Neovascular glaucoma: a review

Integrated Assessment of OCT, Multimodal Imaging, and Cytokine Markers for Predicting Treatment Responses in Retinal Vein Occlusion Associated Macular Edema: A Comparative Review of Anti-VEGF and Steroid Therapies

Retinal vein occlusion (RVO) is a significant cause of vision loss, characterized by the occlusion of retinal veins, leading to conditions such as central retinal vein occlusion (CRVO) and branch retinal vein occlusion (BRVO). Macular edema (ME), a prevalent consequence of RVO, is the primary cause of vision impairment in affected patients. Anti-VEGF agents have become the standard treatment, showing efficacy in improving visual acuity (VA) and reducing ME. However, a subset of patients exhibit a suboptimal response to anti-VEGF therapy, necessitating alternative treatments. Corticosteroids, which address inflammatory pathways implicated in ME, have shown promise, particularly in cases resistant to anti-VEGF. This review aims to identify biomarkers that predict treatment response to corticosteroids in RVO-associated ME, utilizing multimodal imaging and cytokine assessments. Baseline imaging, including SD-OCT and OCT-A, is essential for evaluating biomarkers like hyperreflective foci (HRF), serous retinal detachment (SRF), and central retinal thickness (CRT). Elevated cytokine levels, such as IL-6 and MCP-1, correlate with ME severity and poor anti-VEGF response. Early identification of these biomarkers can guide timely transitions to corticosteroid therapy, potentially enhancing treatment outcomes. The practical conclusion of this review is that integrating biomarker assessment into clinical practice enables personalized treatment decisions, allowing for earlier and more effective management of RVO-associated ME by transitioning patients to corticosteroid therapy when anti-VEGF agents are insufficient. Advanced diagnostics and machine learning may further refine personalized treatment strategies, improving the management of RVO-associated ME.

Risk Factors for Developing Neovascular Glaucoma in Central Retinal Vein Occlusion: Two-Year Real-World Study

PURPOSE

To explore potential risk factors for the development of neovascular glaucoma (NVG) in central retinal vein occlusion (CRVO) over a two-year intensive follow-up period.

METHODS

This study reviewed 1545 patients with CRVO between 2005 and 2019 at Taipei Veterans General Hospital. Inclusion was restricted to (1) patients with acute CRVO within 3 months; (2) patients with ocular neovascularization at initial presentation (3) patients had not received any treatment at the time of CRVO; (4) at least bimonthly follow-up schedule over the course of 2 years. The included patients were screened for potential risk factors for developing NVG and assessed with Kaplan-Meier survival analysis and Cox regression model.

RESULTS

Among the included 123 patients, the cumulative probability of developing NVG was 26.8% (33/123 cases) in overall follow-up period. The mean interval between the onset of CRVO and NVG was 507 days. Neither macular edema nor central macular thickness at baseline was correlated with the development of NVG (p =.104 and .25, respectively). Patients with diabetes mellitus (DM), older age, and poor vision independently played significant risk factors for developing NVG after controlling other covariates. (p =.034, .001, and .013, respectively).

CONCLUSIONS

Patients presenting with CRVO who have comorbidities such as DM, older age, and worse VA warrant closer attention and intensive follow-up for the development of NVG. Additionally, the statistical analysis indicated that the presence of macular edema, increased central macular thickness, CV events, history of glaucoma, and early PRP within 3 months had no significant impact on the likelihood of developing NVG.

Neuroretinal Cell Culture Model as a Tool for the Development of New Therapeutic Approaches for Oxidative Stress-Induced Ocular Diseases, with a Focus on Glaucoma

