The IOP at 1 day and 1 week were not significantly different between groups though the IOP at 1, 3, and 6 months. IOP was lower in group 1 eyes with the 6-month IOP, being significantly lower in group 1, P = 0.05. Three eyes in group 1 and 11 eyes in group 2 required anti-glaucoma medications in the postoperative period. Multivariate regression identified preoperative IVB >3 (β =0.7, P < 0.001) and recurrent vitreous hemorrhage (β = 0.7, P = 0.004) as prognostic factors ( R2 = 40.6%) determining the need for anti-glaucoma medication (AGM) postoperatively in both groups.

CONCLUSION

Concurrent IVB with trabeculectomy with mitomycin-C is a feasible alternative in patients with NVG with refractory high-presenting IOP. This may serve to address raised IOP as well as retinal ischemia, thereby improving surgical success rates in the most challenging NVG cases.

A Rare Association: Neovascular Glaucoma Accompanying Anterior Chamber Synchysis Scintillans

Synchysis scintillans, also known as cholesterolosis bulbi, is a degenerative eye pathology characterized by the accumulation of cholesterol crystals in the vitreous. It is typically observed bilaterally but can rarely be unilateral. It can be triggered by severe trauma, chronic inflammation, chronic retinal detachment, hyphema, vitreous hemorrhage, Coats’ disease, and retinoblastoma. In this report, we present a case with an uncommon association of anterior chamber synchysis scintillans and neovascular glaucoma.

Two-year outcomes of patients presenting to Sydney Eye Hospital with neovascular glaucoma

BACKGROUND

Neovascular glaucoma (NVG) is a sight-threatening condition that is often refractory to treatment. Current management principles are yet to be standardized due to lack of evidence. We studied the interventions used to treat NVG at Sydney Eye Hospital (SEH) and the two-year surgical outcomes.

METHODS

We performed a retrospective audit of 67 eyes of 58 patients with NVG from January 1, 2013, to December 31, 2018. Intraocular pressure (IOP), best-corrected visual acuity (BCVA), number of medications, repeat surgery, recurrent neovascularization, loss of light perception and pain were studied.

RESULTS

The average age of the cohort was 59.67 years (SD 14.22). The most common etiologies were proliferative diabetic retinopathy (35 eyes; 52.2%), central retinal vein occlusion (18 eyes; 26.9%) and ocular ischemic syndrome (7 eyes; 10.4%). 70.1% of eyes (47) received vascular endothelial growth factor injections (VEGFI), 41.8% (28 eyes) received pan-retinal photocoagulation (PRP) and 37.3% (25 eyes) received both prior to or within the first week of presentation to SEH. The most common initial surgical interventions were trans-scleral cyclophotocoagulation (TSCPC) (36 eyes; 53.7%) and Baerveldt tube insertion (18 eyes; 26.9%). 62.7% of eyes (42 eyes) failed (IOP > 21 or < 6 mmHg for two consecutive reviews, further IOP-lowering surgery or loss of light perception) during follow-up. Initial TSCPC failed in 75.0% (27/36 eyes) compared with 44.4% (8/18 eyes) after Baerveldt tube insertion.

CONCLUSION

Our study reinforces the refractory nature of NVG, often despite intensive treatment and surgery. Improvements in patient outcomes may be achieved with earlier consideration of VEGFI and PRP. This study identifies the limitations of surgical interventions for NVG and highlights the need for a standardized management approach.

Visual prognosis and surgical timing of Ahmed glaucoma valve implantation for neovascular glaucoma secondary to diabetic vitrectomy

BACKGROUND

Evaluate the visual outcomes of Ahmed glaucoma valve implantation (AGVI) in patients with neovascular glaucoma (NVG) who underwent diabetic vitrectomy and suggest appropriate AGVI timing.

METHODS

Medical records of patients who underwent AGVI due to NVG after diabetic vitrectomy were reviewed. Successful intraocular pressure (IOP) control was defined as an IOP between 6 and 21 mmHg. Visual outcome was compared before NVG diagnosis and after AGVI, and the "favorable" visual outcome was defined as a postoperative deterioration in BCVA of less than 0.3 logMAR units compared to those before the development of NVG. Various factors including surgical timing were evaluated to identify the risk factors associated with unfavorable visual outcome.

RESULTS

A total of 35 eyes were enrolled and divided into group 1(medically uncontrolled NVG group, IOP more than 30mmHg, 16 eyes) and group 2(NVG group responded well to the initial non-surgical treatment but eventually required AGVI, 19 eyes). Despite the favorable rate of normalization of post-AGVI IOP (85.7%), 43.8% in Group 1 and 26.3% in Group 2 showed unfavorable visual outcomes. In group 1, delayed surgical timing more than 1 week from the NVG diagnosis showed a significant association with unfavorable visual outcomes (P = 0.041). In group 2, poor patient compliance (follow up loss, refuse surgery) was the main factor of unfavorable visual outcomes.

CONCLUSION

When NVG occurs in patients with proliferative diabetic retinopathy after vitrectomy, physicians should be cautious not to delay the surgical intervention, especially in patients with IOP of 30 or more despite non-surgical treatment. Early AGVI within six days might be necessary to preserve useful vision in these patients.

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. High concentrations of vasogenic substances such as vascular endothelial growth factor (VEGF) induce neovascularization of the iris (NVI) and neovascularization of the angle (NVA) that limits the outflow of aqueous humor from the anterior chamber and increases the IOP. NVG clinical, if untreated, progresses from secondary open-angle glaucoma to angle-closure glaucoma, leading to irreversible blindness. It is an urgent ophthalmic condition; early diagnosis and treatment are necessary to preserve vision and prevent eye loss. The management of NVG requires the cooperation of retinal and glaucoma specialists. The treatment of NVG includes both control of the underlying disease and management of IOP. The main goal is the prevention of angle-closure glaucoma by combining panretinal photocoagulation (PRP) and antiangiogenic therapy. The aim of this review is to summarize the current available knowledge about the etiology, pathogenesis, and symptoms of NVG and determine the most effective treatment methods.

Case Report: Pediatric Ocular Ischemia and Neovascular Glaucoma in Neurofibromatosis Type 1

SIGNIFICANCE

Neovascular glaucoma is an important subset of secondary glaucoma in neurofibromatosis patients. Vasculopathy of the ophthalmic circulation needs to be borne in mind while evaluating their etiology.

PURPOSE

This study aimed to report the presentation, diagnostic work-up and management of an unusual case of neovascular glaucoma in a child.

