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

Neovascular glaucoma (NVG) is a devastating secondary glaucoma characterized by the appearance of neovascular over the iris and the proliferation of fibrovascular tissue in the anterior chamber angle. Proliferative diabetic retinopathy (PDR) is one of the leading causes of NVG. Currently increasing diabetes population drive the prevalence rate of NVG into a fast-rising lane. The pathogenesis underlying NVG makes it refractory to routine management for other types of glaucoma in clinical practice. The combination of panretinal photocoagulation (PRP), anti-vascular endothelial growth factor (VEGF) injections, anti-glaucoma drugs, surgical intervention as well as blood glucose control is needed. Early diagnosis and aggressive treatment in time are crucial in halting the neovascularization process and preserving vision. This review provides an overview of NVG secondary to diabetic retinopathy (DR), including the epidemiology, pathogenesis and management, so as to provide a better understanding as well as potential therapeutic strategies for future treatment.

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.

Severe vaso-occlusive lupus retinopathy in the early stage of a pediatric patient with systemic lupus erythematosus: a case report

INTRODUCTION

Systemic lupus erythematosus (SLE) is a multisystem, chronic, autoimmune disease which can affect any organ system including the eye. About one-third of the patients can be diagnosed with SLE-related eye involvement which is usually indicative of disease activity. Retinopathy is one of the most vision-threatening complications that can be associated with the disease.

PATIENT CONCERNS

An 11-year-old girl was hospitalized with complains of repeated swelling and pain in her extremities for 1 month, chest pain for 24 days, rash for 5 days and proteinuria for 1 day. On the morning of her fourth day in hospital, she suddenly complained of sudden, painless vision loss in the left eye. The ophthalmologist found that she had obstruction of central retinal vein and artery with diffuse retinal hemorrhages and macular edema.

DIAGNOSIS

The patient was diagnosed with systemic lupus erythematosus, lupus nephritis, and lupus retinopathy through her clinical manifestations and laboratory tests.

INTERVENTIONS

After diagnosis, she received steroid therapy, retinal laser photocoagulation, and intravitreal injection of dexamethasone (OZURDEX, Allergan Pharmaceuticals, Dublin, Ireland) early in her course.

OUTCOMES

At the latest follow-up, her vision improved partially. However, she still has the possibility of subsequent neovascular glaucoma and bleeding in the future.

CONCLUSIONS

An early diagnosis and the prompt therapeutic measures are necessary to prevent sight-threatening consequences, especially in pediatric patients with SLE.

Neovascular glaucoma after vitrectomy in patients with proliferative diabetic retinopathy

To evaluate the prevalence and risk factors of neovascular glaucoma (NVG) after vitrectomy in patients with vitreous hemorrhage associated with proliferative diabetic retinopathy (PDR). This retrospective, noncomparative, observational study included 127 eyes of 127 patients with PDR who received vitrectomy with a follow-up period of at least 6 months. The prevalence of NVG and associated risk factors were assessed including sex, age, previous panretinal photocoagulation, baseline intraocular pressure, combined phacovitrectomy, and pretreatment with intravitreal bevacizumab (IVB) before vitrectomy for the treatment of vitreous hemorrhage. NVG developed in 15 (11.8%) of 127 patients. Of the 15 eyes with NVG, 11 cases (73.3%) postoperatively developed NVG within 6 months. Postoperative NVG was associated with preoperative IVB treatment (odds ratio, 4.43; P = 0.019). The prevalence of NVG after vitrectomy was 11.8%, and an associated risk factor for NVG was preoperative IVB for the treatment of vitreous hemorrhage.

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.

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 in a Nigerian African population

OBJECTIVE

To determine the ocular and systemic factors associated with neovascular glaucoma (NVG) in an African population.

DESIGN

Hospital based cross sectional study.

SETTING

Eye clinic, Department of Ophthalmology, University College Hospital, Ibadan, Nigeria.

SUBJECTS

Sixty one consecutive patients with clinical diagnosis of NVG seen between January 1995 and December 1999 had a complete ocular evaluation.

RESULTS

Among the 61 subjects studied with an identifiable aetiological factor presumably causing neovascular glaucoma, 82% had associated posterior segment diseases producing ischaemia. These were retinal venous obstruction (78.7%), retinal arterial occlusion (1.6%). Those with no identifiable vaso-occlusive disease had couching (11.5%), aphakia with vitreous loss (3.3%) and chronic uveitis (1.6%). Systemic arterial hypertension was present in 62.3% while diabetes mellitus was present in only 8.3% of the subjects studied. Chronic uveitis and penetrating eye injury were infrequently diagnosed. Chronic open angle glaucoma was present in the other eye of 37.7% of subjects. Neovascular glaucoma was unilateral in 95.1% of subjects. 84.4% of affected eyes were blind on presentation. Males outnumbered females among subjects with NVG above 40 years, while females outnumbered males in the subjects below 40 years of age. Eyes of that were couched constitute a significant proportion of subjects with neovascular glaucoma.