Glaucoma is a heterogeneous group of optic neuropathies characterized by a progressive degeneration of the retinal ganglion cells (RGCs), leading to irreversible vision loss. Nowadays, the traditional therapeutic approach to glaucoma consists of lowering the intraocular pressure (IOP), which does not address the neurodegenerative features of the disease. Besides animal models of glaucoma, there is a considerable need for in vitro experimental models to propose new therapeutic strategies for this ocular disease. In this study, we elucidated the pathological mechanisms leading to neuroretinal R28 cell death after exposure to glutamate and hydrogen peroxide (H2O2) in order to develop new therapeutic approaches for oxidative stress-induced retinal diseases, including glaucoma. We were able to show that glutamate and H2O2 can induce a decrease in R28 cell viability in a concentration-dependent manner. A cell viability of about 42% was found after exposure to 3 mM of glutamate and about 56% after exposure to 100 µM of H2O2 (n = 4). Label-free quantitative mass spectrometry analysis revealed differential alterations of 193 and 311 proteins in R28 cells exposed to 3 mM of glutamate and 100 µM of H2O2, respectively (FDR < 1%; p < 0.05). Bioinformatics analysis indicated that the protein changes were associated with the dysregulation of signaling pathways, which was similar to those observed in glaucoma. Thus, the proteomic alteration induced by glutamate was associated with the inhibition of the PI3K/AKT signaling pathway. On the other hand, H2O2-induced toxicity in R28 cells was linked to the activation of apoptosis signaling and the inhibition of the mTOR and ERK/MAPK signaling pathways. Furthermore, the data show a similarity in the inhibition of the EIF2 and AMPK signaling pathways and the activation of the sumoylation and WNT/β-catenin signaling pathways in both groups. Our findings suggest that the exposure of R28 cells to glutamate and H2O2 could induce glaucoma-like neurodegenerative features and potentially provide a suitable tool for the development of new therapeutic strategies for retinal diseases.

Surgical outcomes including visual improvement after glaucoma surgery in patients with neovascular glaucoma

Purpose

This study aimed to evaluate the prognostic factors affecting surgical outcomes, including visual acuity (VA) improvement, after glaucoma surgery in patients with neovascular glaucoma (NVG).

Methods

The medical records of 116 patients (116 eyes) with NVG who had undergone trabeculectomy or Ahmed glaucoma valve implantation were reviewed retrospectively. The primary outcome measure was surgical success at 6 postoperative months, defined as sufficient intraocular pressure (IOP) reduction (IOP ≤21 mmHg, ≥20% reduction, regardless of topical medication use) without additional glaucoma surgery, hypotony, or progression to no light perception. Success was categorized as complete or qualified based on whether an improvement in VA was observed in addition to the abovementioned definition.

Results

The complete and qualified success rates at 6 months were 44.6% and 92.2%, respectively. Age (p = 0.001), preoperative best-corrected VA (p = 0.031), duration of decreased VA (p = 0.001), closed-angle status (p = 0.013), and etiology (p = 0.007) differed significantly between the groups with and without complete success. Multivariate analysis revealed that age (odds ratio [OR] 1.05; p = 0.026), duration of decreased VA (OR 1.05; p = 0.016), and 360° closed-angle status (OR 3.27; p = 0.031) were risk factors for surgical failure according to the complete success criteria, but not the qualified success criteria.

Conclusions

Patients with NVG showed improved visual prognosis and successful IOP reduction after glaucoma surgery at a relatively younger age if the duration of visual loss was not prolonged and the angle status was not completely closed.

Efficacy and safety of transscleral cyclophotocoagulation versus cyclocryotherapy in the treatment of intractable glaucoma: A systematic review and meta-analysis

To perform a meta-analysis to compare the efficacy and safety of diode laser transscleral cyclophotocoagulation (TSCPC) and cyclocryotherapy (CCT) in the treatment of intractable glaucoma. Systemic searches of the Ovid MEDLINE, EMBASE, and Cochrane Library databases yielded experimental and observational comparative studies. TSCPC and CCT efficacy and safety outcomes were compared. Subgroup analyses of participant ethnicity, preoperative intraocular pressure (IOP) level, and underlying causes of glaucoma were conducted. The pooled effects were computed using the random-effects model. The meta-analysis included nine studies totalling 668 eyes. There was no statistically significant difference between the TSCPC and CCT groups in the IOP reduction (IOPR%), decrease in antiglaucoma medications, the operative success rate with or without medications, or retreatment rate in the efficacy analysis. In the subgroup analysis, CCT had a better IOP-lowering effect among non-Asian participants and a non-inferior IOPR% to TSCPC among Asian participants. TSCPC and CCT were associated with similar rates of deterioration in visual acuity, postoperative visual analog scale, and other analysed postoperative complications in the safety analysis. In both groups, severe complications were uncommon. Diode laser TSCPC and CCT had nearly equivalent clinical efficacy in treating intractable glaucoma, while CCT demonstrated a better IOP-lowering effect in non-Asian. Both cyclodestructive procedures have a comparable safety profile.