CASE REPORT

A 7-year-old boy presented with uniocular ischemic fundus and secondary neovascular glaucoma. Detailed family history and evaluation led to a diagnosis of familial neurofibromatosis type 1. Fundus fluorescein angiography revealed compromised retinal and choroidal circulations in the affected eye. Ocular ultrasound B scan and neuroimaging did not show any contributory lesions. Cardiovascular evaluation was within normal limits. Ophthalmic Doppler imaging revealed normal proximal ophthalmic arteries in both eyes; however, the central retinal artery of the affected eye showed low flow in its proximal part and absent flow in the distal part, as compared with the fellow eye showing regular flow until the optic disc margin. Corroborating the clinical, fundus fluorescein angiography and Doppler findings, a diagnosis of neurofibromatosis type 1-related vasculopathy of the distal ophthalmic artery was made. Poor visual prognosis for the affected eye was explained, and anterior retinal cryopexy along with cyclocryotherapy was performed to treat the neovascular glaucoma.

CONCLUSIONS

Vasculopathy of the ophthalmic circulation is an important cause of neovascular glaucoma in neurofibromatosis patients. The morphology of Lisch nodules may be altered in an ischemic eye, and therefore, careful examination of the other eye and systemic evaluation is vital in such unusual scenarios.

Incidence of Proliferative Diabetic Retinopathy and Other Neovascular Sequelae at 5 Years Following Diagnosis of Type 2 Diabetes

OBJECTIVE

To determine the incidence and risk factors for developing proliferative diabetic retinopathy (PDR), tractional retinal detachment (TRD), and neovascular glaucoma (NVG) at 5 years after the initial diagnosis of type 2 diabetes.

RESEARCH DESIGN AND METHODS

Insured patients aged ≥18 years with newly diagnosed type 2 diabetes and 5 years of continuous enrollment were identified from a nationwide commercial claims database containing data from 2007 to 2015. The incidences of PDR, TRD, and NVG were computed at 5 years following the index diagnosis of type 2 diabetes. Associations between these outcomes and demographic, socioeconomic, and medical factors were tested with multivariable logistic regression.

RESULTS

At 5 years following the initial diagnosis of type 2 diabetes, 1.74% (1,249 of 71,817) of patients had developed PDR, 0.25% of patients had developed TRD, and 0.14% of patients had developed NVG. Insulin use (odds ratio [OR] 3.59, 95% CI 3.16-4.08), maximum HbA1c >9% or >75 mmol/mol (OR 2.10, 95% CI 1.54-2.69), renal disease (OR 2.68, 95% CI 2.09-3.42), peripheral circulatory disorders (OR 1.88, 95% CI 1.25-2.83), neurological disease (OR 1.62, 95% CI 1.24-2.11), and older age (age 65-74 years) at diagnosis (OR 1.62, 95% CI 1.28-2.03) were identified as risk factors for development of PDR at 5 years. Young age (age 18-23 years) at diagnosis (OR 0.46, 95% CI 0.29-0.74), Medicare insurance (OR 0.60, 95% CI 0.70-0.76), morbid obesity (OR 0.72, 95% CI 0.59-0.87), and smoking (OR 0.84, 95% CI 0.70-1.00) were identified as protective factors.

CONCLUSIONS

A subset of patients with type 2 diabetes develop PDR and other neovascular sequelae within the first 5 years following the diagnosis with type 2 diabetes. These patients may benefit from increased efforts for screening and early intervention.

Trabeculectomy for neovascular glaucoma in proliferative diabetic retinopathy, central retinal vein occlusion, and ocular ischemic syndrome: Surgical outcomes and prognostic factors for failure

PURPOSE

To evaluate the outcomes of trabeculectomy in the eyes with neovascular glaucoma (NVG), caused by proliferative diabetic retinopathy (PDR), central retinal vein occlusion (CRVO), and ocular ischemic syndrome (OIS).

METHODS

A retrospective review of NVG eyes that underwent trabeculectomy between 1991 and 2019. Complete success was defined as intraocular pressure (IOP) between 6 and 21 mmHg without antiglaucoma medications (AGM). The risk factors were analyzed by Cox's proportional hazard model.

RESULTS

The study included 100 eyes of 100 subjects with a mean age of 58 ± 9.8 years and a median follow-up of 1.27 years (interquartile range: 0.63, 2.27). The cause of NVG was PDR in 59 eyes (59%), CRVO in 25 eyes (25%), and OIS in 16 eyes (16%). Trabeculectomy with mitomycin-C was performed in 88 eyes and trabeculectomy in 12 eyes. The cumulative complete success probability of trabeculectomy in PDR was 50% (95% confidence interval [CI]: 38, 65) at 1 year, 8% (1, 46) at 3-5 years. In OIS, it was 64% (43, 96) from 1 to 5 years. In CRVO, it was 75% (59, 94) at 1 year, 45% (23, 86) from 2 to 5 years. The PDR was associated with a higher risk of surgical failure compared to OIS (P = 0.04) and CRVO (P = 0.004). Other significant risk factors were increasing age (P = 0.02), persistent neovascularization of iris (NVI) (P = 0.03), higher number of anti-vascular endothelial growth factor (VEGF) injections prior to trabeculectomy (P = 0.02), and delay in performing trabeculectomy (P = 0.02).

CONCLUSION

Compared to CRVO and OIS, the eyes with NVG secondary to PDR had poor success with trabeculectomy. Older age, persistent NVI, need for a higher number of anti-VEGF injections, and delayed surgery were associated with a higher risk for trabeculectomy failure.

