Rubeosis iridis and macular hemorrhages from multiple Corkscrew retinal vessels in a patient with NF1

PURPOSE

To report a case of a patient with NF1 presenting with ocular findings of AV malformation, multiple retinal hemorrhages, and neovascular glaucoma in the absence of retinal ischemia.

METHODS

Review of the medical record was conducted in accordance with the local IRBt.

RESULTS

A 60-year-old female patient with diagnosis of Neurofibromatosis type1 (NF1) and sudden decrease of vision in her left eye was found to have rubeosis iridis and high intraocular pressure (IOP). On fundus exam multiple corkscrew retinal vessels and retinal hemorrhages were present in her left eye. On Optical Coherence Tomography (OCT) the foveal hemorrhages appeared as outer layer hyperreflective retinal infiltrates whereas in the parafoveal area the hyperreflectivity was present between the RPE and neurosensory retina. Fluorescein Angiogram (FA) showed normal perfusion and no areas of leakage or ischemia. Treatment with anti-angiogenics in a timely manner correlated with a good visual outcome.

CONCLUSIONS

We present a unique patient with NF1, rubeosis iridis, high IOP, and macular hemorrhages from multiple corkscrew retinal vessels in a well perfused retina, who underwent treatment with a single dose of intravitreal Bevacizumab and had an excellent response.

Neovascular glaucoma in patients with central retinal vein occlusion: A real-life study in the anti-VEGF era

PURPOSE

To investigate the characteristics and treatment patterns of patients developing a neovascular event (NE) in the anterior chamber secondary to central retinal vein occlusion (CRVO) in an ordinary clinical setting.

METHODS

In this retrospective real-life study, data from 243 eyes presenting with CRVO during 2012-2013 were collected. Maximum follow-up was 5 years. All patients that developed NE were included in the analysis.

RESULTS

Of 243 eligible patients, 72 (30%) either presented with or developed NE during the follow-up. In these 72 patients, 23 (32%) eyes already had evidence of NE at baseline. Twenty-eight eyes (39%) developed NE after discontinuation of intravitreal therapy for macular oedema (ME). In this subgroup, the NE occurred 15.6 ± 13.8 months after the baseline visit and 4.1 ± 2.6 months after the last injection. Final best-corrected visual acuity was 8.6 Early Treatment Diabetic Retinopathy Study (ETDRS) letters in the group of patients presenting with NE compared to 8.1 ETDRS letters in the group that developed NE later on. Of the patients presenting with intraocular pressure (IOP) below 30 mmHg, 3/29 (10%) needed subsequent cyclodiode laser therapy compared to 35/43 (81%) patients with a baseline IOP above 30 mmHg (p < 0.001).

CONCLUSIONS

In a clinical setting, many patients show evidence of NE already at the first visit. A substantial part of patients develops NE a long time after presentation, commonly a few months after discontinuation of intravitreal therapy for ME. The visual prognosis is similar for patients presenting with NE and patients developing NE during follow-up. A high baseline IOP predicts the need for subsequent pressure-lowering procedures.

Evaluation of Relevance between Advanced Glycation End Products and Diabetic Retinopathy Stages Using Skin Autofluorescence

Advanced glycation end products (AGEs) are thought to play important roles in the pathogenesis of diabetic microangiopathy, particularly in the progression of diabetic retinopathy (DR). We assessed the levels of skin autofluorescence (sAF) to assess the association between AGEs and DR stages. A total of 394 eyes of 394 Japanese subjects (172 men, 222 women; mean age ± standard deviation [SD], 68.4 ± 13.7 years) comprised the study population, i.e., subjects with diabetes mellitus (DM) (n = 229) and non-diabetic controls (n = 165). The patients with DM were divided into those without DR (NDR, n = 101) and DR (n = 128). DR included simple (SDR, n = 36), pre-proliferative (PPDR, n = 25), and PDR (n = 67). Compared to controls (0.52 ± 0.12), the AGE scores were significantly higher in patients with DM (0.59 ± 0.17, p < 0.0001), NDR (0.58 ± 0.16, p = 0.0012), and DR (0.60 ± 0.18, p < 0.0001). The proportion of patients with PDR was significantly higher in the highest quartile of AGE scores than the other quartiles (p < 0.0001). Compared to those without PDR (SDR and PPDR), those with PDR were younger (p = 0.0006), more were pseudophakic (p < 0.0001), had worse visual acuity (VA) (p < 0.0001), had higher intraocular pressure (IOP) (p < 0.0001), and had higher AGE scores (p = 0.0016). Multivariate models also suggested that younger age, male gender, pseudophakia, worse VA, higher IOP, and higher AGE scores were risk factors for PDR. The results suggested that AGE scores were higher in patients with DM and were independently associated with progression of DR. In addition, more PDR was seen in the highest quartile of AGE scores. This study highlights the clinical use of the AGE score as a non-invasive, reliable marker to identity patients at risk of sight-threatening DR.