Baerveldt glaucoma implant with Supramid© ripcord stent in neovascular glaucoma: a case series

AIM

To report the outcome of Baerveldt glaucoma implant (BGI) with Supramid© ripcord use in neovascular glaucoma (NVG).

METHODS

We retrospectively evaluated the surgical outcome of the BGI with Supramid© 3/0 ripcord stent in patients with NVG. No tube ligation or venting slits were performed. Supramid was removed after 3mo if the target intraocular pressure (IOP) was not achieved. Surgical success was defined as IOP≤21 mm Hg with (qualified success) or without IOP-lowering medications (complete success).

RESULTS

Twenty-six eyes from 24 patients were included in the study. The median duration of follow-up was 4 [interquartile range (IQR)=1-5]y, ranging from 0.5 to 5y. IOP decreased by a mean of 24.2 mm Hg (59.7%); from a mean of 40.5±12.6 mm Hg at baseline to 16.3±11.9 mm Hg, P≤0.001. The number of glaucoma medications reduced from a median of 5 (IQR=5-6) to 1 (IQR=0-2, P≤0.001) at the final follow-up. Overall success rates were 88.0% at 1y, 34.8% at 3y, 66.7% at 4y, and 50% at 5y. Hypertensive phase (HP) in the first 3mo occurred in 15/26 eyes (57.7%) with a mean IOP of 31.1 mm Hg.

CONCLUSION

BGI with Supramid© ripcord stent gives close to 90% of the overall survival rate at the final follow-up without significant early hypotony. However, early HP is still a challenge.

Chemical Insights into Topical Agents in Intraocular Pressure Management: From Glaucoma Etiopathology to Therapeutic Approaches

Glaucoma encompasses a group of optic neuropathies characterized by complex and often elusive etiopathology, involvihttng neurodegeneration of the optic nerve in conjunction with abnormal intraocular pressure (IOP). Currently, there is no cure for glaucoma, and treatment strategies primarily aim to halt disease progression by managing IOP. This review delves into the etiopathology, diagnostic methods, and treatment approaches for glaucoma, with a special focus on IOP management. We discuss a range of active pharmaceutical ingredients used in glaucoma therapy, emphasizing their chemical structure, pharmacological action, therapeutic effectiveness, and safety/tolerability profiles. Notably, most of these therapeutic agents are administered as topical formulations, a critical aspect considering patient compliance and drug delivery efficiency. The classes of glaucoma therapeutics covered in this review include prostaglandin analogs, beta blockers, alpha agonists, carbonic anhydrase inhibitors, Rho kinase inhibitors, and miotic (cholinergic) agents. This comprehensive overview highlights the importance of topical administration in glaucoma treatment, offering insights into the current state and future directions of pharmacological management in glaucoma.

[Current views on pathogenesis and treatment of neovascular glaucoma]

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.

Incidence of Total Blindness After Central Retinal Artery Occlusion With Ocular Neovascularization

Purpose: To determine the time-based incidence of total blindness after central retinal artery occlusion (CRAO) with secondary ocular neovascularization (ONV). Methods: In this retrospective cohort study, electronic records were queried using ICD-9 and ICD-10 codes to identify patients with secondary ONV post-CRAO. Patients with possible alternative ONV etiologies, previous panretinal photocoagulation (PRP), and/or previous antivascular endothelial growth factor (anti-VEGF) therapy were excluded. Clinical data included demographics, medical comorbidities, ONV manifestations, medical/surgical management, and best-corrected visual acuity (BCVA). Kaplan-Meier analysis was performed with total blindness (defined as a BCVA of no light perception) as the outcome of interest. Results: Of 345 eyes with CRAO, 34 met the inclusion criteria with a mean (±SD) follow-up of 22.0 ± 26.2 months. ONV management included PRP (70.6%), glaucoma drainage implant surgery or transscleral cyclophotocoagulation (32.4%), and intravitreal anti-VEGF therapy (mean 2.8 ± 5.6 injections per patient). The cumulative incidence of total blindness was 49.4% (95% confidence interval, 27.2%-71.6%) at 24 months, with 53.3% of cases occurring within 4 months of ONV onset. Conclusions: Post-CRAO ONV is associated with a high risk for progression from severe vision loss to total blindness. Neovascular glaucoma can present up to 4 months after CRAO, challenging the paradigm of "30-day-glaucoma." Routine gonioscopy should extend through this period, while glaucoma surgery can delay further vision loss. These findings can be used to counsel patients on the importance of follow-up adherence.

