[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.

Voxel-based morphometry reveals altered gray matter volume related to cognitive dysfunctioning in neovascular glaucoma patients.

We used correlation analysis to examine whether changes in grey matter volume in patients correlated with clinical presentation. gray matter volume was markedly reduced in neovascular glaucoma patients than healthy controls in the following brain regions: left cingulum anterior/medial frontal gyrus; left middle frontal gyrus, orbital part; left inferior frontal gyrus, orbital part; superior temporal gyrus/right frontal inferior orbital part. VBM directly suggests that neovascular glaucoma patients have changed in the volume of multiple brain regions. These changes exist in brain areas related to the visual pathway, as well as other brain areas which are not related to vision. The alteration of specific brain areas are closely related to clinical symptoms such as increased intraocular pressure and optic nerve atrophy in neovascular glaucoma patients. In conclusion, neovascular glaucoma may cause paralgesia, anxiety, and depression in patients.

Increased expression of periostin and tenascin-C in eyes with neovascular glaucoma secondary to PDR.

PURPOSE: To investigate periostin (PN) and tenascin-C (TNC) expression in the aqueous humor and trabeculectomy specimens of patients with neovascular glaucoma (NVG) secondary to proliferative diabetic retinopathy (PDR). METHODS: This study enrolled 37 eyes of 37 patients who were grouped into (1) NVG secondary to PDR (NVG; n = 8); (2) PDR without NVG (PDR; n = 9); (3) primary open-angle glaucoma (POAG; n = 11); and (4) cataract surgery patients as a control group (CG; n = 9). Aqueous humor samples were collected from the anterior chamber at the start of surgery or intravitreal injection of anti-VEGF drug. The concentrations of PN, TNC, VEGF, and TGF-ß2 (transforming growth factor-beta 2) were measured by ELISA. Sclerostomy tissues containing trabecular meshwork were obtained from two NVG patients and a POAG patient who underwent trabeculectomy surgery. Immunohistochemical analyses were performed to determine the localization of PN and TNC expression in the sclerostomy tissues. RESULTS: PN and TNC-C levels were below detection threshold in the POAG and CG groups. The NVG group had significantly higher levels of PN and TNC compared with the PDR group (84.7 ng/ml vs 2.2 ng/ml and 18.5 ng/ml vs 4.6 ng/ml, respectively; p < 0.05). There was a significant correlation between the levels of PN and TNC-C in the NVG group (r = 0.86, p < 0.05). We found significant expression of PN in the trabecular meshwork and Schlemm's canal of sclerostomy tissues excised from patients with NVG. CONCLUSIONS: Increased PN and TNC expression suggests their possible involvement in the pathogenesis of NVG secondary to PDR.

Efficacy of Ahmed Glaucoma Valve Implantation on Neovascular Glaucoma.

To evaluate the efficacy of Ahmed glaucoma valve (AGV) implantation in treating neovascular glaucoma (NVG) and analyze the factors influencing the surgical success rate, a retrospective investigation of 59 NVG patients (66 eyes) who underwent AGV implantation was conducted at Jiangsu Province Hospital, China, from January 2014 to June 2018. Intraocular pressure (IOP), visual acuity, surgical success rates, medications, and complications were monitored at post-operative 1 day, 1 week, 1, 3, 6 and 12 months. Surgical success criteria were defined as 6 mm Hg < IOP < 21 mmHg with or without additional medications. Results showed average IOP was statistically significant between pre-operative visit and each follow-up visit (all P<0.05). At 12 months, the success rate was 66.7%. Multiple stepwise regression analysis suggested that age, panretinal photocoagulation (PRP), complications and hyphema were significant factors influencing the surgical success rate (all P<0.05). Thus, we conclude that AGV implantation is effective and safe for treatment of NVG. Surgical success is dependent on age, PRP, complications, and hyphema.

Surgical treatment of neovascular glaucoma: a systematic review and meta-analysis.