Severe Neovascular Glaucoma Exacerbation as a Complication of Carotid Artery Stenting: A Case Report

Introduction

Neovascular glaucoma (NVG) has been rarely reported as an acute complication of carotid endarterectomy, but there is scant literature available regarding this potential condition following carotid artery stenting (CAS). We present a case of severe worsening of NVG occurring after bilateral CAS with progressive deterioration of vision ultimately leading to blindness.

Case Description

A 66-year-old male with multiple stroke risk factors, bilateral cataract extraction, proliferative diabetic retinopathy of left eye, and nonproliferative diabetic retinopathy of right eye, and prior left eye pars plana vitrectomy presented with episodes of transient right eye vision loss in context of bilateral high-grade internal carotid artery stenoses. He underwent right CAS with subsequent elevation of bilateral intraocular pressures (IOPs) concerning for acute NVG. Over time, the patient had some interval improvement in IOPs and underwent planned left CAS. After the procedure, he again developed elevated IOPs, concerning for acute NVG which eventually led to right eye pars plana vitrectomy for vitreous hemorrhage and refractory IOP elevation. At 6-month follow-up from initial stenting, the patient was blind in both eyes.

Discussion

We present a case of recurrent IOP elevations following CAS eventually resulting in bilateral eye blindness. This case is important not only as an illustration of an underrecognized postprocedural CAS complication but also as a demonstration of likely elevated risk of NVG following CAS for patients with other predisposing risk factors for ocular hypertension such as glaucoma, proliferative diabetic retinopathy, prior cataract extraction, and prior pars plana vitrectomy.

Bariatric surgery might aggravate proliferative diabetic retinopathy

PURPOSE

This study aimed to assess the changes experienced by patients with proliferative diabetic retinopathy (PDR) after bariatric surgery (BS).

METHODS

This retrospective observational study includes 37 eyes of 21 patients with PDR who underwent BS at a tertiary university hospital over the period of 2014-2018. The control group (CG) comprised 37 eyes of 27 patients with PDR who attended the same research hospital for diabetes care without undergoing BS. Preoperative and postoperative glycated haemoglobin (HbA1c) levels, weight and diabetic retinopathy screening results were collected from the medical records of the patients. Patients who had undergone preoperative retinal screening and at least one postoperative retinal screening were included in the analysis.

RESULTS

Both groups exhibited statistically significant visual acuity (VA) loss at 6 months and 1 year (p < 0.001). At postoperative 6 months the VA loss experienced by the control BS group was significantly more severe than that experienced by the CG (p = 0.03). The first-year HbA1c levels of the BS group were significantly lower than those of the CG (p = 0.02). The BS group had significantly higher intraocular haemorrhage (p = 0.04), neovascular glaucoma (p = 0.04) and retinal vein occlusion (p = 0.04) rates than the CG group. All complications occurred at different patients.

CONCLUSION

Patients with PDR who received BS showed more severe retinopathy than patients who were matched for age, sex, HbA1c levels and follow-up duration and who did not receive BS.