Anterior chamber fluorescein leakage in a child with intraocular pressure elevation and vitreous hemorrhage

Purpose

To report a case of a child with neovascular and ghost cell glaucoma in the setting of previously treated vitreous hemorrhage with unique fluorescein leakage from abnormal iris vessels ultimately preventing successful fluorescein angiography.

Observations

A 3-year-9-month-old female with a medical history of very high-risk B-cell acute lymphoblastic leukemia presented with eye pain and was noted to have a complete vitreous hemorrhage and intraocular pressure elevation in the right eye which was refractory to maximum medical therapy and vitrectomy. Following vitreous hemorrhage resolution, an examination under anesthesia with fluorescein angiography was found to have diffuse leakage of fluorescein into the anterior chamber, presumably due to the active iris neovascularization. This anterior chamber fluorescein signal prevented visualization of the retinal vasculature. The patient was diagnosed with mixed mechanism glaucoma (neovascular and ghost cell) due to a resolved vitreous hemorrhage in the setting of a presumed prior ischemic event.

Conclusions and Importance

We report a case of an unsuccessful fluorescein angiogram in the setting of anterior chamber fluorescein leakage due to active iris neovascularization, and review considerations for the differential diagnosis and useful diagnostic tests in this clinical scenario.

Evaluation of Quality of Life and Emotional Disturbances in Patients with Diabetic Retinopathy

Diabetes has detrimental effects on many organs, including the kidneys, heart, and the central nervous system, with ophthalmic involvement and Diabetic Retinopathy (DR), specifically, being among the most severe and prominent consequences. Diabetic Retinopathy and especially advanced stages of the disease, have a crucial impact on patients' quality of life and emotional status. In this context, emotional imbalance, psychological side effects and comorbidities, like anxiety disorders, could emerge, deteriorating the patients' condition further. A number of questionnaires can be employed in the evaluation of the potential impact of Diabetic Retinopathy on patients' quality of life, including the Beck Anxiety Inventory (BAI) and The National Eye Institute Visual Function Questionnaire-25 (NEI VFQ-25).

PURPOSE

The purpose of this study was to evaluate the association of Diabetic Retinopathy (DR) and diabetic macular edema with vision-related quality of life, as well as the potential association between the disease's severity, emotional status of patients and the manifestation of anxiety and psychological features.

RESULTS

Patients with fundoscopic findings had significantly lower scores in all VFQ-25 subscales, indicating worse quality of life in comparison to patients without DR. Severity of DR, greater levels of anxiety, daily sitting time, unemployment and lower education level, were all found to be significantly, negatively associated with a worse quality of life. Regarding emotional status, more years of suffering from diabetes, treatment with insulin and the hours being idle per day were associated with an increased burden of anxiety. In addition, the presence of a concomitant disease, findings in fundoscopy, diabetic macular edema and treatment with anti-VEFG injections, as well as the number of doses, were significantly associated with greater anxiety. Multivariate analysis showed that having Severe Non-Proliferative Diabetic Retinopathy or having Proliferative Diabetic Retinopathy and receiving insulin therapy (alone or in combination with another treatment), were significantly associated with higher levels of anxiety.

CONCLUSION

The well-established impact of DR on the patients' well-being, quality of life and emotional status render DR and CME prevention, stabilization or delaying progression as a necessity in order to protect patients from developing psychiatric symptoms. On the other hand, the speculated bi-directional association between emotional problems and DR progression highlights the importance of acknowledging and dealing with psychological issues with the aim of delaying DR progression.

Latanoprost PF vs. Bimatoprost PF: Which Treats the Ocular Surface Better?