PURPOSE: This literature review and meta-analysis aims to compare intraocular pressure (IOP) lowering efficacy, failure rates and loss of light perception (LP) rates 6 months after an IOP-lowering surgical procedure in neovascular glaucoma (NVG) eyes. METHODS: MEDLINE and EMBASE were used as data sources. Only studies including NVG patients who underwent two different surgical approaches were considered. The treatment effect measures were (i) weighted mean difference (WMD) for IOP reduction, (ii) risk ratio (RR) for failure rates and (iii) risk difference (RD) for loss of LP. Outcome measures were reported with a 95% confidence interval (CI) and P < 0.05 was considered statistically significant. Analysis was performed using RevMan v5.0. RESULTS: No RCT were retrieved. Seven comparative non-randomised studies were eligible. In glaucoma drainage devices (GDDs) vs cyclophotocoagulation arm, there was no statistical difference in IOP-lowering efficacy (WMD = - 3.63; CI [- 8.69, 1.43], P = 0.16), although failure rates and loss of LP were lower in the GDDs group (RR = 0.64, CI [0.41, 0.99], P = 0.05; and RD = - 0.15, CI [- 0.25, - 0.05], P = 0.004, respectively). In the Ahmed glaucoma valve (AGV) vs trabeculectomy arm, there was no statistical difference in IOP-lowering efficacy and loss of LP (WMD = 0.78, CI [- 2.29, 3.85], P = 0.62 and RD of 0.04, CI [- 0.05, 0.14], P = 0.34, respectively), but failure rates were lower in trabeculectomy group (RR of 2.25, CI [1.14, 3.71], P = 0.02). CONCLUSIONS: There is lack of high-quality evidence on the subject as no RCT were retrieved comparing two different IOP-lowering procedures in NVG patients. Our findings are based, therefore, on non-RCT studies and should be interpreted with caution. There appears to be no difference in IOP-lowering efficacy between GDDs and cyclophotocoagulation, although GDDs appear to be safer. AGV and trabeculectomy also seem to provide similar IOP-lowering results with trabeculectomy showing lower failure rates.

Ahmed glaucoma valve implantation versus suprachoroidal silicone tube implantation following the injection of bevacizumab into the anterior chamber in patients with neovascular glaucoma.

PURPOSE: This study compared the efficacy and safety of Ahmed glaucoma valve (AGV) implantation versus suprachoroidal silicone tube (SST) implantation after the injection of bevacizumab into the anterior chamber in patients with neovascular glaucoma. METHODS: Patients were randomly assigned to undergo AGV or SST implantation. Bevacizumab was injected into the anterior chamber at a dosage of 1.25 mg/0.1 mL, 1 week before surgery. Intraocular pressure (IOP) control, complication, and success rates were compared between the groups. Success was defined as a final IOP > 5 mmHg, < 22 mmHg with or without any antiglaucoma drug. RESULTS: A total of 23 patients were enrolled in the study, including 13 (56.5%) in the AGV group (group 1) and 10 (43.5%) in the SST group (group 2). The mean baseline IOP was 42.0 ± 9.1 mmHg in group 1 and 39.5 ± 10 mmHg in group 2 (p > 0.05). The mean IOP was 16.9 ± 7.0 mmHg in group 1 and 12.5 ± 6.7 mmHg in group 2 on the first day after surgery. After a mean follow-up period of 19.4 ± 5.2 months, success was achieved in 12 (92.3%) patients in group 1 and in 1 (10%) patient in group 2. There was a statistically significant difference in terms of the success rate between groups (p < 0.05). Complications included hyphema in three (23%) patients, obstruction of the AGV tube by iris tissue in one (7.7%) patient, and tube exposure in one patient (7.7%) in group 1. Suprachoroidal silicone tube dislocation to the anterior chamber was observed in one (10%) patient in group 2. CONCLUSION: AGV implantation after the injection of bevacizumab into the anterior chamber had a higher success rate than SST implantation. Complications were seen more frequently in the AGV group.

Efficacy and safety of Ex-PRESS® mini shunt surgery versus trabeculectomy for neovascular glaucoma: a retrospective comparative study.