Receptor-Associated Prorenin System in the Trabecular Meshwork of Patients with Primary Open-Angle Glaucoma and Neovascular Glaucoma

The receptor-associated prorenin system (RAPS) is associated with several pathologic conditions, including diabetic retinopathy, age-related macular degeneration, and uveitis. Here, we show the involvement of RAPS in the trabecular meshwork (TM) from patients with primary open-angle glaucoma (POAG) and neovascular glaucoma (NVG) due to proliferative diabetic retinopathy. Anterior chamber (AC) levels of prorenin significantly increased in both POAG and NVG, as did those of angiotensin II in NVG alone, compared to cataract. In surgically excised TM tissues, (pro)renin receptor ((P)RR) and angiotensin II type 1 receptor (AT1R) co-localized with prorenin and angiotensinogen, respectively. In screening for various genes related to glaucoma, prorenin stimulation to human TM cells exclusively upregulated cell junction constituents connexin 43 and zona occludens 1, while downregulating an extracellular matrix-degrading enzyme tissue plasminogen activator, all of which were reversed by (P)RR blockade. In contrast, angiotensin II application upregulated a pro-angiogenic factor placental growth factor alone, which was abolished by AT1R blockade. Consistently, (P)RR and AT1R co-localized with these corresponding proteins in patient TM tissues. Oxidative stress, a known etiology for glaucoma, induced the expression of prorenin and angiotensinogen in human TM cells. These data suggest the contribution of RAPS to the molecular pathogenesis of POAG and NVG through TM tissue remodeling and AC angle angiogenesis.

Updates on the Management of Ocular Vasculopathies with VEGF Inhibitor Conbercept

Purpose: To provide a detailed review on the therapeutic efficacy of conbercept for the management of ocular vasculopathies. Methods: A comprehensive literature search of various electronic databases was performed. Results: Ocular vasculopathy is one of the major causes of visual impairment and blindness which includes a range of disorders. Vascular endothelial growth factor (VEGF) regulates angiogenesis, enhances vascular permeability, and drives the formation of neovascularization. Anti-VEGF therapy has been shown to prevent vision loss or potentially improve vision in patients with exudative or neovascular retinal disease. The most recent anti-VEGF drug in China is conbercept. In the USA and Europe, bevacizumab is the most recently approved anti-VEGF agent. Conclusions: Conbercept serves as another anti-VEGF option for patients with neovascular AMD and other retinal vascular disorders. There have not been many clinical trials that study conbercept as compared with other currently available anti-VEGF drugs. There is a need for large-scale, well-designed, randomized clinical trials to ensure its long-term safety and efficacy and to determine if it has any advantages over other anti-VEGF agents.

Ocular decompression retinopathy following intracameral bevacizumab injection in a case of proliferative diabetic retinopathy with neovascular glaucoma

A 49-year-old diabetic female was diagnosed to have both eyes proliferative diabetic retinopathy (PDR) and neovascular glaucoma (NVG [rubeosis stage in the right eye and angle-closure stage in the left eye]). The right eye anterior and posterior segment new vessels regressed 2 weeks following intravitreal bevacizumab (IVB) injection. The left eye fundus revealed fibrovascular proliferation (FVP) for which panretinal photocoagulation (PRP) was started and subsequently intracameral bevacizumab (ICB) was injected. Following this intervention, the left eye new vessels of iris regressed but fundus showed multiple peripapillary white-centered intraretinal and subhyaloid hemorrhage suggestive of decompression retinopathy. Ocular decompression retinopathy presents as retinal hemorrhages following the acute lowering of the intraocular pressure (IOP). This case describes the rare occurrence of ocular decompression retinopathy following ICB in a case of PDR with NVG.

Clinical efficacy of Ahmed glaucoma valve implantation combined with 23-gauge vitrectomy for medically uncontrolled neovascular glaucoma with proliferative diabetic retinopathy

AIM

To describe the clinical results of combined Ahmed valve implantation and 23-gauge vitrectomy for medically uncontrolled neovascular glaucoma (NVG) secondary to proliferative diabetic retinopathy (PDR).

METHODS

The medical records of medically uncontrolled NVG patients with PDR who underwent Ahmed valve implantation and 23-gauge vitrectomy between March 2016 and December 2018 were reviewed. Enrolled patients had at least 6-month follow-up. Panretinal photocoagulation (PRP), anti-vascular endothelial growth factor, surgery and medication history were documented.

RESULTS

Eleven eyes of 11 patients were included in our study. The visual acuity improved in 8 eyes and remained unchanged in 3 eyes. The preoperative intraocular pressure (IOP) was significantly decreased at the last follow-up (48.8±4.3 to 17.0±1.5 mm Hg, P<0.001). All eyes needed three topical anti-glaucomatous medications before surgery, but the number was significantly reduced to 0.72±0.19 at the last visit (P<0.001). Four eyes had choroidal detachment and 3 eyes had minor hyphemia, all of which gradually resolved without treatments in one week.