A review of neovascular glaucoma. Etiopathogenesis and treatment

Neovascular glaucoma (NVG) is a type of secondary glaucoma, refractory to treatment, often incurable, with very poor visual prognosis. It is characterized by the appearance of new vessels over the iris and iridocorneal angle and frequently associates the presence of a fibrovascular membrane which limits the aqueous humor outflow from the anterior chamber. The most common causes of NVG are: central retinal vein occlusion, proliferative diabetic retinopathy, and ocular ischemic syndrome. Once the gonioscopy developed as a part of clinical examination, it became possible to visualize the new vessels of the anterior segment of the eye in early stages and to understand the mechanisms of increased intraocular pressure (IOP), including narrowing and closing of the iridocorneal angle. Also, the modern imaging techniques, such as optical coherence tomography angiography and fluorescein angiography became indispensable for the clinician. Thus, an early diagnosis, followed by starting an appropriate therapy: panretinal photocoagulation or administration of anti-VEGF drugs, with or without hypotensive ocular therapy, allows the preservation of visual functions for patient's better quality of life. However, one or more surgeries will often be required, especially in the advanced stages of the disease, which do not respond to drug therapy. Managing the NVG we should aim to: 1) reduce ocular ischemia and treat its underlying cause, 2) reduce elevated IOP, once installed and 3) control the inflammatory process. Anyway, the best treatment is prevention, so we must be very attentive at patients with risk factors for developing the NVG. Abbreviations: NVG = neovascular glaucoma, ICA = iridocorneal angle, IOP = intraocular pressure, TM = trabecular meshwork, AH = aqueous humor, AC = anterior chamber, PRP = panretinal photocoagulation, VEGF = vascular endothelial growing factor, Anti-VEGF = anti- vascular endothelial growing factor, PAS = peripheral anterior synechiae, CRVO = central retinal vein occlusion, PDR = proliferative diabetic retinopathy, DR = diabetic retinopathy, OIS = ocular ischemic syndrome, CRAO = central retinal artery occlusion, ROP = retinopathy of prematurity, FEVR = familial exudative vitreoretinopathy, PVR = proliferative vitreoretinopathy, MMPs = matrix metalloproteinases, VEGFR = vascular endothelial growing factor receptor, PDGF = platelet-derived growth factor, PIGF = placental growth factor, NRP = neuropilins, HIF = hypoxia-inducible factor, SDF1 = stromal cell-derived factor 1, DDL4 = delta like ligand 4, NICD = Notch intracellular domain, TIMMPs = tissue inhibitors of matrix metalloproteinases, ANGPT = angiopoietin, Tie 2 = tyrosine-protein kinase receptor for angiopoietins, IGF-1 = insulin-like growth factor 1, RPE = retinal pigment epithelium, IL = interleukin, TNF = tumor necrosis factor, bFGF = basic fibroblast growth factor, TGF = transforming growth factor, HGF = hepatocyte growth factor, TNFR 2 = tumor necrosis factor receptor 2, OIR = oxygen induced retinopathy, NVI = neovascularization of the iris, NVA = neovascularization of the iridocorneal angle, FA = fluorescein angiography, RAPD = relative afferent pupillary defect, CNP = capillary non-perfusion, NVE = neovascularization elsewhere in the retina, NVD = neovascularization of the optic disc, FFA = fundus fluorescein angiography, OCTA = optical coherence tomography angiography, B-scan US = B-scan ocular ultrasound, AS-OCT = anterior segment optical coherence tomography, ARC = anterior retinal cryotherapy, FDA = food and drug administration, United States of America, BVZ = bevacizumab, RBZ = ranibizumab, AFB = aflibercept, AMD/ ARMD = age related macular degeneration, DME = diabetic macular edema, GDDs = glaucoma drainage devices, MMC = mitomycin C, 5-FU = 5-fluorouracil, AGV = Ahmed glaucoma valve, AADI = Aurolab aqueous drainage implant, MIGS = minimally invasive glaucoma surgery, BCVA = best corrected visual acuity, TVT = Tube versus Trabeculectomy study, MPC = micro-pulse cyclophotocoagulation.

Presentation, etiology and treatment outcome of neovascular glaucoma in Ekiti state, South Western Nigeria

Background

Neovascular glaucoma (NVG), a form of secondary glaucoma has varying causes across geographical locations.

Objective

The objective of this study was to determine the presentation, aetiology, and outcome of treatment of patients with NVG in a Nigerian tertiary hospital.

Method

A retrospective review of records of all cases of NVG seen over a 5year period was carried out. Demographic characteristics, presenting visual acuity and coexisting ocular and systemic conditions were noted. Data were analysed with Statistical Package for Social Sciences (SPSS) version 25.

Results

29 eyes of patients with NVG were analysed. Most of the patients (89.70%) presented with visual acuity less than 3/60 in the affected eye. All patients except one were treated with anti-glaucoma medications while only 9(31%) consented to and received anti-vascular endothelial growth factor. No patient had improvement in visual acuity despite resolution of other symptoms at 12week follow up.

Conclusion

NVG though not as common as other forms of glaucoma accounted for a large proportion of monocular blindness in the affected eyes at presentation. There is need for health promotion and education among our people on the need for early preventive eye check practices.

NEOVASCULAR COMPLICATIONS FROM CYTOMEGALOVIRUS NECROTIZING RETINOPATHY IN PATIENTS AFTER HAPLOIDENTICAL HEMATOPOIETIC STEM CELL TRANSPLANTATION

PURPOSE

To report the incidence and clinical features of neovascular complications from cytomegalovirus (CMV) necrotizing retinopathy in patients after haploidentical hematopoietic stem cell transplantation.

METHODS

Thirty-nine patients (58 eyes) of CMV necrotizing retinopathy after haploidentical hematopoietic stem cell transplantation in our institute between January 2018 and June 2020 were retrospectively reviewed, and cases that developed neovascular complications during follow-up were identified and described.

RESULTS

Two (2 eyes) cases that developed neovascular glaucoma from CMV necrotizing retinopathy were identified. Both of them manifested as granular peripheral retinitis, panretinal occlusive vasculitis, and some degree of intraocular inflammation, which were consistent with chronic retinal necrosis. Insidious progression of isolated immune-mediated occlusive vasculitis that could only be observed on fundus fluorescein angiography without active retinitis or intraocular inflammation was recognized to be the cause in one of two cases.

CONCLUSION

Neovascular glaucoma developed in 5.1%/cases and 3.4%/eyes complicated by CMV chronic retinal necrosis and vasculitis in patients after haploidentical hematopoietic stem cell transplantation, which warrants the needs for long-term follow-up. Immune-mediated CMV vasculitis could be an isolated manifestation in patients with a minimal immune deviation and may only be found on fundus fluorescein angiography, which emphasizes the importance of fundus fluorescein angiography on a regular basis during follow-up.

Increased levels of cytokines in the aqueous humor correlate with the severity of diabetic retinopathy

AIMS

To determine the associations between the levels of certain cytokines in the aqueous humor and the severity of diabetic retinopathy.

METHODS

A total of 103 patients (one eye per patient) who received intravitreal injection with ranibizumab for diabetic retinopathy were enrolled and divided into 3 groups: nonproliferative diabetic retinopathy (NPDR) with macular edema group (42 eyes), proliferative diabetic retinopathy (PDR) group (40 eyes) and neovascular glaucoma due to PDR (NVG-PDR) group (21 eyes). The concentrations of interleukin (IL)-6, IL-8, IL-10, vascular endothelial growth factor (VEGF), transforming growth factor-β (TGF-β), vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), and monocyte chemoattractant protein-1 (MCP-1) in the aqueous humor were measured.