BACKGROUND: The objective of this study is to evaluate and compare the short-term efficacy and safety of Ex-PRESS® mini shunt surgery and trabeculectomy for neovascular glaucoma (NVG). METHODS: Patients with NVG who underwent Ex-PRESS® mini shunt surgery or trabeculectomy as a primary glaucoma surgery between March 2013 and October 2015 were included in the study, and their medical charts were retrospectively reviewed. The Ex-PRESS® and trabeculectomy groups included 14 eyes and 30 eyes, respectively. Surgical failure was defined by an intraocular pressure (IOP) of ≥21 mmHg (condition A) or ≥ 18 mmHg (condition B); Kaplan-Meier survival analyses and the multivariable Cox proportional hazards model were used to assess efficacies. RESULTS: Kaplan-Meier survival analyses indicated that the probabilities of success at 1 year for the Ex-PRESS® group were 25.7 and 31.8% based on complete and qualified success under condition A, respectively. The corresponding values for the trabeculectomy group were 47.8 and 69.3%, and there was a significant difference in qualified success with condition A (Fig. 1; P = 0.018), while there were no significant differences in the other criteria. Ex-PRESS® mini shunt surgery and higher intraocular pressure were independent prognostic factors using Cox proportional hazards model analyses in qualified success as in condition A (P = 0.012 and 0.0495, respectively). The occurrences of postsurgical hyphema and bleb leaks were significantly higher in the trabeculectomy group (P = 0.005 and 0.008, respectively). CONCLUSION: During a 1 year follow-up, Ex-PRESS® mini shunt surgery was a less effective, but safer treatment for NVG compared with trabeculectomy.

What is the impact of intravitreal injection of conbercept on neovascular glaucoma patients: a prospective, interventional case series study.

BACKGROUND: The aim of the present study was to evaluate the efficacy and safety of intravitreal conbercept combined with trabeculectomy and panretinal photocoagulation for neovascular glaucoma (NVG). METHODS: Fifty patients (54 eyes) with NVG were included in this prospective study. Fifty-two eyes initially underwent intravitreal conbercept (0.5 mg/0.05 ml) treatment followed by trabeculectomy and panretinal photocoagulation. Preoperative and postoperative best-corrected visual acuity (BCVA), intraocular pressure (IOP), the number of antiglaucoma medications, and surgical complications were recorded. The levels of VEGF-A, TGF-ß1 and PLGF in aqueous humour samples collected during surgery were measured by enzyme-linked immunosorbent assay (ELISA). Light microscopy and transmission electron microscopy were used to observe the surgically excised trabecular tissue; enucleation was performed in 2 eyes, and light microscopy was used as the histopathological control. RESULTS: The follow-up period after trabeculectomy was 1 year. Of the 52 eyes, 39 completed 1 year of follow-up, and 13 were lost to follow-up. Recurrence of iris neovascularization was observed in 5 eyes, 9 had hyphema, 16 had filter-bled scarring, and no eye had complications attributable to the drug. The mean IOP was reduced from 48.1 ± 14.2 to 23.2 ± 8.7 mmHg, and the mean number of antiglaucoma medications used decreased from 3.0 (3.0, 4.0) to 1.0 (0.0, 1.0) after 1 year (both P < 0.05). The complete success rate was 76.9, 76.9, 71.0, 51.6, and 32.3% at 1 week, 1 month, 3 months, 6 months and 12 months, respectively, when the cut-off IOP was 18 mmHg. After patients underwent intravitreal injection, the concentrations of VEGF-A and TGF-ß1 in the aqueous humour in NVG patients decreased from 168.8 ± 13.4 and 159.6 ± 15.4 pg/ml to 160.2 ± 7.6 and 151.9 ± 2.3 pg/ml, respectively (both P < 0.05). Light microscopy revealed neovascularization regression in the iris in specimens treated with intravitreal conbercept. Electron microscopy revealed trabecular endothelial cell degeneration in the conbercept-treated specimens. CONCLUSIONS: Our initial findings suggest that intravitreal conbercept is an effective treatment for managing NVG that has fewer short-term postoperative complications. TRIAL REGISTRATION: Current Controlled Trials ChiCTR1800019918 , 8 December 2018, retrospectively registered.