CONCLUSION

Ahmed glaucoma valve implantation combined with 23-gauge vitrectomy might be a safe and alternative treatment for NVG with PDR.

Unusual Association of Inverse Retinitis Pigmentosa, Scleromalacia, and Neovascular Glaucoma

A 31-year-old woman with inverse retinitis pigmentosa presented with severe ocular pain and ingrained visual loss. Biomicroscopy revealed a large scleromalacia area above the superior limbus, minimal Descemet’s membrane folds, aqueous flare, rubeosis iridis, and mature cataract. Intraocular pressure was 39 mmHg, and the clinical picture was consistent with neovascular glaucoma. After immediate medication to reduce ocular discomfort, an anterior chamber bevacizumab injection was performed. At 1 week post-injection, the rubeosis iridis had largely regressed and intraocular pressure was 21 mmHg. At post-injection 1 month, antiglaucomatous medication was discontinued because intraocular pressure was stable. Clear cornea, normal anterior chamber depth, and mature cataract were seen via biomicroscopy, and increased axial length with no significant change in posterior segment echogenicity were observed on ultrasonography. Three years after the single dose of bevacizumab, neovascularization was not seen in either the anterior chamber angle or on the iris surface, and intraocular pressure remained within normal range. The most important aspect of this case report is that it is the first to show an unusual association between neovascular glaucoma, scleromalacia, and inverse retinitis pigmentosa.

Trabeculectomy in an unsuspected extramedullary iris-ciliary body plasmacytoma

Extramedullary plasmacytoma of the iris and ciliary body is extremely rare. We present a case which was misdiagnosed as granulomatous uveitis with neovascular glaucoma, and underwent a trabeculectomy with mitomycin-c along with iris biopsy. The post-operative period showed early bleb failure and catastrophic growth of the suspected mass. Histopathological examination revealed a diagnosis iris plasmacytoma. Subsequent ultrasound biomicroscopy showed involvement of the iris and ciliary body. A prompt systemic workup was done, and an associated systemic plasma cell dyscrasia was ruled out. The affected eye was enucleated, and the patient remains disease free at the end of 3-year follow-up.

Tumour size criteria for Group D and E eyes in the International Classification System for Retinoblastoma: effects on rates of globe salvage and high-risk histopathologic features

PURPOSE

To determine the significance of large tumour size as a criteria for classifying advanced intraocular retinoblastoma, analysing rates of globe survival and high-risk (HE) histopathologic features.

METHODS

Retrospective chart review of 212 eyes diagnosed with Group D (111 eyes) or Group E (101 eyes) retinoblastoma in at least one eye from January 1, 2006 to December 31, 2016 using the Los Angeles (LA) Classification System (no tumour size criteria for Group E). The 111 Group D tumours were then reclassified to Group E using 10, 12, 14, 16, 18 mm tumour size criteria, as determined by ultrasound or magnetic resonance imaging dimensions.

RESULTS

For eyes in the original LA classification, 66.7% of Group D and 10.5% of Group E eyes undergoing globe preservation therapy avoided enucleation or radiotherapy (p < 0.0001; median follow-up of 33.0 months). In the LA classification, 8.5% of Group D and 26.3% of Group E enucleated globes had HE histopathologic features (p = 0.0065). When Group D eyes with tumours meeting the size criteria were reclassified to Group E, 65.7-74.4% of Group D and 16.1-36.7% of Group E eyes avoided enucleation or radiotherapy. Applying the tumour size criteria, 0-10.9% of Group D and 20.7-23.8% of Group E eyes had HE histopathologic features.

CONCLUSION

Our retrospective analysis suggests that a large tumour size criteria for Group E retinoblastoma have no clinical basis, given that the LA classification system provided the greatest separation in globe salvage rates between Group D and E eyes. The LA classification system was also able to show a statistically significant difference in the rates of HE histopathologic features between Group D and E eyes. To avoid discrepancies in the literature, we recommend that centres use one uniform system for classifying advanced intraocular retinoblastoma.