RESULTS

In this study, 42, 40 and 21 patients (one eye per patient) were included in the NPDR, PDR and NVG-PDR groups, respectively. The median concentrations of IL-6, IL-8, IL-10, VEGF, TGF-β, VCAM-1, ICAM-1 and MCP-1 in the groups were measured. The levels of these 8 cytokines increased with the severity of diabetic retinopathy, especially in the NVG-PDR group. Compared with those in the NPDR group, the aqueous concentrations of these 8 cytokines were higher in the PDR group and were the highest in the NVG-PDR group. There were significant differences in all cytokines among the three groups (P < 0.05). Multivariate analysis showed that in the NPDR and PDR groups, the risk of PDR associated with elevated levels of TGF-β (P = 0.0004, OR 1.11, 95% CI [1.05-1.18]) and ICAM-1 (P = 0.0408, OR 10.75, 95% CI [1.10-104.61]). In the PDR and NVG groups, the risk of NVG associated with elevated levels of IL-10 (P = 0.0486, OR 0.7040, 95% CI [0.4966, 0.9979]), VEGF (P = 0.0279, OR 0.9963, 95% CI [0.9931, 0.9996]), and VCAM-1 (P = 0.0316, OR 0.9998, 95% CI [0.9996, 0.99998]). In the three groups, the risk of developing NVG associated with elevated levels of TGF-β (P < 0.001, OR 1.04, 95% CI [1.02, 1.05]).

CONCLUSIONS

The levels of these eight cytokines in the aqueous humor increased with the severity of diabetic retinopathy, especially in NVG-PDR. This study suggests that TGF-β, ICAM-1, IL-10, VEGF, and VCAM-1 may play a role in the progression of diabetic retinopathy, especially TGF-β, which may plays a significant role in NVG-PDR. These cytokines potentially may be used as biomarkers to predict the progress of diabetic retinopathy, contribute to the choice of treatment options and/or monitor treatment responses.

The efficacy and safety of intravitreal conbercept combined with mitomycin C augmented trabeculectomy for treating neovascular glaucoma

AIM

To investigate the efficacy and safety of intravitreal Conbercept (IVC) and trabeculectomy for treating neovascular glaucoma (NVG).

METHODS

We retrospectively reviewed a total of 29 eyes from 29 NVG patients. All patients received preoperative IVC combined with mitomycin C (MMC) augmented trabeculectomy with a 12-month follow-up. The best-corrected visual acuities (BCVA), intraocular pressure (IOP), and cumulative survival rate were calculated.

RESULTS

All 29 cases had complete regression of iris neovascularization at 7 days after the combination treatment, and 2 cases had residual iris neovascularization which regressed completely 1 month later. IOP decreased while BCVA improved significantly following the combination treatment. The success rates were 96.6%, 93.1%, 89.7%, 86.2%, and 82.8% at 1 week, 1, 3, 6, and 12 months after trabeculectomy, respectively. IVC injection combined trabeculectomy had few complications.

CONCLUSIONS

IVC injection of conbercept combined with trabeculectomy is effective and safe for the treatment of NVG.

Risk Factors of Neovascular Glaucoma After 25-gauge Vitrectomy for Proliferative Diabetic Retinopathy with Vitreous Hemorrhage: A Retrospective Multicenter Study

Neovascular glaucoma (NVG) is a terminal severe complication in eyes with proliferative diabetic retinopathy (PDR), and PDR eyes with vitreous hemorrhage (VH) which undergo vitrectomy may have higher risk of postoperative NVG. The incidence and the prognostic factor of postoperative NVG after 25-gauge vitrectomy with advanced surgical options remain unclear. We retrospectively reviewed medical records of 268 eyes of 268 consecutive PDR patients with VH who underwent 25-gauge vitrectomy and 12 months follow-up at seven centers. Preoperative ocular factors (visual acuity, tractional retinal detachment, panretinal photocoagulation [PRP]), demographics and clinical factors (sex, age, diabetic duration, HbA1c, hypertension, anticoagulant medication, and kidney function), surgical procedures, and postoperative complications were compared between patients who developed postoperative NVG (9.3%) and those who did not. NVG eyes was significantly younger (P = 0.026), had shorter diabetic duration (P = 0.022), higher HbA1c (P = 0.028), absence of PRP (P = 0.039) and higher frequency of postoperative VH (P = 0.0075) than non-NVG eyes. Logistic regression analysis identified postoperative VH (P = 0.014), shorter diabetic duration (P = 0.029), and no PRP (P = 0.028) as prognostic factors for postoperative NVG. This multicenter study indicates that younger age, uncontrolled diabetes, no PRP, and postoperative VH are risk factors of post-vitrectomy NVG.

Predictors of Neovascular Glaucoma in Central Retinal Vein Occlusion

PURPOSE

To determine the risk factors for development of neovascular glaucoma (NVG) in patients after an acute central retinal vein occlusion (CRVO).

DESIGN

Retrospective cohort study.

METHODS

Review of medical records of 646 patients with a diagnosis of CRVO between 2013 and 2017 at the Bascom Palmer Eye Institute.

INCLUSION CRITERIA

(1) CRVO onset to presentation <90 days; (2) absence of anterior segment neovascularization on presentation; (3) no intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection before presentation. Patients meeting inclusion criteria were screened for potential risk factors for development of NVG. Risk of developing NVG was assessed with Kaplan-Meier survival analysis and Cox proportional hazards models.

RESULTS

Thirteen of 98 patients (13%) who met inclusion criteria developed NVG. The mean adjusted time to NVG diagnosis from onset of CRVO-related symptoms was 212 days. Patients presenting with a worse initial visual acuity (P = .034), a relative afferent pupillary defect (RAPD) (P = .002), or a history of systemic hypertension (P = .026) had an increased risk of NVG compared to those who did not. Age, body mass index, history of glaucoma, history of diabetes, and central retinal thickness were not significantly associated with development of NVG.

CONCLUSIONS

Risk factors for NVG development included history of systemic hypertension, worse visual acuity on presentation, and RAPD on presentation. Patients presenting with these findings should be followed at closer intervals and informed of the greater risk for neovascularization. Intravitreal anti-VEGF therapy delayed but did not prevent NVG.

Retinal Vein Occlusion in a Woman with Heterozygous Fabry's Disease

Fabry's disease is associated with high incidence of thrombosis in hemizygous males and heterozygous females. We describe a woman with Fabry's disease who developed hemi-central retinal vein occlusion during the follow-up. The vein occlusion showed a fulminant course ending with a painful blind eye within a short period. Fabry's disease should be considered in the differential diagnosis of the vascular occlusive disorders especially in young patients.

Role of Platelet Parameters on Neovascular Glaucoma: A Retrospective Case-Control Study in China

Purpose

Retinal vein occlusion (RVO) and diabetic retinopathy (DR) are two major sight-threatening diseases which may lead to neovascular glaucoma (NVG). The aim of this study was to explore the association between platelet parameters and NVG.