Choroidal hypoperfusion: an indicator of low tension neovascular glaucoma.

PURPOSE: To report a case of low tension neovascular glaucoma in ocular ischemic syndrome. METHODS: An elderly man presenting with vision loss after an episode of hemiparesis was investigated to look for the cause of vision loss and treated. RESULTS: Fluorescein angiography demonstrated poor uveal perfusion and treatment with panretinal photocoagulation led to rapid closure of the angle. CONCLUSION: This case highlights the typical ophthalmic features of ocular ischemic syndrome and emphasizes the necessity of patient education and prognostication.

Neovascular glaucoma after proton beam therapy of choroidal melanoma: incidence and risk factors.

PURPOSE: To analyze the risk factors for the development of neovascular glaucoma (NVG) of patients with choroidal melanoma after proton beam therapy (PBT). METHOD: Clinical case series, retrospective study. We evaluated 629 consecutive patients receiving proton beam therapy for the treatment of a choroidal melanoma at the oncology service at Charité, Berlin and Helmholtz-Zentrum, Berlin between 05/1998 and 11/2008 regarding the development and risk factors of NVG. Patients with tumor resection, salvage proton beam therapy for recurrent disease and known glaucoma of other origin were excluded from the cohort. RESULTS: Of the 629 patients matching the inclusion criteria, 20.8% developed neovascularization of the iris after a mean time of 2.0 years (range 0.45 to 8.4 years) after PBT. Forty-seven percent of the patients with a neovascularization of the iris developed NVG after a mean time of 2.0 years after PBT, ranging from 5 months to 11.6 years. Univariate analysis revealed tumor height [p < 0.001, hazard ratio (HR): 2.71, 95% confidence interval (CI): 1.36-5.35 for tumors >6 mm ≤9 mm and 11.32 (4.03-31.73) for tumors >9 mm], distance of the tumor to the optic disc (p < 0.001, HR: 0.43, 95% CI: 0.24-0.77 for >0 mm ≤3 mm and HR: 0.13, 95% CI: 0.04-0.37 for >3 mm), dose to the ciliary body (p < 0.001, HR: 9.21, 95% CI: 5.08-16.71 (21-40 cobalt gray equivalents (CGE), HR 27.23, 95% CI: 6.33-116.97 (41-60 CGE)), dose to the optic disc (p < 0.001, HR: 3.53, 95% CI: 1.11-11.27 (21-40CGE), HR: 5.37, 95% CI: 2.72-10.63 (41-60CGE)), the irradiated length of the optic nerve (p < 0.001, HR: 4.48, 95% CI: 2.47-8.13) and diabetes mellitus (p < 0.05, HR: 2.53, 95% CI: 1.4-4.5) were found to be risk factors for the development of NVG. Multivariate regression analysis identified the dose to the ciliary body [p < 0.001, HR: 4.39, 95% CI: 2.28-8.44 (21-40 CGE), HR: 11.04, 95% CI: 1.97-61.69 (41-60 CGE)], the irradiated length of the optic nerve (p < 0.001, HR: 3.88, 95% CI: 2.11-7.16), the existence of diabetes mellitus (p < 0.01, HR: 1.28, 95% CI: 1.24-4.21) and tumor height [p < 0.05, HR: 2.28, 95% CI: 1.17-4.83 (>6 mm ≤9 mm), HR: 3.74, 95% CI: 1.05-13.23, (>9 mm)] to be independent risk factors for the development of NVG. CONCLUSIONS: In the present analysis we found tumor height, dose to the ciliary body, irradiated length of the optic nerve and diabetes mellitus to be risk factors for the development of NVG. Whenever possible, critical structures of the anterior and posterior segment should be spared by beam shaping or changing of the beam entry angle.

Circumpapillary retinal nerve fiber layer thickness, anterior lamina cribrosa depth, and lamina cribrosa thickness in neovascular glaucoma secondary to proliferative diabetic retinopathy: a cross-sectional study.