Altered Intrinsic Functional Connectivity of the Primary Visual Cortex in Patients with Neovascular Glaucoma: A Resting-State Functional Magnetic Resonance Imaging Study

PURPOSE

The purpose was to investigate the differences in spontaneous functional connectivity (FC) of the primary visual cortex (V1) between patients with neovascular glaucoma (NVG) and healthy controls (HCs) using resting-state functional magnetic resonance imaging data.

METHODS

A total of 18 patients with NVG (nine males and nine females) and 18 HCs with similar age and sex background were enrolled in the study and inspected using resting-state functional magnetic resonance imaging. The differences in FC of the V1 between the two groups were compared using the independent samples t-test. We used the receiver operating characteristic (ROC) curve to compare the average FC values of NVG subjects with those of HCs.

RESULTS

FC in the left V1 and right fusiform gyrus, bilateral cuneus, and left precuneus was significantly decreased in the NVG group compared with that reported in the HC group. Meanwhile, patients with NVG presented increased FC between the right V1 and bilateral middle frontal gyrus. However, they also exhibited declining FC between the right V1 and left precuneus, and bilateral cuneus. The ROC curve analysis of each brain region indicated that the accuracy of the area under the ROC curves regarding NVG was excellent.

CONCLUSION

NVG involves aberrant FC in the V1 in different brain areas, including the visual-related and cognitive-related regions. These findings may assist in unveiling the underlying neural mechanisms of impaired visual function in NVG.

[Anti-VEGF drugs in the treatment of neovascular glaucoma]

Neovascular glaucoma (NVG) is the most frequently occurring type of secondary glaucoma characterized by significant decrease in visual functions. Its pathogenesis consists mainly of ischemia of the posterior segment, which is often secondary to proliferative diabetic retinopathy or ischemic central retinal vein occlusion. Development of neovascularization in the eye is associated with processes that change homeostatic balance between proangiogenic (vascular endothelial growth factor (VEGF)) and antiangiogenic (pigment epithelium-derived factor (PEDF)) factors. The aim of the therapy is to reduce the production of aqueous humour. Application of antiangiogenic preparations in patients with NVG as adjuvant therapy is the method of choice for both prevention and treatment of the disease. The article reviews literature on current possibilities of using anti-VEGF drugs in the treatment of NVG.

Neutrophil-To-Lymphocyte Ratio as a Potential Biomarker of Neovascular Glaucoma

Purpose: To evaluate blood count-derived inflammation indexes as a detection or predictive marker for neovascular glaucoma (NVG) secondary to retinal vein occlusion (RVO) and diabetic retinopathy (DR).Methods: This was a retrospective, case-control study design. The level of white blood cell (WBC), neutrophil (N), neutrophil/lymphocyte ratio (NLR), and lymphocyte/monocyte ratio (LMR) were evaluated in NVG patients secondary to RVO or DR.Results: A significant difference was found in those biomarkers between control group and NVG secondary to RVO or DR. Logistic regression analysis revealed these indexes were associated with the risk of NVG in DR and RVO patients. Multiple linear regression analysis showed a significant correlation between NLR and visual fields mean deviation in the NVG-RVO group.Conclusions: This study indicated that WBC, N, NLR, and LMR were related to NVG, and NLR may be useful as an potential inflammation biomarker indicating the risk and severity for NVG secondary to RVO.

Intravitreal Ranibizumab With Panretinal Photocoagulation Followed by Trabeculectomy Versus Visco-Trabeculotomy in Management of Neovascular Glaucoma

PURPOSE

The aim of the current study was to compare visco-trabeculotomy (VT) with standard trabeculectomy with mitomycin C (Trab-MMC) in the treatment of quiescent neovascular glaucoma (NVG).

METHODS

The study was conducted on 51 eyes of 51 patients presenting with NVG and treated at an Ophthalmic Center in Egypt between March 2014 and April 2017. All study eyes were subjected to a standard protocol of intravitreal injection of ranibizumab followed by panretinal photocoagulation. Eyes were then randomized to either VT or Trab-MMC. Study eyes were followed up for at least 18 months. Success was defined as an intraocular pressure of ≤21 mm Hg and without vision-threatening complications. Complications were noted.