Methods

A total of 185 subjects were enrolled for the study from January, 2012 to December, 2015 at the Eye-ENT Hospital of Fudan University. Patients include those with NVG secondary to RVO (RVO group, n = 38), patients with NVG secondary to DR (DR group, n = 47), diabetics mellitus without retinopathy (DM group, n = 52), and healthy individuals (control group, n = 48). A complete ophthalmological examination including visual field examination, A-scan ultrasound, Fundus photography, and measurement of platelet parameters were performed for NVG subjects.

Results

There was no statistical difference in the mean age and gender among the RVO, DR, and control groups (p>0.05). The mean level of platelet distribution width (PDW) was higher (p<0.001) in the RVO group (15.16±2.13fl) and DR group (16.17±1.66fl) when compared with the control group (13.77±2.99fl). The mean plateletcrit (PCT) value of the RVO group (0.229±0.063%) was also higher (p = 0.049) than the control group (0.199±0.045). In the DR group, mean platelet volume (MPV) value (10.72±1.57fl) was significantly higher (p = 0.002) than the control group (9.75±0.89fl). A similar trend was observed when platelet parameters were compared among the 3 groups with respect to age. The mean level of PDW was significantly higher (p<0.001) in the DR group (16.17±1.66fl) compared with the DM group (13.80±3.32fl). Stepwise multiple logistic regression analysis revealed that PDW (OR = 1.44, 95%CI = 1.149–1.805, p = 0.002) and MPV (OR = 1.503, 95%CI = 1.031–2.192, p = 0.034) were associated with the DR group, PDW (OR = 1.207, 95%CI = 1.010–1.443, p = 0.039) and PCT (OR = 1.663, 95%CI = 1.870–2.654, p = 0.036) were associated with the RVO group.

Conclusion

Our results suggest that increased PDW and MPV are associated with the NVG secondary to DR group, elevated PDW and PCT are associated with the RVO group. It indicates that platelets might be an important factor in the onset and/or development of NVG.

CLINICAL IMPACT IN THE MANAGEMENT OF NEOVASCULAR GLAUCOMA

INTRODUCTION

Neovascular glaucoma (NVG), participates in the group of secondary glaucoma causing the-increase of intraocular pressure (IOP) as a result of iridocorneal angle enclosure with the development of neovase derived from the retinal ischemic and other inflamatory diseases.

PURPOSE OF THE STUDY

Is to show the incidence, etiopathogenesis, clinical development and the management of NVG by comparing the contemporary and referring literature to other clinics.

METHODS

In this study there were presented the results of NVG treatment for the 2010- 2014 interval. The data processing were conducted using statistically package SPSS 22.

RESULTS

In this scientific study were included 61 patients with NVG containing 4.3% of all cases with glaucoma and 14% of cases with secondary glaucoma, aged 22-79. The mean age of the patients was 60.9 year (SD + 10.6 year), 39 cases or 63.9% were of masculine gender and 22 cases or 36.1% of feminine gender, as it seems there is a differentiation with a statistical significance (X2 = 4.74, P = 0.03, therefore P < 0.05). The most frequent cause of NVG was PDR in 55 cases or 55.6% of them, then, ischemic CRVO with 11 cases or 11.1%. The most frequent complications to the NVG were hemophthalmos, cataract and absolute glaucoma.

CONCLUSION

In many aspects our results were in line with the results of other authors. Therefore we should focus on the adequate treatment of ocular ischemic in time, as it is only prevention method of NVG.

NEOVASCULAR SECONDARY GLAUCOMA, ETIOLOGY AND PATHOGENESIS

RATIONALE

Neovascular secondary glaucoma is a condition characterized by increased intraocular pressure due to the neovascularization occurring at the iridocorneal angle and iris, the most common complication of end-stage ischemic retina. The early diagnosis and treatment of this disease are important, because the functional prognosis is reserved.

OBJECTIVE

Knowing and understanding the etiology and pathogenesis of neovascular secondary glaucoma.

METHODS AND RESULTS

Review of the angiogenesis theory to understand the etiology and pathogenesis of neovascular secondary glaucoma. VEGF is the most studied proangiogenic factor involved in the neovascular glaucoma pathogenesis. The 9 isoforms contain consensus signal sequences for extracellular secretion, all of them binding to a specific receptor subtype and stimulating tissue specific angiogenesis. VEGF and VEGF-m RNA levels are significantly increased in the ischemic retina. Diabetes mellitus (with diabetic retinopathy), central retinal vein thrombosis and repeated retinal detachments are diseases that cause neovascular glaucoma through ischemia.

DISCUSSION

Correct evaluation of the iris neovascularization followed by a proper treatment is the most important in a case of secondary neovascular glaucoma. Repeated gonioscopy is indicated in cases with high risk of developing neovascular glaucoma. Close monitoring of a patient with high thromboembolic risk: valvular heart disease, open-heart surgery, other angioplasties.

The fixed combination efficacy assessment in patients with secondary neovascular glaucoma and diabetes mellitus

PURPOSE

To assess IOP-lowering efficacy of bimatoprost/timolol fixed combination (Ganfort®) in patients with diabetes mellitus (DM) and uncontrolled secondary neovascular glaucoma (NG).

MATERIALS AND METHODS

Fifty patients (51 eyes) with uncontrolled secondary neovascular glaucoma and diabetes mellitus were enrolled in the study. All patients with an uncontrolled IOP have been proposed to switch current IOP-lowering therapy to Ganfort®. In case target IOP level was not reached filtration surgery was recommended. Ganfort® administration - once a day in the morning.

RESULTS

IOP-lowering has been observed in all patients when switched to Ganfort®. Mean IOP level was almost 3-x lower versus baseline in 72.5% of patients (37 eyes). The patients achieved target IOP of 15-17 mmHg. As a result, no surgical intervention was required. Significant IOP-lowering has been observed in another group of patients (14 eyes, 27.5 %) nevertheless due to glaucoma progression, these patients are still subjected to surgical treatment.

CONCLUSION

IOP-lowering fixed combination Ganfort® (Allergan) can be used in patients with secondary neovascular glaucoma and diabetes mellitus as a drug of choice to control the IOP level. Even in cases when target IOP is not achieved, Ganfort® can be administered in pre-operative period and helps to reduce postoperative complications.