BACKGROUND: To compare the lamina cribrosa between eyes with and without neovascular glaucoma (NVG) using enhanced depth imaging spectral-domain optical coherence tomography. METHODS: Forty-six patients with proliferative diabetic retinopathy were enrolled in this cross-sectional study. The patients were divided into two groups based on the absence or presence of NVG (the non-NVG group and the NVG group, respectively). The intraocular pressure (IOP), circumpapillary retinal nerve fiber layer (cpRNFL) thickness, anterior lamina cribrosa depth (ALD), and laminar thickness (LT) were compared between the groups. RESULTS: In the non-NVG group, the mean age was 66.2 ± 2.4 (mean ± standard error) years, mean maximum IOP was 18.8 ± 1.8 mmHg, mean cpRNFL thickness was 91.2 ± 3.9 µm, mean ALD was 407.0 ± 22.9 µm, and mean LT was 155.0 ± 4.7 µm. In the NVG group, the mean age was 61.4 ± 2.1 years, mean maximum IOP was 33.1 ± 1.6 mmHg, mean cpRNFL thickness was 73.6 ± 3.4 µm, mean ALD was 403.9 ± 20.1 µm, and mean LT was 156.9 ± 4.2 µm. The IOP was significantly higher and the cpRNFL was significantly thinner in the NVG group (P < 0.001 and P = 0.002, respectively). However, the age, ALD, and LT were not statistically different between the groups (P = 0.151, 0.919, and 0.757, respectively). CONCLUSIONS: Although the cpRNFL was thinner, the structure of the lamina cribrosa was unchanged in the NVG eyes. Axonal loss of the retinal ganglion cells in NVG patients was prior to lamina cribrosa deformation.

Results of the Baerveldt® Glaucoma Implant for Neovascular Glaucoma Patients.

Purpose: To evaluate the efficacy and safety of the Baerveldt® glaucoma implant (BGI) for eyes with neovascular glaucoma (NVG). Methods: This was a retrospective study. Thirty-five eyes (31 patients) diagnosed with refractory NVG at Toyama University Hospital were enrolled from January 2012 to December 2015. All patients underwent BGI and were followed up for more than 6 months. Results: The mean age of patients was 62.7±13.9 years old. The mean postoperative follow-up periods was 22.0±12.7 months. The mean preoperative IOP was 35.5±9.6 mmHg and the mean postoperative IOP at 6, 12, 24, 36, 48 month were 12.7±5.9, 12.8±3.7, 12.2±3.3, 13.1±3.3, 15.0±1.4 mmHg respectively. Postoperative visual acuity was not significantly improved. Complications were Hoffmann Elbow erosion in 2 patients who needed additional surgery. The success rate at one year was 82.7%. Postoperative intervention was not required. Conclusion: BGI surgery should be considered a useful treatment to lower the IOP for NVG.

Current management of glaucoma and vascular occlusive disease.

PURPOSE OF REVIEW: This article summarizes recent findings pertaining to advancements in the treatment of glaucomas secondary to vascular occlusive disease to maximize visual outcomes. RECENT FINDINGS: Retinal ischemia leads to a local increase in transcription of proteins responsible for aberrant angiogenesis and subsequent neovascular glaucoma. Antivascular endothelial growth factor (VEGF) therapy is helpful in the management of this condition. Although bevacizumab and ranibizumab offer relatively short-term effects, preliminary studies suggest that aflibercept may allow for longer term treatment. Preoperative anti-VEGF injection therapy improves outcomes after trabeculectomy and glaucoma drainage implant surgeries. The treatments for vascular occlusive disease may lead to intraocular pressure elevation and subsequent glaucoma. Aflibercept appears to be a safer agent in this regard. SUMMARY: Prompt diagnosis and management of glaucomas associated with vascular occlusive disease are required to allow for the best possible outcome. Novel anti-VEGF agents, particularly aflibercept, should be strongly considered in the management of these conditions.

Anti-VEGF treatment is the key strategy for neovascular glaucoma management in the short term.