RESULTS

The mean ± SD (range, median) age of the study patients was 54.1 ± 6.4 (40-67, 54.5) and 52.4 ± 8.8 (38-66, 53) years in the VT (26 eyes) and Trab-MMC (25 eyes) groups, respectively (P = 0.45). The mean ± SD (range, median) intraocular pressure (IOP) of the study eyes was 45.19 ± 2.97 (39-52, 45.5) and 45.64 ± 3.56 (3-53, 45) mm Hg on maximal medical therapy in the VT and Trab-MMC groups, respectively (P = 0.61). At 18 months' follow-up, the mean ± SD (range, median) IOP of the study eyes was 18.19 ± 2.0 (16-23, 17) and 19.92 ± 2.6 (18-26, 19) mm Hg in the VT and Trab-MMC groups, respectively (P = 0.004). There was no difference in postoperative antiglaucoma medication between the 2 groups (P = 0.62). Complications included hyphema and Descemet split in the VT group and an IOP spike in the Trab-MMC group. Success rates were 84.6% and 80% in the VT and Trab-MMC groups, respectively (P = 0.726).

CONCLUSIONS

Both VT and Trab-MMC groups are effective in reducing the IOP in cases of NVG after control of neovascularization with anti-vascular endothelial growth factor and pan retinal photocoagulation.

Large choroidal melanoma presenting as neovascular glaucoma

Choroidal melanoma is a relatively rare tumour with a poor prognosis, though it is the most common primary malignancy of the eye among adults. Choroidal melanoma has been reported to present as acute angle closure glaucoma, secondary glaucoma, chronic uveitis, cataract, and staphyloma. We report a case of a28-year-old male presenting with features of neovascular glaucoma in the right eye and having initially been treated with anti-glaucoma medications. However, ultrasonography revealed a mushroom-shaped, elevated, solid lesion with low to moderate internal reflectivity and regular internal structure suggestive of choroidal melanoma. Histopathological examination along with the immunohistochemistry studies of the lesion following enucleation of the eye confirmed the diagnosis of malignant choroidal melanoma. We highlight with this case that large choroidal melanoma may rarely present with features of neovascular glaucoma. The etiology of neovascular glaucoma should be investigated carefully and a potentially life-threatening intraocular tumour should be excluded, although it is a rare presentation.

Cyclophotocoagulation with an illuminated laser probe under a noncontact wide-angle retinoscope: A modified technique of ciliary body photocoagulation

Purpose:

This study aimed to investigate the efficacy of cyclophotocoagulation with an illuminated laser probe under a noncontact wide-angle retinoscope in treating refractory glaucoma.

Methods:

Eleven patients (11 eyes) with refractory neovascular glaucoma were treated with ciliary body photocoagulation. Preoperative and postoperative corrected visual acuity, intraocular pressure (IOP), ophthalmofundoscopy, B-ultrasound and ultrasound biomicroscopy, optical coherence tomography, and fundus fluorescein angiography were performed.

Results:

Preoperative IOP ranged from 45 to 58 mmHg (mean 51.9 mmHg). At postoperative 1, 3, and 6 months, the IOPs ranged between 16 and 33 mmHg (mean 27.1 mmHg), 14–28 mmHg (mean 20.6 mmHg), and 14–28 mmHg (mean 18.5 mmHg), respectively. IOP at the last follow-up (range 7–12 months) was 15–24 mmHg (mean 18.8 mmHg). An average of 63.8% decrease in postoperative IOP was found in these patients with no associated complications. The postoperative fibrotic exudate, anterior chamber hyphema, and exudative choroidal detachment were all well-managed and resolved. No patients experienced intraocular lens deviation or dislocation, hypotonia oculi, atrophy of eyeball, retinal detachment, endophthalmitis, or sympathetic ophthalmia.

Conclusion:

Cyclophotocoagulation with an illuminated laser probe under a noncontact wide-angle retinoscope is a safe and effective technique for the treatment of neovascular glaucoma.

Current profile of secondary glaucoma in a Northern India tertiary eye care hospital

PURPOSE

To study the current profile of secondary glaucoma in all age groups of patients presenting to a tertiary eye care hospital in Northern India Materials and methods: In this retrospective study, files of 5725 patients who were newly diagnosed to have glaucoma in our tertiary eye care centre from January 2014 to December 2016 were reviewed. Detailed data were collected from patient's records, including history, best-corrected visual acuity (BCVA), intraocular pressure (IOP), slit-lamp biomicroscopy findings, gonioscopy, and fundus findings. Demographic data, aetiology, and management in all these patients were also noted.