(1) Background: The current study aimed to compare two of the most frequently prescribed preservative-free (PF) antiglaucoma drops, (Latanoprost PF vs. Bimatoprost PF) in promoting OSD in patients with POAG. (2) Methods: In this prospective study, 44 eyes from 44 participants were included. In the control group we enrolled 24 eyes, 11 eyes treated only with Latanoprost PF were enrolled in the Latanoprost PF group, and 9 eyes treated only with Bimatoprost PF in the Bimatoprost PF group. In all eyes, we evaluated the ocular levels of MMP-9 using the InflammaDry kit. We also performed Schirmer's test and the TBUT test. (3) Results: We found elevated ocular levels of MMP-9 (>40 ng/mL) in the Bimatoprost PF group (88.89% of the participants) compared to the control (8.33%) and the Latanoprost PF group (27.27%), and the difference was statistically significant (p < 0.001). The Schirmer's test values were statistically significantly lower in the Bimatoprost PF group compared to the other two groups. Additionally, the TBUT values were lower in the Bimatoprost PF group compared to the control group, and the difference was statistically significant. (4) Conclusions: Latanoprost PF eye drops treat the ocular surface better and they do not induce overexpression of MMP-9, a molecule that is related to OSD.

Short-Term Outcomes of Trabeculectomy With or Without Anti-VEGF in Patients With Neovascular Glaucoma: A Systematic Review and Meta-Analysis

Objectives

The aim of this study was to compare the safety and efficacy of trabeculectomy alone or combined with intravitreal injections of anti-vascular endothelial growth factor (anti-VEGF) agents for the treatment of neovascular glaucoma.

Methods

We conducted a systematic review and meta-analysis to compare the effects of trabeculectomy alone or combined with intravitreal injections of anti-VEGF agents for the treatment of neovascular glaucoma. We searched four databases (PubMed, Cochrane Library, Embase, and Web of Science) up to January 2023 and extracted data on three surgical outcomes: postoperative intraocular pressure, success rate and complications. We used a random-effects model to calculate pooled relative risk (RR) or standardized mean difference (SMD) estimates and 95% confidence intervals (CIs). We assessed publication bias using Begg and Egger tests.

Results

We included seven studies with 353 eyes. Compared to trabeculectomy alone, trabeculectomy with anti-VEGF had a lower risk of postoperative complications (RR, 0.60; 95% CI, 0.41-0.89) and higher success rate (RR, 1.19; 95% CI, 1.02-1.40). The intraocular pressure reduction was significantly greater in the trabeculectomy with anti-VEGF augmentation group than the trabeculectomy group from 1 week (SMD, -1.36; 95% CI, -2.76 to 0.04) to 6 months (SMD, -0.79; 95% CI, -1.50 to -0.07) after surgery.

Conclusions

According to current evidence, adding intravitreal injection of anti-VEGF agents to trabeculectomy may improve the short time outcomes of patients with neovascular glaucoma.

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.

RISK FACTORS FOR SURGERY OR BLINDNESS IN NEOVASCULAR GLAUCOMA EYES TREATED WITH ANTI-VEGF INJECTIONS BY A RETINA SPECIALIST

PURPOSE

To determine baseline patient characteristics that predict the need for glaucoma surgery or blindness in eyes with neovascular glaucoma (NVG) despite intravitreal antivascular endothelial growth factor therapy.

METHODS

This is a retrospective cohort study of patients with NVG who had not previously received glaucoma surgery and were treated with intravitreal antivascular endothelial growth factor injections at the time of diagnosis, from September 8, 2011, to May 8, 2020, at a large, retina subspecialty practice.

RESULTS

Of 301 newly presenting NVG eyes, 31% required glaucoma surgery and 20% progressed to no light perception vision despite treatment. Patients with intraocular pressure >35 mmHg ( P < 0.001), two or more topical glaucoma medications ( P = 0.003), worse than 20/100 vision ( P = 0.024), proliferative diabetic retinopathy ( P = 0.001), eye pain or discomfort ( P = 0.010), and new patient status ( P = 0.015) at the time of NVG diagnosis were at a higher risk of glaucoma surgery or blindness regardless of antivascular endothelial growth factor therapy. The effect of panretinal photocoagulation was not statistically significant in a subgroup analysis of patients without media opacity ( P = 0.199).

CONCLUSION

Several baseline characteristics at the time of presentation to a retina specialist with NVG seem to portend a higher risk of uncontrolled glaucoma despite the use of antivascular endothelial growth factor therapy. Prompt referral of these patients to a glaucoma specialist should be strongly considered.