BACKGROUND: To present a comprehensive approach for the management of patients with neovascular glaucoma (NVG) aiming to preserve visual function and complement pan-retinal photocoagulation (PRP) by anti-vascular endothelial growth factor (anti-VEGF) treatment and anti-glaucoma surgery. METHODS: This study includes a prospective, interventional case series. A process flow chart for NVG management was designed. Totally 50 patients (51 eyes) with NVG were included. Of these, 43 patients (44 eyes) completed the treatment process. Patients were divided into central retinal vein occlusion (CRVO) and proliferative diabetic retinopathy (PDR) groups according to their original diagnosis. Intraocular pressure (IOP), visual function, and the status of iris and angle neovascularization were recorded before and after treatment. RESULTS: Patients were followed up for 6-30 months (mean 12.2 months). The IOP of all 44 patients was effectively controlled and was significantly less after treatment (16.68 ± 4.69 mmHg) than before treatment (42.59 ± 9.44 mmHg, P < 0.05). Thirty-nine eyes displayed controlled IOP (≤21 mmHg) after treatment. Visual acuity improved, to some extent, in 32 eyes (72.9 %), and 12 eyes (27.3 %) had a visual acuity better than 0.1. There was no significant difference in IOP between the PDR and CRVO groups at the end of follow-up (P = 0.8657), but the visual acuity in the PDR group was much better than that in the CRVO group (P = 0.0079). CONCLUSIONS: A comprehensive therapy for NVG can effectively control IOP and preserve visual function in patients by anti-VEGF injection and anti-glaucoma surgery.

Efficacy of intravitreal ranibizumab combined with Ahmed glaucoma valve implantation for the treatment of neovascular glaucoma.

BACKGROUND: Neovascular glaucoma is a refractive glaucoma. Recently, anti-VEGF factors have been used alone or in combination for the treatment of neovascular glaucoma. However, the medium- and long-term efficacy of such drugs remains to be evaluated. This study was to determine the efficacy of intravitreal ranibizumab combined with Ahmed glaucoma valve implantation for the treatment of neovascular glaucoma. METHODS: In this prospective non-randomized study, 43 neovascular glaucoma patients (43 eyes) were assigned to receive either 0.5 mg intravitreal ranibizumab for three to 14 days before Ahmed glaucoma valve implantation (injection group, n = 21) or Ahmed glaucoma valve implantation alone (control group, n = 22). The patients were followed up for six to 12 months. Differences in surgical success rate, intraocular pressure, best corrected visual acuity, anti-glaucoma medications and postoperative complications were compared between the two groups. Surgical success was defined as IOP > = 6 mm Hg and < = 21 mm Hg, with or without the use of anti-glaucoma medications, and without severe complications or reoperation. RESULTS: Of the 43 patients, 40 completed the 6-month follow-up and 37 completed the 1-year follow-up. Success rate was 73.7% vs. 71.4% at six months and 72.2% vs. 68.4% at 12 months in the injection group and the control group respectively. No significant difference was noted between the two groups (six months: P = 0.87, 12 months: P = 1.00). There were no significant differences in the two groups with respect to intraocular pressure, best corrected visual acuity, anti-glaucoma medications or postoperative complications at six months or 12 months. CONCLUSIONS: Single intravitreal ranibizumab (0.5 mg) before surgery has no significant effect on the medium- or long-term outcomes of neovascular glaucoma treated with Ahmed glaucoma valve implantation. TRIAL REGISTRATION: Chinese Clinical Trial Registry ( ChiCTR-OOC-14005709, Trial registration date: 2014-12-01).

Combined pars plana vitrectomy and pars plana Baerveldt tube placement in eyes with neovascular glaucoma.