Advanced exudative retinopathy with neovascular glaucoma as the clinical presentation of diabetes mellitus and severe combined hyperlipidemia: a case report

A 50-year-old man presented with bilateralprogressive visual loss for 5 months. Visual acuity was reduced to countingfingers in the right eye and light perception in the left. Although neovascularizations were detected in the angles of the eyes, neovascular glaucoma and rubeosis iridis were demonstrated only in the left. Fundus examination showed bilateral advanced exudative retinopathy in both eyes. Severe attenuated retinal arteries and enlarged cupping with disc pallor were observed in the left eye. Generalized eruptive xanthomas were found on the back and extremities. Extreme dyslipidemia (serum cholesterol 1311 mg/dl and triglycerides 6356 mg/dl) and diabetes mellitus (fasting plasma glucose 325 mg/dl and HbA1 c 12.1%) were first diagnosed. The serum lipid profiles and glucose levels were dramatically decreased within a month after treatment with subcutaneous insulin injections and oral hypolipidemic agents; notwithstanding, his vision was not significantly improved, even after treatment with intravitreal anti-VEGF injection, intravitreal steroid injection and panretinal photocoagulation.

CONCLUSION

The principle causes of advanced exudative retinopathy are severe breakdown of the blood-retinal barrier due to diabetes mellitus and altered retinal pigment epithelium lipid metabolism. In ourpatient, central retinal vascular occlusion was also the suspected cause ofneovascular glaucoma.

[Evaluation of the effectiveness of Ganfort treatment in patients with secondary neovascular glaucoma associated with diabetes mellitus]

PURPOSE

To evaluate the effectiveness of bimatoprost/timolol fixed combination (Ganfort) in decreasing intraocular pressure (IOP) in patients with diabetes mellitus (DM) and uncontrolled secondary neovascular glaucoma (NG).

MATERIAL AND METHODS

The study included 50 patients (51 eyes) with diabetes mellitus and sings of uncontrolled secondary NG, which was later confirmed by the results of ophthalmological assessment. All the patients were offered to change their IOP-lowering medications and if the new regimen is still ineffective--to undergo drainage surgery. Therefore they were switched to Ganfort once daily in the morning.

RESULTS

After switching the therapy a decrease of intraocular pressure was observed in 100% of cases. In 72.5% of patients (37 eyes) the average IOP was almost 3 times lower than at the baseline and achieved target values (15-17 mm Hg), thus allowing to avoid surgical intervention. In 27.5% of patients (14 eyes), despite a significant decrease of IOP, surgical treatment was considered still necessary due to glaucoma progression and, therefore, drainage surgery was performed.

CONCLUSION

The IOP-lowering combination Ganfort (Allergan) can be used in patients with secondary neovascular glaucoma and diabetes mellitus as the treatment of choice. Even if target IOP is not achieved, Ganfort is still useful as a preoperative medication able to reduce postoperative hemorrhagic complications.

[Ocular ischemic syndrome--a case report]

Ocular ischemic syndrome, also known as hypoperfusion/ hypotensive retinopathy or as ischemic oculopathy is a rare ocular disease determined by chronic arterial hypoperfusion through central retinal artery, posterior and anterior ciliary arteries. It is bilateral in 20% of the cases. Most often it appears due to severe occlusion of the carotid arteries (ICA, MCA>ECA), described in 1963 by Kearns and Hollenhorst. Occasionally it can be determined by the obstruction of ophtalmic artery or some arterities (Takayasu, giant cell arteritis). The risk factors are: age between 50-80 years, males (M:F = 2:1), arterial hypertension, diabetes, coronary diseases (5% of the cases develop ocular ischemic syndrome), vascular stroke, hemodialysis. The case we present is of an 63 years old man known with primary arterial hypertension, hypercholesterolemia, diabetes type 2 non insulin dependent and diagnosticated with ischemic cerebral stroke and bilateral obstruction of internal carotid arteries in march 2010, who is presenting for visual impairment in both eyes. The imaging investigations show important carotid occlusion and at the ophthalmologic evaluation there are ocular hypertension and rubeosis iridis at the right eye, optic atrophy at both eyes (complete in the right eye and partial in the left eye), with superior altitudinal visual field defect in left eye. The following diagnosis was established: Chronic ocular ischemic syndrome in both eyes with Neovascular glaucoma at the right eye, Anterior ischemic optic neuropathy at the left eye and laser panphotocoagulation at the right eye was started.

Management of neovascular glaucoma

INTRODUCTION

Neovascular glaucoma is an atrophic optic neuropathy resulting from the neovascularization of the iridocorneal angle increasing the intraocular pressure.

PURPOSE OF THE STUDY

To show the incidence of NVG in comparison to the other types of glaucoma and to compare with the relevant literature data and other referent clinics.

MATERIAL AND METHODS

In this study were included 116 patients with NVG, of whom 75 or 64.7% male and 41 or 35.3% female, treated from January 2003 until February 2013.

RESULTS

Visual acuity damages from NVG, were classified as big damages with 84.7% of cases and minor damages with 15.3% of cases. Cases with heavy damages were the cases with blindness, L+P+/- up to V = 0.3 and cases with slightly damages with V = 0.4-1.0. NVG caused by PDR with 52 cases or 44.8% and CRVO with 12 cases or 10.3%.

CONCLUSION

We should be focused on prevention of diabetic retinopathy which requires interdisciplinary cooperation. In cases when diabetic retinopathy is present, we have to advise patients to undergo PRP as soon as possible, since it is the only way to prevent NVG and heavy consequences.

Neovascular glaucoma: a retrospective review of 5-year experience in Songklanagarind Hospital

OBJECTIVE

To review causes, treatment modalities, and success of neovascular glaucoma treatment in the past five years at Songklanagarind Hospital.

MATERIAL AND METHOD

Neovascular glaucoma of any causes between February 2005 and January 2010 were retrospectively reviewed. The patients were divided into six major treatment subgroups. A medical treatment group, an intraocular bevacizumab injection group (IOB), a trabeculectomy with mitomycin C group, a trabeculectomy with mitomycin C plus adjunctive intraocular bevacizumab injection group, a glaucoma drainage device group, and a transscleral cyclophotocoagulation group. All treatment outcomes were compared and classified as success or failure according to the specific criteria.

RESULTS

One hundred and sixty-six eyes were reviewed. The mean age at the time of diagnosis was 60 +/- 16 years and the average follow-up duration was 21 +/- 18 months. The most common etiology was central retinal vein occlusion (47%) followed by proliferative diabetic retinopathy (42%) and ocular ischemic syndrome (5%). The mean pressure was reduced from 38.1 +/- 12.5 mmHg at baseline to 17.8 +/- 12.3 mmHg at the final visit. After treatment, visual acuity was worse, remained stable, and improved in 45%, 37%, and 18% of the patients, respectively. In the trabeculectomy with mitomycin C plus intraocular bevacizumab injection group 54% of eyes were classified as a complete success, which was significantly higher than the other groups (p < 0.001). Although filtering surgeries with adjunctive bevacizumab showed no benefit over standard filtering surgeries in terms of VA change, pressure reduction, and success criteria but complications were found to be less in eyes treated with adjuvant bevacizumab.