Homocysteine and Glaucoma

Elevated levels of homocysteine (Hcy), a non-proteinogenic amino acid, may lead to a host of manifestations across the biological systems, particularly the nervous system. Defects in Hcy metabolism have been associated with many neurodegenerative diseases including glaucoma, i.e., the leading cause of blindness. However, the pathophysiology of elevated Hcy and its eligibility as a risk factor for glaucoma remain unclear. We aimed to provide a comprehensive review of the relationship between elevated Hcy levels and glaucoma. Through a systemic search of the PubMed and Google Scholar databases, we found that elevated Hcy might play an important role in the pathogenesis of glaucoma. Further research will be necessary to help clarify the specific contribution of elevated Hcy in the pathogenesis of glaucoma. A discovery and conceptual understanding of Hcy-associated glaucoma could be the keys to providing better therapeutic treatment, if not prophylactic treatment, for this disease.

Murphy's Law and Ophthalmic Complications in a Patient With Type 1 Diabetes Mellitus

Diabetes can lead to various acute clinical complications, although the occurrence of ophthalmic signs and symptoms is uncommon. Neovascular glaucoma (NG), a rare complication associated with diabetes mellitus, is one such condition. Additionally, anti-vascular endothelial growth factor (VEGF)-induced toxic anterior segment syndrome (TASS) is a rare complication of intravitreal bevacizumab. In this case report, we present a unique case of a patient with juvenile diabetes (type 1 diabetes mellitus) who presented to the emergency room (ER) with typical features of diabetic ketoacidosis (DKA) accompanied by bilateral ocular pain. Subsequent investigation revealed secondary angle-closure neovascular glaucoma as the underlying cause. The patient received management for DKA in the ER and subsequent medicine ward. Various interventions were performed for glaucoma in the right eye, including addressing cataracts, which ultimately resulted in TASS. The patient was successfully treated with cryo-diode laser therapy.

Anti-vascular endothelial growth factor for neovascular glaucoma

BACKGROUND

Neovascular glaucoma (NVG) is a potentially blinding, secondary glaucoma. It is caused by the formation of abnormal new blood vessels, which prevent normal drainage of aqueous from the anterior segment of the eye. Anti-vascular endothelial growth factor (anti-VEGF) medications are specific inhibitors of the primary mediators of neovascularization. Studies have reported the effectiveness of anti-VEGF medications for the control of intraocular pressure (IOP) in NVG.

OBJECTIVES

To assess the effectiveness of intraocular anti-VEGF medications, alone or with one or more types of conventional therapy, compared with no anti-VEGF medications for the treatment of NVG.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Trials Register); MEDLINE; Embase; PubMed; and LILACS to 19 October 2021; metaRegister of Controlled Trials to 19 October 2021; and two additional trial registers to 19 October 2021. We did not use any date or language restrictions in the electronic search for trials.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) of people treated with anti-VEGF medications for NVG.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the search results for trials, extracted data, and assessed risk of bias, and the certainty of the evidence. We resolved discrepancies through discussion.