PURPOSE: To describe characteristics and outcomes of combined pars plana vitrectomy and Baerveldt tube insertion procedure from 2005 to 2010 in eyes with neovascular glaucoma. METHODS: Seventy-nine patients (89 eyes) with ≥2 months of follow-up were included. Outcome measures were visual acuity, intraocular pressure (IOP), number of glaucoma medications, and complications. Changes in mean logMAR visual acuity, IOP, and glaucoma medications were compared by a two-tailed t-test. RESULTS: Mean patient age was 69.0 years. Forty-three (54%) were male. Mean follow-up time was 19.9 months. Most common causes of neovascular glaucoma was diabetes (n = 63 [71%]) and central retinal vein occlusion (n = 21 [24%]). Eighty-six eyes (97%) underwent a 250 mm Baerveldt drainage device and 3 (3.4%) a 350 mm Baerveldt. Forty-five (51%) 20-gauge, 12 (13%) 23-gauge, and 32 (36%) 25-gauge pars plana vitrectomies were performed. Fifty-two eyes (58%) preoperatively and 23 (33%) postoperatively received intraocular injections for rubeosis and macular edema. Mean ± standard deviation logMAR visual acuity at 18-, 24-, 36-, and 48-month follow-up time points was significantly better than preoperative vision (P < 0.05). Preoperative versus final IOP and number of glaucoma medications were significantly decreased (P < 0.05). Fourteen eyes (16%) had a final visual acuity of no light perception. Most common complications included transient ocular hypertension (n = 82 [92%]), transient hypotony (n = 20 [22%]), hyphema (n = 19 [21%]), corneal edema (n = 17 [19%]), and vitreous hemorrhage (n = 14 [16%]). The frequency of transient hypotony, vitreous hemorrhage, and rubeosis was significantly (P < 0.05) higher in 20-gauge versus 23-/25-gauge pars plana vitrectomy eyes. Nine eyes (10%) required return to the operating room after combined procedure, including 4 eyes (4.5%) for retinal detachment and 3 (3.4%) for high IOP due to tube occlusion. Three eyes (3.4%) developed endophthalmitis and 2 (2.2%) progressed to being pre/phthisical (none were enucleated). CONCLUSION: Combined pars plana vitrectomy and Baerveldt glaucoma shunt may be a useful procedure in reducing IOP and number of glaucoma medications in eyes with neovascular glaucoma along with stabilizing visual acuity in a majority of these eyes. Further studies are warranted to verify and expand on these findings.

Case-matched comparison of vitrectomy, peripheral retinal endolaser, and endocyclophotocoagulation versus standard care in neovascular glaucoma.

PURPOSE: To evaluate the efficacy of combination pars plana vitrectomy, endoscopic peripheral panretinal photocoagulation, and endocyclophotocoagulation (ECP) as compared with standard care in patients with neovascular glaucoma. METHODS: This age-matched case-controlled retrospective series of 54 eyes compared the clinical outcomes between a consecutive series of combination pars plana vitrectomy/panretinal photocoagulation/ECP (n = 27) versus the current standard of care (n = 27) for patients with neovascular glaucoma. "Standard" treatments for patients with neovascular glaucoma include panretinal photocoagulation, intravitreal bevacizumab, filtration surgery, pars plana vitrectomy, and Ahmed valve placement. RESULTS: After 1 year, mean intraocular pressure reduced from 40.7 ± 12.40 mmHg preoperatively to 12.3 ± 4.84 mmHg (P < 0.001) in the ECP group and from 34.7 ± 12.38 mmHg to 23.2 ± 12.34 mmHg in the control group (P = 0.002). Compared with controls, the mean drop in intraocular pressure in the ECP group was significantly greater at all postoperative visits. Logarithm of the minimal angle of resolution visual acuity outcomes were similar in both groups. There were 2 cases (7.4%) of postoperative phthisis bulbi in each group. CONCLUSION: Endoscopic pars plana vitrectomy, panretinal photocoagulation, and ECP seem to control intraocular pressure to a greater extent than standard glaucoma treatments in patients with neovascular glaucoma. In this aged-matched comparative case series, there was no significant difference between the two treatments' effects on visual acuity.

Aflibercept for the treatment of neovascular glaucoma.