CONCLUSION

Key factors are treatment of the underlying disease responsible for ischemic triggers and treatment of the increased intra-ocular pressure. Even treatment with bevacizumab cannot increase the success rate but this seems to reduce the surgical complications.

[Neovascular glaucoma--etipathogeny and diagnosis]

Neovascular glaucoma is defined as an iris and/or anterior chamber angle neovascularization associated with increased intraocular presure. It is a secondary glaucoma most frequently determined by a severe retinal ischemia. The most common diseases responsible for the development of neovascular glaucoma are diabetic retinopathy, ischemic central retinal vein occlusion and ocular ischemic syndrome; the uncommon causes include ocular radiation, ocular tumors, uveitis and other miscellaneous conditions. Vascular endothelial growth factor is an important and probably predominant agent in the pathogenesis of both intraocular neovascularization and neovascular glaucoma. The evolution of clinical and histopathological changes from predisposing conditions to the occurrence of rubeosis iridis as well as neovacular glaucoma is divided into four grades that is prerubeotic, preglaucomatous, open-angle and angle closure glaucoma stages.

[Treatment of neovascular glaucoma]

Neovascular glaucoma management is divided into preventive and curative procedures.Pre vention therapy consists of the treatment of the common underlying causes of the disease (ie diabetic retinopathy, ischemic central retinal vein occlusion and ocular ischemic syndrome) as well as the less frequent causes attributed to ocular radiation, ocular tumors, uveitis and other miscellaneous condi tions.Curative therapy includes both the neovascularization treatment and the treatment of the in creased intraocular pressure.lntravitreal Bevacizumab injection enables us to block up the neovascular trigger preparing thereby the pacient to a complement of panretinal photocoagulation or surgical treatment. Since Bevacizumab injection activity is transient, the retinal ischemia treatment by panretinal photocoagulation is mandeited in order to avoid neovascular recurrence.Short term efficacy of Bevacizumab injection is obvious with a constant, marked and swift intraocular pressure lowering espe cially in less severe and/or early forms of the disorder. In more advanced stages of neovascular glaucoma after closing the chamber angle by peripheric anterior synechiae the outcomes of this treatment are inconstant, most of cases necessitating the resorting to surgery (trabeculectomy with antifi brosis drugs or glaucoma drainage implants).

Relationship between sleep-disordered breathing and iris and/or angle neovascularization in proliferative diabetic retinopathy cases

PURPOSE

To investigate whether sleep-disordered breathing is a risk factor for iris and/or angle neovascularization in patients with proliferative diabetic retinopathy (PDR).

DESIGN

Cross-sectional comparative case series.

SUBJECTS AND METHODS

One hundred fifty-one consecutive patients with PDR who underwent surgery in our hospital were divided based on the presence of iris and/or angle neovascularization (NV group, 37 patients) or absence of NV (non-NV group, 114 patients). Pulse oximetry was conducted during the night and the mean SpO(2), 4% oxygen desaturation index (4% ODI times/hour), the lowest SpO(2)% during sleep (lowest SpO(2)), and the cumulative percentage of time at SpO(2) <90% in analysis times (CT90%) were calculated. When the 4% ODI exceeded 5 times/hour, sleep-disordered breathing was diagnosed. The results were compared between the 2 groups. Preoperative systemic parameters also were analyzed by logistic regression to clarify risk factors for the NV group.

RESULTS

A mean total of 50% (62% of the NV group and 46% of the non-NV group) was diagnosed with sleep-disordered breathing. The mean SpO(2) and lowest SpO(2) did not differ significantly between the 2 groups; the 4% ODI (12.3 vs 6.6) and CT90% (3.8 vs 1.7) were significantly higher in the NV group (P=.02, for both comparisons). Logistic regression analysis identified insulin therapy (odds ratio [OR], 3.01; 95% confidence interval [CI], 1.26∼7.20; P=.01); and 4% ODI (OR, 1.09; CI, 1.01∼1.16; P=.02) as risk factors for the NV group.

CONCLUSIONS

In patients with PDR, nocturnal intermittent hypoxia/reoxygenation resulting from sleep-disordered breathing may be a risk factor for iris and/or angle neovascularization.

[A surgical treatment for neovascular terminal glaucoma (preliminary communication)]

In 40 patients with terminal neovascular glaucoma of various genesis (visual acuity 0 to wrong light projection), 4 rectus muscles were tightly ligated at the insertion site of their strings to the sclera of the eyeball with silk threads under local anesthesia. The threads were not postoperatively removed and left under the conjunctiva (Invention Patent No. 2286752 of November 10, 2006). The proposed procedure for blocking the anterior ciliary arteries may be used as the method of choice in patients with terminal neovascular glaucoma. It makes it possible to achieve a steady-state reduction in intraocular pressure, by improving humor outflow from the corner of the anterior chamber, to diminish or completely eliminate pain syndrome and corneal edema, by maintaining the mobility of the eye in corpore, and to avoid enucleation.

[Clinical features of hypoperfusion retinopathy induced neovascular glaucoma]

OBJECTIVE

To analyze the clinical features of hypoperfusion retinopathy induced neovascular glaucoma

METHODS

This retrospective case series included 18 cases (18 eyes) with hypoperfusion retinopathy induced neovascular glaucoma Among them, there were 15 male and 3 female; 10 right eye and 5 left eye. The average age was 40-year-old (ranged from 18- to 78-year-old). Visual acuity and fundus were examined using fundus fluorescein angiography (FFA), Color Doppler Flow Imaging (CDFI), magnetic resonance angiography (MRA), and Digital subtraction angiography (DSA) etc in all patients.

RESULTS

The visual acuity was ranged from light perception to 0. 8 in all patients. The clinical features in hypoperfusion retinopathy induced neovascular glaucoma were characterized by midperipheral intraretinal hemorrhages, narrowed retinal arteries, dilated retinal veins, neovascularisation in iris and anterior chamber angle, ocular hypertension, excavation and atrophy of optic disk, and visual field defects when glaucoma progressed. All eyes have either ipsilateral common carotid artery obstruction or severe bilateral obstruction of the internal carotid arteries.

CONCLUSIONS

Neovascular glaucoma is a rare and severe complication of hypoperfusion retinopathy associated with either ipsilateral common carotid artery obstruction or severe bilateral obstruction of the internal carotid arteries. Fundus degeneration is commonly involved in one eye. The characteristic clinical features are presented during the process of the disease.

Ocular complications associated with diabetes mellitus

Diabetes is a progressive disease that may adversely affect healthy functioning of the body. The eyes are often indicators of systemic disease and are particularly vulnerable to the pathophysiological changes that occur as a result of diabetes. This article provides an overview of five main ocular complications associated with diabetes, cataract, diabetic retinopathy, central retinal vein occlusion, central retinal artery occlusion and neovascular glaucoma. The assessment and treatment of such complications and the role of the nurse in the care and management of patients are discussed.

