Management of neovascular glaucoma

Abstract

Neovascular glaucoma is a refractory glaucoma associated with a significant risk of blindness. The first line of treatment is ablation of retina to lessen retinal ischemia. The combination of bevacizumab and panretinal photocoagulation is effective in preventing progression of neovascular glaucoma. The adjunctive use of bevacizumab also reduces the risk of postoperative hyphema after filtering surgery. Prior vitrectomy in these eyes more frequently results in bleb failure after trabeculectomy. Advances in minimally invasive vitreous surgery reduce conjunctival scar formation, which can be beneficial if further filtering surgery is required. Pars plana implantation of glaucoma drainage devices is also an option for the reduction of intraocular pressure in vitrectomized eyes with neovascular glaucoma.

Keywords::

• Ahmed glaucoma valve
• Baerveldt glaucoma implant
• central retinal vein occlusion
• cyclophotocoagulation
• mitomycin C
• Molteno implant
• neovascularization
• proliferative diabetic retinopathy
• rubeosis
• VEGF

Financial & competing interests disclosure

This study was supported, in part, by Grants-in-Aid for Scientific Research from the Ministry of Education, Culture, Sports, Science and Technology (MEXT), Tokyo, Japan. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• The ablation of ischemic retina using transpupillary photocoagulation is the first choice for attenuating the progression of neovascular glaucoma (NVG).

• To perform further filtering surgery, microincision vitreous surgery using a 25-gage vitreous cutter is preferred in eyes with NVG and vitreous hemorrhage.

• The intravitreal injection of bevacizumab transiently relieves neovascularization in the anterior chamber, provides the time to complete panretinal photocoagulation and reduces hyphema after filtering surgery in eyes with NVG.

• Vitrectomized eyes often show surgical failure of trabeculectomy with mitomycin C.

• The combination of bevacizumab injection and tube-shunt surgery using a Baerveldt glaucoma implant or double-plate Molteno implant is preferred for controlling intraocular pressure in NVG eyes that had undergone trabeculectomy or vitrectomy.

• Pars plana insertion of the tube is an option for tube-shunt surgery in vitrectomized eyes.