RESULTS

Out of 5820 patients who visited glaucoma outpatient department (OPD) in a tertiary eye care hospital during 1 January 2014 to 31 December 2016, 5725 patients were diagnosed to have glaucoma by the glaucoma specialists. Five thousand three hundred and six patients (92.68%) were diagnosed to have primary glaucoma and 419 patients (7.32%) were diagnosed to have secondary glaucoma. The leading causes of secondary glaucoma were found to be neovascular glaucoma (17.42%), trauma (14.80%), post-keratoplasty (13.60%), post-cataract surgery (13.13%), and lens-induced glaucoma (12.41%). Secondary glaucoma was found to be an important cause of visual morbidity with 71.17% eyes presenting with BCVA < 6/60, IOP > 30 mm Hg in 62% eyes and 72% with cup-to-disc ratio of ≥0.7:1.

CONCLUSION

Secondary glaucoma is an important cause of visual morbidity. Timely diagnosis and prompt management are essential to prevent irreversible visual loss due to secondary glaucoma.

Uncontrolled neovascular glaucoma - an alarming manifestation of chronic myeloid leukemia on imatinib therapy - a case report and review of literature

A 45-year-old diabetic male, with diabetic retinopathy and medically uncontrolled neovascular glaucoma (NVG) underwent intracameral bevacizumab followed by trabeculectomy, with controlled intraocular pressures (IOP) post-operatively, OD: 12 mmHg; OS: 14 mmHg. Patient was referred to hematology, where he was diagnosed as chronic myeloid leukemia (CML) and started on imatinib mesylate. Thereafter, he presented with recurrence of neovascularization and vascularization of the bleb along with OS vitreous hemorrhage at 6 weeks follow-up. While he was planned for OS vitreo-retinal surgery, he presented with OD spontaneous hyphema with raised IOP (OD: 38 mmHg, OS: 16 mmHg). He had maintained a tight glycemic control. Following imatinib therapy, there was a rapid progression and recurrence of neovascularization, eventually leading to failure of trabeculectomy OD and bilateral severe loss of vision. Imatinib may be implicated in the worsening of NVG in CML patients, especially with co-existing diabetes and thus, such patients should receive regular thorough ophthalmic evaluation as long as imatinib continues.

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.

Baerveldt or Ahmed glaucoma valve implantation with pars plana tube insertion in Japanese eyes with neovascular glaucoma: 1-year outcomes

Purpose

To describe the 1-year surgical outcomes of both Baerveldt glaucoma implant (BGI) and the Ahmed glaucoma valve (AGV) implant with pars plana tube insertion in Japanese eyes with neovascular glaucoma (NVG).

Patients and methods

This was a retrospective study of 21 eyes of 18 patients who had undergone BGI (10 eyes) or AGV (11 eyes) implantation. The 1-year surgical outcomes in the two groups were compared. Surgical success was defined as an intraocular pressure (IOP) of 6–21 mmHg (criterion A) or 6–18 mmHg (criterion B) with >20% reduction regardless of the use of antiglaucoma medications.

Results

The mean preoperative IOP was 33.9±6.6 mmHg in the BGI group and 30.9±5.3 mmHg in the AGV group (P=0.31). The IOP at 1-year was lower in the BGI group at 10.3±5.9 mmHg than in the AGV group at 14.8±3.3 mmHg (P=0.044). The mean number of glaucoma medications at 1 year was 1.0±1.3 in the BGI group and 1.4±1.4 in the AGV group (P=0.57). The incidence of postoperative complications during the 1-year follow-up was not statistically different between the two groups; however, one eye in the BGI group lost light perception after additional surgery for Hoffman elbow exposure. The 1-year success rates of the BGI group was 60.0% and that in the AGV group was 90.9% based on criterion A (P=0.095), and 50.0% and 81.8% based on criterion B (P=0.074).

Conclusions

Significant reductions of the IOP and number of glaucoma medications were achieved at 1 year after both types of implants in Japanese eyes with NVG.

Risk factors for neovascular glaucoma after vitrectomy in eyes with proliferative diabetic retinopathy

Purpose

To investigate the potential risk factors for neovascular glaucoma (NVG) after vitrectomy in eyes with proliferative diabetic retinopathy.

