[Current views on pathogenesis and treatment of neovascular glaucoma]. / Sovremennye vzglyady na patogenez i lechenie neovaskulyarnoi glaukomy.

Neovascular glaucoma is a type of secondary glaucoma characterized by the most severe course, and ranking second among the causes of irreversible blindness. This review summarizes the results of numerous studies devoted to the search for prevention measures and the most effective treatment strategy. The main ways of preventing the development of neovascular glaucoma are timely diagnosis and elimination of ischemic processes in the retina, combined with adequate control of intraocular pressure and treatment of the underlying disease.

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.

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.

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 (ß =0.7, P < 0.001) and recurrent vitreous hemorrhage (ß = 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.

Retinal vein occlusions associated or complicated with glaucoma. Aspects of prediction and paths of progression.

Background and Objectives: The aim of the study is to evaluate prediction factors and progression paths when retinal vein occlusions are associated with preexisting glaucoma or complicated with neovascular glaucoma. Materials and Methods: The study included 111 patients diagnosed with retinal vein occlusions, of whom 21 with preexisting open angle glaucoma and 12 with neovascular glaucoma as complication. The study was conducted from September 2020 to September 2022 in Timisoara, Romania. We assessed intraocular pressure, cup-disc ratio and retinal nerve fiber layer from the moment of retinal vein occlusion diagnosis until at least one year of follow-up, considering these aspects as values of prediction concerning the paths of progression when glaucoma and retinal vein occlusions come together. Results: The mean initial IOP for the affected eyes was higher (15.89 ± 2.73) than for fellow eyes (15.20 ± 3.11), with an increase of the IOP after one year, but with no statistically significant differences for the affected eyes (p=0.116) or for the other eyes (p=0.684), neither for the affected eyes associated with glaucoma in comparison with affected eyes without glaucoma association. The mean cup-disc ratio was higher for the affected eyes in comparison with the fellow eyes (0.4812 ± 0.219 for the affected eyes and 0.4738 ± 0.229 for the fellow ones in cases without associated glaucoma and 0.681 ± 0.157 for the affected eyes and 0.600 ± 0.241 for the fellow eyes in cases with associated glaucoma), with statistical significant differences in the evolution for both groups in comparison with the unaffected eyes (p=0.0056 for the first group and p=0.0003 for the second group). Comparing the evolution of the affected eyes with the preexisting glaucoma and the affected eyes without preexisting glaucoma, no statistical difference has been found (p=0.1104). The mean retinal nerve fiber layer decreased significantly in affected eyes without glaucoma (from 96 ± 14.71 to 89.16 ± 13.07) and in affected eyes with associated glaucoma (from 78.50 ± 4.23 to 75.50 ± 5.83), but with no significant differences (p=0.182). The level of decreasing was significantly more consistent in association with a venous occlusion (p= 0.0001). Conclusions: The findings of the current study fortify the correlation between glaucoma as a risk factor for retinal venous occlusion development, the intraocular pressure and optic nerve cupping as prediction factors in retinal venous occlusions, the association of a well-controlled preexisting glaucoma with no effect on the progression of the retinal venous occlusions and the development of a neovascular glaucoma with a much aggressive and different path of disease progression.

Neovascular glaucoma with combined retinal vascular occlusion in carotid cavernous fistula.

Carotid cavernous fistulas (CCFs) can present with varied ophthalmic manifestations. The most important vision-threatening complications of CCF include glaucoma and retinal vascular occlusions. We report a case of a man in his early 30s who developed a post-traumatic direct CCF. The patient denied undergoing embolisation therapy. This resulted in aggravation of his condition with onset of combined retinal venous and artery occlusion leading to neovascular glaucoma and severe vision loss. He was treated with medical management followed by diode laser photocoagulation to control intraocular pressure. Diagnostic cerebral angiography done 3 months later showed complete closure of the fistula; hence, no further intervention was advocated. Combined vascular occlusion is a rare vision-threatening occurrence in cases of CCF. Timely intervention with closure of the fistula can prevent the development of vision-threatening complications.

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.

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.

Neovascular Glaucoma: An Update.

Neovascular glaucoma (NVG) is a severe type of secondary glaucoma with devastating complications and generally poor visual prognosis. NVG is defined by the development of pathological neovessels over the iris and the iridocorneal angle that can block the outflow of aqueous humor, causing elevation of intraocular pressure (IOP). The pathogenesis of NVG is, in most cases, associated with ischemia of the posterior segment, which is most frequently associated with proliferative diabetic retinopathy or central retinal vein occlusion. The advanced stages of NVG are by iris and angle neovascularization, angle, and extremely high IOP, accompanied by ocular pain and poor vision. The therapeutic approach of NVG is based on the reduction of retinal ischemia by panretinal photocoagulation. Intravitreal anti-VEGF administration can contribute to the regression of neovascularization, and topical and systemic medications may be necessary for IOP control. However, if medical treatment with these agents is not enough, surgical procedures may be required to lower IOP and prevent glaucomatous optic neuropathy. Early and prompt diagnosis, with identification of the underlying etiology, can improve IOP control and final visual outcome. The aim of this study is to review current knowledge of the pathogenesis and management of NVG.

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.

The pathological association between the anterior eye segment and the retina in a murine model of neovascular glaucoma.