Bilateral choroidal metastases presenting as acute glaucoma crisis

We report a case of bilateral choroidal metastasis presenting with acute unilateral glaucoma. Primary tumor was found in the lung and choroidal masses in both eyes. Anterior segment neovascularization causing intraocular pressure elevation was the only presenting sign of metastatic choroidal tumor. A painful and hypertensive eye could be symptoms of choroidal metastasis even if no systemic malignancy is encountered.

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.

[Neovascular glaucoma: aetiology, pathogenesis and treatment]

Neovascular glaucoma, as a typical secondary glaucoma, is due to ocular or (earlier) systemic diseases. The formation of a fibrovascular membrane on the anterior surface of the iris (rubeosis iridis) and extending into the chamber angle leads to irreversible obliteration of the outflow system, with a corresponding rise in intraocular pressure. The most frequent cause is retinal ischaemia resulting either from vascular occlusion or from diabetic alterations. The differential diagnosis must include acute angle-closure glaucoma and uncontrolled open-angle glaucoma. Treatment is aimed at eliminating the actual cause or at least reducing the risk factors (e.g. by retinal laser coagulation), or consists in cyclodestructive procedures. Medicamentous therapy comprises anti-inflammatory agents (steroids, cycloplegic agents) and substances that reduce the production of aqueous humour (carbonic anhydrase antagonists, beta blockers). In the near future, antiangiogenic medication might be another effective option. For end-stage neovascular glaucoma, the implantation of drainage devices is also discussed.

Ocular neovascularization in a patient with Fanconi anemia

CASE REPORT

An 11-year-old girl diagnosed with Fanconi anemia was referred to us for redness and pain in her right eye. Findings in the right eye included visual acuity of counting fingers, neovascular glaucoma, vitreous hemorrhage, optic disc neovascularization, and features of peripheral ischemic retinopathy. Findings in the left eye included peripheral retinal neovascularization and areas of retinal capillary nonperfusion.

COMMENTS

Patients with Fanconi anemia may develop ocular neovascularization with subsequent severe visual loss due to vitreous hemorrhage or neovascular glaucoma. Regular ophthalmic examination, including ophthalmoscopy and fluorescein angiography in selected cases, is recommended in such patients.

Combined central retinal artery and vein occlusion in Churg-Strauss syndrome: case report

PURPOSE

To describe a rare case of Churg-Strauss syndrome presenting with severe visual loss due to a combined central retinal vein and artery occlusion.

METHODS

A 42-year old man with a medical history of asthma and blood hypereosinophilia developed a sudden loss of vision in his right eye. We describe the clinical features and evolution of the case after treatment.

RESULTS

A combined occlusion of the central retinal artery and central retinal vein was diagnosed by the funduscopic appearance of retinal whitening, macular cherry-red spot, papilloedema, retinal haemorrhages in all four quadrants and dilated and tortuous veins. The diagnosis was confirmed by a fluorescein angiogram showing absence of retinal filling and normal choroidal filling. Churg-Strauss syndrome was diagnosed based on the necessary presence of four of six criteria for the disease proposed by the American College of Rheumatology. Corticosteroid therapy was initiated. However, during the following year when tapering off the daily dosage, the patient experienced two relapses, with pulmonary symptoms and hypereosinophilia, and the corticosteroid dosage had to be augmented. The patient presented with neovascular glaucoma 7 weeks after the vascular occlusion and experienced no visual improvement.

CONCLUSION

Combined central retinal artery and vein occlusion can occur in Churg-Strauss syndrome. We suggest that regional vasculitis may be the pathological mechanism underlying the vascular occlusions observed in our case. The condition carries a very poor prognosis for vision, due to the resulting retinal ischaemia, and a poor general prognosis due to the late stage of the systemic disease. Corticosteroids should be instigated promptly in order to prevent further systemic or ocular vasculitis.

[Clinical features of central retinal vein occlusion complicating exudative retinal detachment]

OBJECTIVE

To investigate the clinical features of central retinal vein occlusion (CRVO) complicating exudative retinal detachment (ERD).

METHODS

General health, vision, intraocular pressure, appearance of the fundus and fundus fluorescein angiography (FFA) and the results of ultrasound examination in cases with CRVO complicating ERD were analyzed.

RESULTS

Eight patients were male and 7 patients were female. Age of those patients ranged from 18 to 42 years, averaged 25 years. Five cases combined with neovascular glaucoma. Initial vision ranged from 0.05 to light perception. There were notably edema and hemorrhage in the macular region. Extensive exudative appeared at the edge of edema and detachment region. The extent of retinal detachment was 2/12 - 5/12 quadrant at sitting position. No collateral vessels were found on the optic disk. FFA showed extensive blockage by the hemorrhages or capillary nonperfusion.

CONCLUSIONS

ERD is a rare and severe complication of CRVO, which usually develops in young patients and combines with neovascular glaucoma. The appearance in fundus and FFA shows a characteristic features.

Differential diagnosis of anterior chamber cysts with ultrasound biomicroscopy: ciliary body medulloepithelioma

PURPOSE

To describe a case with motile cyst in the anterior chamber in the right eye of a 7-year-old boy.

METHODS

The right eye's visual acuity was 20/50. Intraocular pressure was 59 mmHg. Slit-lamp examination showed prominent rubeosis iridis and a grey-white mass floating freely in the anterior chamber. Ultrasound biomicroscopy revealed a cystic mass in the anterior chamber. A diagnostic cyclectomy with removal of the anterior chamber cyst was performed. Histopathology of the anterior chamber lesion showed an intact cyst composed of medullary epithelial cells. Medulloepithelioma with malignant criteria was diagnosed and the eye was enucleated.

RESULTS

Pathology demonstrated an medulloepithelioma with a few mitotic figures and nuclear pleomorphisms within the ciliary body. The patient was followed for 8 months without any metastasis in the orbit or elsewhere.

CONCLUSION

Intraocular medulloepithelioma is a rare embryonic benign or malignant neoplasm typically diagnosed in the first decade of life as a ciliary body mass. A dislodged, free-floating anterior chamber cyst associated with neovascular glaucoma is typical of medulloepithelioma in children. This unique presentation should be differentiated from congenital iris epithelial, post-traumatic, epithelial, parasitic and neoplastic cysts. Ultrasound biomicroscopy is useful for analysing the structure of the anterior segment mass. Ciliary body medulloepithelioma is characterized by echogenic mass heterogeneity and an irregular surface containing multiple cystic cavities. Lack of glial differentiation may predict a better clinical outcome in primary neuroectodermal brain tumours.