CONCLUSION

Medical conditions such as systemic hypertension, diabetes and ocular conditions like retinal vein, retinal artery occlusion, couching and glaucoma were associated with NVG. Most of these ocular and systemic associations should be identified early and treated to prevent neovascular glaucoma in the other eye of the subject.

[Prevalence of glaucomas in a Black Cameroonian population]

OBJECTIVES

To determine the prevalence and the various types of glaucoma in a Black urban Cameroonian population.

MATERIAL AND METHOD

A retrospective analysis of 1,343 glaucomatous patients' files (757 men and 586 women) from a total of 24,462 Cameroonian patients of all ages was carried out from January 1991 to December 2001 in the Douala General Hospital in Cameroon in Central Africa.

RESULTS

The prevalence of glaucoma of all types is 5.5%. It increases with age. Of subjects with glaucoma, 79.6% had not been previously diagnosed. The mean patient's age is 53.3 (+/-17.1) years. The mean intraocular pressure is 29.6 (+/-12.6) mmHg. The mean vertical cup-disc ratio is 0.7 (+/-0.2). The prevalence of primary glaucoma of any type is 4.5%. The overall prevalence of primary open-angle glaucoma, primary angle-closure glaucoma and congenital glaucoma was 4.3%, 0.03% and 0.07%, respectively. The normal-tension glaucoma is rare in this study (6.3% of primary open-angle glaucoma).The most common form of primary angle closure glaucoma is chronic angle closure glaucoma (61,1%) and is usually undiagnosed due to a lack of gonioscopic evaluation. The prevalence of secondary glaucoma of any type is 1%. The most common forms of secondary angle closure glaucoma were neovascular glaucoma (47.4% of cases with the prevalence of 0.5%) and post-traumatic glaucoma (23.1% of cases with the prevalence of 0.2%). Prevalence of bilateral and monocular blindness due to glaucoma is 8% (108/1,343) and 32.9% (441/1,343) respectively of glaucoma patients.

CONCLUSION

This study confirms the high prevalence of glaucoma in a black African population. Gonioscopy is an important diagnostic tool that should be promoted to guide more effective glaucoma treatment in our region. The very high rate of blindness among the glaucoma patients in Cameroon is due to a lack of care. The patients are young, the disease is advanced, and compliance and follow-up are poor. Glaucoma surgery therefore offers a favourable option from an economical standpoint. Glaucoma is a devastating disease and constitutes a significant public health problem.

Rubeosis iridis als Komplikation bei Zentralarterienverschluss

BACKGROUND

Iris neovascularization (IN) with a secondary angle closure glaucoma is a complication of central retinal artery occlusion (CRAO). Its incidence is greatly underestimated.

MATERIALS AND METHODS

In a retrospective study we analyzed all patients with CRAO seen within 2 years who were treated in our department. We looked especially for the frequency of the occurrence of IN.

RESULTS

In 27 patients with CRAO, 5 developed an IN with a secondary neovascular glaucoma with high intraocular pressure. Thus, the frequency of IN was 18 % in our patients. The IN occurred 2 months to 2 years after the occlusion. Visual acuity in three eyes was between 1/20 and light perception and two eyes had no light perception. In all cases a panretinal laser treatment was performed. Three eyes were additionally treated with a peripheral retinal cryocoagulation and cyclophotocoagulation. In the histories of these patients, diabetes mellitus and arterial hypertension were found.

CONCLUSIONS

In previous studies it has been shown, that ischemia/reperfusion injuries of the retina after CRAO predispose to IN (incidence 3 - 18 %). Although it has been shown that the majority of IN occurs within three months, our data show that IN may occur as a severe complication of CRAO even later. Patients should be followed-up closely (including gonioscopy), to diagnose the occurrence of IN early. Recommended treatment is panretinal laser coagulation or -- in the case of a secondary angle closure glaucoma -- cyclophotocoagulation, respectively.

Incidence of radiation retinopathy after high-dosage single-fraction gamma knife radiosurgery for choroidal melanoma

OBJECTIVE

To investigate the incidence and clinical findings of radiation retinopathy after single-fraction high-dose gamma knife radiosurgery for choroidal melanoma.

DESIGN

Retrospective noncomparative interventional case series.

PARTICIPANTS

Thirty-two patients with choroidal melanoma.

METHODS

Review of charts, color fundus photographs, and fluorescein angiograms of 32 choroidal melanoma patients after radiosurgery. All patients were treated with the Leksell gamma knife in one fraction with a marginal dose between 40 and 80 Gy (median, 50 Gy) and were followed for at least 24 months (or until enucleation because of complications secondary to radiation).

MAIN OUTCOME MEASURES

Any clinical feature of radiation retinopathy and neovascular glaucoma.

RESULTS

During a mean follow-up of 38 months (range, 6-81 months) we found radiation retinopathy in 84% of our patients. The most common findings in these patients were intraretinal hemorrhages with an incidence of 70%, macular edema and capillary nonperfusion in 63%, and hard exudates in 52% of the patients. Less common were microaneurysms in 30% and retinal neovascularization in 22%. The time of onset of the various radiation-associated retinal findings ranged between 1 and 22 months. Forty-seven percent of all patients developed neovascular glaucoma. In our study there was no correlation between radiation dosage applied and clinical findings.