Subjects and methods

In this retrospective, observational, comparative study, patients with proliferative diabetic retinopathy who underwent vitrectomy at Toho University Sakura Medical Center between December 2011 and November 2016 and who were followed for ≥12 months after surgery were included. Subject parameters examined included age, glycated hemoglobin (HbA1c), fasting blood glucose, administration of insulin, and estimated glomerular filtration rate. Ocular parameters examined included preoperative best-corrected visual acuity, preoperative IOP, operative history (specifically panretinal photocoagulation), lens status, ocular pathology (eg, iris/angle neovascularization, tractional retinal detachment, diabetic macular edema, vitreous hemorrhage, combined tractional retinal detachment), intraoperative retinal tamponade use, vitrectomy gauge, combined lens extraction/vitrectomy procedure, subsequent surgical procedures, and pre- and postoperative intravitreal bevacizumab. Correlations between variables and postoperative NVG development were examined using logistic regression analyses (backward elimination method).

Results

A total of 254 eyes of 196 consecutive subjects (146 men [74.5%], 54.0±10.8 years old) were included. Sixty of 254 eyes (23.6%) developed NVG. Several preoperative factors increased the risk of developing NVG, including iris/angle neovascularization (P=0.042), preoperative high IOP (P=0.005), low HbA1c (P=0.004), and administration of insulin (P=0.045). Intraoperative retinal tamponade also increased NVG risk (P=0.021, backward elimination method).

Conclusion

Preoperative parameters such as elevated IOP, iris/angle neovascularization, fasting blood sugar and HbA1c discrepancies, administration of insulin, as well as use of retinal tamponade during retinal surgery were identified as the risk factors for developing NVG.

Pars plana insertion of glaucoma shunt in eyes with refractory neovascular glaucoma: Case report

RATIONALE

Neovascular glaucoma (NVG) is one of the most aggressive types of glaucoma in clinical practice. The outcomes are unsatisfactory despite the successful trabeculectomy with glaucoma shunt insertion.

PATIENT CONCERNS

EX-PRESS Glaucoma Filtration Device (Alcon Laboratories, Fort Worth, TX), which is used in open-angle glaucoma surgery, could minimize the potential injury caused by traditional trabeculectomy. However, no study reported about the posterior segment insertion of this device. This article reports an alternative surgical technique and outcomes of pars plana insertion of glaucoma shunt in a patient with refractory NVG.

DIAGNOSES

This research was a retrospective study of a patient with refractory NVG and in whom trabeculectomy with EX-PRESS implantation was performed. However, bleb failure developed three times in four years.

INTERVENTIONS

In this patient, the previous EX-PRESS shunt was retrieved and reinserted into the posterior segment through the pars plana 3.5 mm behind the limbus.

OUTCOMES

The post-operation intraocular pressure was stable for more than eight months after surgery without any surgical intervention or antiglaucoma medication use. No discomfort nor major complication was observed after this operation.

LESSONS

Pars plana insertion of glaucoma shunt may provide an alternative to treat refractory NVG in patients who had received pars plana vitrectomy.

Assessing the role of ranibizumab in improving the outcome of glaucoma filtering surgery and neovascular glaucoma

INTRODUCTION

Ranibizumab was the first anti-vascular endothelial growth factor (VEGF) agent approved for the treatment of neovascular age-related macular degeneration. The use of ranibizumab and other anti-VEGF medications in recent years has revolutionized the treatment of several sight-threatening retinal disorders. Emerging evidence has demonstrated that anti-VEGF treatment can offer advantages in the management of other ocular conditions where VEGFs play a key role: ocular scarring following glaucoma filtering surgery and neovascular glaucoma (NVG). Areas covered: We critically review available evidence on the use of ranibizumab as a wound healing modulator in glaucoma filtering surgery and as an adjunct in the management of NVG. Expert opinion: Based on the available evidence and the authors' clinical experience, ranibizumab is a valuable adjunct in the management of NVG. In glaucoma filtering surgery, however, the role of ranibizumab is less clear and does not provide a significant advantage over mitomycin C. Drawbacks for its use in glaucoma include cost, its off-label use, uncertainty and limited evidence on the various routes of administration, the optimal dosing schemes and its toxicity profile. Future advances in ranibizumab delivery systems allowing less frequent dosing may change this treatment paradigm.