Neovascular glaucoma (NVG) is caused by the formation of new blood vessels in the angle, iris, and cornea in retinal ischemic disease, such as proliferative diabetic retinopathy (PDR) and retinal vein occlusion (RVO), which can reduce the visual acuity. However, the pathophysiological symptoms of NVG are still not well understood because there is no model for the formation of NVG in the angle, iris, and cornea. The aim of this study was to investigate the involvement of NVG during ischemic disease, in a murine model of retinal ischemia. We evaluated the changes of the intraocular pressure (IOP) and pathological symptoms in the anterior eye segment and retina in this model, and the changes in the RNA or protein expression of vascular endothelial growth factor (VEGF) and fibrosis-related factors were analyzed in the retina and cornea by quantitative real-time polymerase chain reaction or western blot, respectively. Furthermore, we examined the changes in IOP after intravitreal injection of an anti-VEGF antibody. First, NVG formed in the retinal ischemic murine model, and the IOP was elevated in mice with NVG formation. Interestingly, VEGF expression was decreased in the retina but increased in the cornea in the murine model of NVG. On the other hand, fibrosis-related factors were increased in the retina and also significantly increased in the cornea in NVG. Moreover, the administration of anti-VEGF antibody immediately after vessel occlusion suppressed the increase in IOP, but administration at 7 days after vessel occlusion accelerated the increase in IOP. These findings suggest that the formation of NVG may be correlated with the pathological symptoms of retinal ischemic disease, via changes in VEGF and fibrosis-related factor expression.

[Secondary open-angle glaucoma: pseudoexfoliative glaucoma, pigmentary glaucoma and neovascular glaucoma]. / Sekundäre Offenwinkelglaukome: Pseudoexfoliationsglaukom, Pigmentglaukom und Neovaskularisationsglaukom.

Secondary open-angle glaucomas are a heterogeneous group of diseases in which a variety of pathophysiological mechanisms result in an elevation of intraocular pressure. This article is the first part of a review of the more common forms of secondary open-angle glaucomas. The pathogenesis, characteristic clinical findings and treatment of pseudoexfoliative glaucoma, pigmentary glaucoma and neovascular glaucoma are discussed. An emphasis is placed on the differences in treatment compared to primary open-angle glaucoma and prophylactic treatment approaches are explained where possible.

Outcomes of Ahmed glaucoma valve and transscleral cyclophotocoagulation in neovascular glaucoma.

Purpose: To determine the outcomes of Ahmed glaucoma valve (AGV) and transscleral diode cyclophotocoagulation (CPC) in neovascular glaucoma (NVG). Methods: This was a single-center retrospective comparative case series involving chart review of consecutive patients who underwent AGV or CPC for treatment of NVG and had ≥6 months of follow-up. Surgical failure at 6 months, defined as an IOP of >21 or <6 mm Hg with hypotony maculopathy after 1 month, progression to no light perception (NLP) vision, glaucoma reoperation, or removal of AGV were the main outcome measures. Results: In total, 121 eyes of 121 patients were included (70 AGV and 51 CPC). Baseline demographics, visual acuity (VA), and intraocular pressure (IOP) were comparable between groups. At 6 months, failure was significantly higher in the CPC group than in the AGV group (43.1% vs. 17.1%, P = 0.020). Both groups had similar IOP and medication number at 6 months, but VA was significantly lower in the CPC group compared to the AGV group (2.4 ± 0.8 vs. 1.9 ± 1.0, P = 0.017). More CPC eyes required reoperation for glaucoma than AGV eyes (11.8% vs. 1.4%, P = 0.041). Multivariate regression analysis identified higher preoperative IOP (P = 0.001) and CPC surgery (P = 0.004) as independent predictors of surgical failure at 6 months. Age, sex, race, NVG etiology, bilaterality of the underlying retinal pathology, perioperative retina treatment, and prior or combined vitrectomy were not significant. Conclusion: AGV and CPC had comparable IOP and medication reduction in NVG eyes at 6 months. CPC was more frequently associated with failure, reoperation for glaucoma, and worse visual outcomes. High preoperative IOP and CPC surgery independently predicted surgical failure.

Secondary Glaucoma in the Context of Retinal Disease. / Sekundärglaukome im Rahmen retinaler Erkrankungen.

A variety of retinal diseases can lead to the development of glaucoma. The most common type of these secondary glaucomas is neovascular glaucoma (NVG), which constitutes the main subject of this review. NVG is a severe condition with a poor prognosis. Treatment becomes increasingly challenging as the disease progresses. Thus emphasis is put on early diagnosis and therapy adapted to the disease stage. The review also covers other less frequent secondary glaucomas, such as glaucomas due to intraocular tumours or associated with retinal detachment (Schwartz-Matsuo syndrome) as well as late onset open-angle glaucomas after uncomplicated vitrectomy.

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.

Neovascular Glaucoma in Children: A case series and a review of the literature.

PURPOSE: To study the uncommon causes and treatment options for neovascular glaucoma in children. PATIENTS AND METHODS: A review of the literature on neovascular glaucoma in children was conducted and we present three cases of neovascular glaucoma in children. RESULTS: We present three cases of neovascular glaucoma: two cases were secondary to a retinal vasoproliferative tumor-one to neurofibromatosis type 1 and the other to exudative retinopathy secondary to mild retinopathy of prematurity-and one case was secondary to a central retina vein occlusion secondary to an optic nerve glioma. Vision in the affected eye was severely impaired in all the children. CONCLUSION: The diagnosis and treatment of neovascular glaucoma in children is challenging and often a complication of a systemic or late-stage ocular condition. An appropriate diagnosis and estimation of the visual potential are essential to determine the correct treatment, especially in young children.