CONCLUSIONS

Single-fraction high-dose Leksell gamma knife radiosurgery of choroidal melanomas with a median marginal dose of 50 Gy is highly associated with early radiation retinopathy and with neovascular glaucoma.

Rubeosis iridis after vitrectomy for diabetic retinopathy

BACKGROUND

Iris rubeosis and neovascular glaucoma (NVG) are serious complications of vitrectomy for proliferative diabetic retinopathy. The present study analyzes incidence and risk factors of these complications.

METHODS

Preoperative and postoperative iris rubeosis were compared in 389 diabetic eyes after vitrectomy. Minimum follow-up was 6 months (median 26 months). Risk factors were studied using multivariate logistic regression analysis.

RESULTS

Following vitrectomy, in 8.5% of the eyes stromal iris rubeosis developed de novo; NVG occurred in 5%. Significant risk factors for postoperative rubeosis were preexisting iris neovascularizations and postoperative retinal detachment. Six months after surgery, regression of preexisting iris rubeosis was observed in 57% of the eyes. In eyes without preoperative iris rubeosis, progression was found in 13% of cases 6 months postoperatively.

CONCLUSION

With current surgical techniques iris rubeosis is more commonly regressive than progressive after vitreous surgery in diabetic eyes.

[The relation between retinal venous occlusions and glaucoma]

The association of the open-angle glaucoma and the retina venous occlusion constitutes an aggravating factor, the two affections influencing to each other. The study of a number of 168 venous obstructions of the retina, 56% of which being obstruction of the central vein and 44% of ramus, have evaluated appearing as edematous capillaropathy for 36% cases, ischemic capillaropathy for 44% and mixed forms for 20% ones. The retina venous occlusions have evaluated for 70% for masculine gender and 30% for feminine. From all the predisposed affections the hypertension and arteriosclerosis were for 58% all over the cases; dyslipidemias for 15%; hypercholesterolemia for 11%, diabetes for 8%. In the occlusion of the venous ramus the opened angle glaucoma, that has preceded thrombosis, was at the same frequency as for the general population, while in the obstruction of the central vein, the opened angle glaucoma has preceded thrombosis for 18% of all the cases, so it may be considered as a favourable factor by slowing down the sangvin flux. The opened-angle glaucoma hasn't influenced the appearing of the retina thrombosis. The second neurovascular glaucoma, an irreducible complication of the ischemic capillaropathy was for 22% of the studied cases. During the presence of a retina venous thrombosis is necessary a systematic examinations of the ocular tension, for finding an opened-angle glaucoma pre-existed to thrombosis.

Long-term results of helium ion irradiation of uveal melanoma

Between 1978 and 1988, 307 patients with uveal melanoma were irradiated using helium ions at Lawrence Berkeley Laboratory. The length of follow-up ranged from 1-115 months (median 42 months). The 5-year actuarial treatment results were: local control rate, 96.8%, determinate survival rate, 81%, freedom from distant metastases, 76%, eye retention rate, 83%, and risk of developing neovascular glaucoma, 36%. Long-term vision outcome was analyzed in 81 patients with a minimum follow-up of 5 years. Forty-seven percent of patients retained vision of 20/200 or better. The median change in vision was a loss of four lines on the standard eye chart. Thirty-eight percent of patients had visual acuity either improve or remain within two lines of their pretreatment vision. A multivariate analysis identified tumor size as the only independently significant risk factor affecting survival, development of neovascular glaucoma, or the risk of enucleation; no risk factor correlated with local recurrence. Tumor size, tumor-fovea distance, and pretreatment visual acuity were independently significant risk factors influencing vision outcome. These results confirm that helium ion irradiation is an effective treatment for uveal melanoma which combines high rates of local control, survival, and eye retention with a substantial likelihood of long-term vision preservation.

Argon laser panretinal photocoagulation in ischemic central retinal vein occlusion. A 10-year prospective study

We conducted a prospective, planned study of argon laser panretinal photocoagulation (PRP) in ischemic central retinal vein occlusion (CRVO) over a 10-year period in 123 eyes. On comparing the lasered eyes versus the nonlasered eyes, there was no statistically significant difference between the two groups in the incidence of development of angle neovascularization (NV), neovascular glaucoma (NVG), retinal and/or optic disc NV, or vitreous hemorrhage, or in visual acuity. Our study, however, did show a statistically significant (P = 0.04) difference in the incidence of iris NV between the two groups, with iris NV less prevalent in the laser group than in the nonlaser group, but only when the PRP was performed within 90 days after the onset of CRVO. The other parameter which showed a statistically significant difference between the two groups was the peripheral visual fields-the laser group suffered a significantly (P less than or equal to 0.03) greater loss than the non-laser group. We discuss the implications of these findings in light of the natural history of ischemic CRVO and of ocular NV. Since the original rationale for advocating PRP in ischemic CRVO was the proven beneficial effect of PRP on ocular NV in proliferative diabetic retinopathy, we also discuss the disparities in the disease process between ischemic CRVO and proliferative diabetic retinopathy and in their responses to PRP.