BACKGROUND: Neovascular glaucoma (NVG) is a potentially blinding disease associated with ocular ischaemia. Use of an anti-vascular endothelial growth factor agent has been reported as a treatment option for NVG. The purpose of this study was to investigate initial results regarding the treatment of NVG with intravitreal aflibercept. DESIGN: This study employed a prospective, interventional case series study design. PARTICIPANTS: Patients with newly diagnosed stage 1 or 2 neovascular glaucoma were eligible to participate in this study. METHODS: Four patients with newly diagnosed stage 1 or 2 NVG were treated with intravitreal aflibercept at the time of diagnosis, with planned repeat injection at 4 weeks, 8 weeks and then every 8 weeks thereafter up until 52 weeks after study initiation. MAIN OUTCOME MEASURES: Primary outcomes were regression of neovascularization of the iris and angle (NVI, NVA). Secondary outcome measurements included visual acuity and intraocular pressure (IOP). RESULTS: Intravitreal aflibercept resulted in rapid regression of NVI and NVA. IOP was stable or reduced in all patients at the 52-week study visit. CONCLUSIONS: These results suggest that intravitreal aflibercept may be an effective treatment for stage 1 and 2 NVG, resulting in rapid and sustained regression of NVI and NVA as well as control of IOP. Further research is needed to determine the full duration of effect and the optimal dose and timing of administration.

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

BACKGROUND: Several retinal ischemic diseases can cause neovascular glaucoma (NVG). Trabeculectomy with mitomycin C (MMC) is a relatively better treatment modality in the management of eyes with NVG than other glaucoma surgeries. The aim of this study was to investigate the factors that may influence the outcome of trabeculectomy with MMC for NVG. METHODS: Forty-nine NVG eyes from 43 patients (26 males and 17 females) underwent primary trabeculectomy with MMC. The mean follow-up period was 16.8 ± 8.1 months (range, 6 to 34 months). Twenty-one eyes of 21 patients received intravitreal bevacizumab (IVB) 3.6 ± 1.8 days before trabeculectomy with MMC. A Kaplan-Meier survival-curve analysis was used to summarize the cumulative probability of success. We examined the relationship between the surgical outcome and the following surgical factors: gender, age, history of panretinal photocoagulation, history of cataract surgery, history of vitrectomy, preoperative IVB, NVG in the fellow eye, and postoperative complications (hyphema, choroidal detachment, and formation of fibrin) by multivariate analysis. RESULTS: The survival rate was 83.7% after 6 months, 70.9% after 12 months, and 60.8% after 24 months. The Kaplan-Meier survival curves showed no significant difference in the survival rate between the eyes with preoperative IVB (n = 21) and the eyes without preoperative IVB (n = 28) (p = 0.14). The multiple logistic regression analysis showed that postoperative hyphema (odds ratio, 6.54; 95% confidence interval, 1.41 to 35.97) was significantly associated with the surgical outcome (p = 0.02). CONCLUSIONS: Postoperative hyphema was significantly correlated with the outcome of trabeculectomy for NVG. There was no significant association between preoperative IVB and postoperative hyphema or the results of trabeculectomy.

Topical bevacizumab for neovascular glaucoma: a pilot study.

BACKGROUND/AIMS: Bevacizumab (Avastin), an anti-vascular endothelial growth factor drug, has been successfully used in recent years to treat ocular pathologies, mostly by intravitreal administration. The aim of this study was to investigate the safety and efficacy of topically applied bevacizumab for the treatment of neovascular glaucoma (NVG). METHODS: Patients with NVG were treated with topical bevacizumab (25 mg/ml) 4 times daily during 2 weeks. The following parameters were evaluated at baseline and on days 3, 7 and 14: visual acuity, slit-lamp examination, intraocular pressure (IOP), heart rate and systemic blood pressure. Iris neovascularization was documented using slit-lamp color photos at baseline and on day 14. RESULTS: Eight eyes of 8 patients with NVG were evaluated. After the 2-week treatment, mean IOP was lowered from 34.9 mm Hg (SD 12.8) at baseline to 28.8 mm Hg (SD 9.9) on day 14, representing a mean reduction of 6.1 mm Hg (17.5%). Three patients had clinical regression of their iris neovascularization. Ocular adverse events were transient and included mild upper eyelid swelling, mild exacerbation of superficial punctate keratitis and mild corneal epithelial bullae in an already edematous cornea. There were no serious systemic adverse events. CONCLUSIONS: Topical application of bevacizumab may lower IOP and result in regression of neovascularization in patients with NVG.