MAIN RESULTS

We included five RCTs (356 eyes of 353 participants). Each trial was conducted in a different country: two in China, and one each in Brazil, Egypt, and Japan. All five RCTs included both men and women; the mean age of participants was 55 years or older. Two RCTs compared intravitreal bevacizumab combined with Ahmed valve implantation and panretinal photocoagulation (PRP) with Ahmed valve implantation and PRP alone. One RCT randomized participants to receive an injection of either intravitreal aflibercept or placebo at the first visit, followed by non-randomized treatment according to clinical findings after one week. The remaining two RCTs randomized participants to PRP with and without ranibizumab, one of which had insufficient details for further analysis. We assessed the RCTs to have an unclear risk of bias for most domains due to insufficient information to permit judgment.   Four RCTs examined achieving control of IOP, three of which reported our time points of interest. Only one RCT reported our critical time point at one month; it found that the anti-VEGF group had a 1.3-fold higher chance of achieving control of IOP at one month (RR 1.32, 95% 1.10 to 1.59; 93 participants) than the non-anti-VEGF group (low certainty of evidence). For other time points, one RCT found a three-fold greater achievement in control of IOP in the anti-VEGF group when compared with the non-anti-VEGF group at one year (RR 3.00; 95% CI:1.35 to 6.68; 40 participants). However, another RCT found an inconclusive result at the time period ranging from 1.5 years to three years (RR 1.08; 95% CI: 0.67 to 1.75; 40 participants).  All five RCTs examined mean IOP, but at different time points. Very-low-certainty evidence showed that anti-VEGFs were effective in reducing mean IOP by 6.37 mmHg (95% CI: -10.09 to -2.65; 3 RCTs; 173 participants) at four to six weeks when compared with no anti-VEGFs.  Anti-VEGFs may reduce mean IOP at three months (MD -4.25; 95% CI -12.05 to 3.54; 2 studies; 75 participants), six months (MD -5.93; 95% CI -18.13 to 6.26; 2 studies; 75 participants), one year (MD -5.36; 95% CI -18.50 to 7.77; 2 studies; 75 participants), and more than one year (MD -7.05; 95% CI -16.61 to 2.51; 2 studies; 75 participants) when compared with no anti-VEGFs, but such effects remain uncertain. Two RCTs reported the proportion of participants who achieved an improvement in visual acuity with specified time points. Participants receiving anti-VEGFs had a 2.6 times (95% CI 1.60 to 4.08; 1 study; 93 participants) higher chance of improving visual acuity when compared with those not receiving anti-VEGFs at one month (very low certainty of evidence). Likewise, another RCT found a similar result at 18 months (RR 4.00, 95% CI 1.33 to 12.05; 1 study; 40 participants).  Two RCTs reported the outcome, complete regression of new iris vessels, at our time points of interest. Low-certainty evidence showed that anti-VEGFs had a nearly three times higher chance of complete regression of new iris vessels when compared with no anti-VEGFs (RR 2.63, 95% CI 1.65 to 4.18; 1 study; 93 participants). A similar finding was observed at more than one year in another RCT (RR 3.20, 95% CI 1.45 to 7.05; 1 study; 40 participants).  Regarding adverse events, there was no evidence that the risks of hypotony and tractional retinal detachment were different between the two groups (RR 0.67; 95% CI: 0.12 to 3.57 and RR 0.33; 95% CI: 0.01 to 7.72, respectively; 1 study; 40 participants). No RCTs reported incidents of endophthalmitis, vitreous hemorrhage, no light perception, and serious adverse events. Evidence for the adverse events of anti-VEGFs was low due to limitations in the study design due to insufficient information to permit judgments and imprecision of results due to the small sample size. No trial reported the proportion of participants with relief of pain and resolution of redness at any time point.

AUTHORS' CONCLUSIONS

Anti-VEGFs as an adjunct to conventional treatment could help reduce IOP in NVG in the short term (four to six weeks), but there is no evidence that this is likely in the longer term. Currently available evidence regarding the short- and long-term effectiveness and safety of anti-VEGFs in achieving control of IOP, visual acuity, and complete regression of new iris vessels in NVG is insufficient. More research is needed to investigate the effect of these medications compared with, or in addition to, conventional surgical or medical treatment in achieving these outcomes in NVG.

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.

The alterations of brain network degree centrality in patients with neovascular glaucoma: a resting-state fMRI study

PURPOSE

To explore the alterations of whole brain functional network using the degree centrality (DC) analysis in neovascular glaucoma (NVG) and the correlation between DC values and NVG clinical indices.

MATERIALS AND METHODS

Twenty NVG patients and twenty normal controls (NC), closely matched in age, sex, and education, were recruited for this study. All subjects underwent comprehensive ophthalmologic examinations and a resting-state functional magnetic resonance imaging (rs-fMRI) scan. The differences in DC values of brain network between NVG and NC groups were analyzed, and correlation analysis was performed to explore the relationships between DC values and clinical ophthalmological indices in NVG group.

RESULTS

Compared with NC group, significantly decreased DC values were found in the left superior occipital gyrus and left postcentral gyrus, while significantly increased DC values in the right anterior cingulate gyrus and left medial frontal gyrus in NVG group. (All P < 0.05, FDR corrected). In the NVG group, the DC value in left superior occipital gyrus showed significantly positive correlations with retinal nerve fiber layer (RNFL) thickness (R = 0.484, P = 0.031) and mean deviation of visual field (MDVF) (R = 0.678, P = 0.001). Meanwhile, the DC value in the left medial frontal gyrus demonstrated significantly negative correlations with RNFL (R = - 0.544, P = 0.013) and MDVF (R = - 0.481, P = 0.032).

CONCLUSIONS

NVG exhibited decreased network degree centrality in visual and sensorimotor brain regions and increased degree centrality in cognitive-emotional processing brain region. Additionally, the DC alterations might be complementary imaging biomarkers to assess disease severity.

Individualized Treatment for Glaucoma Patients with Diabetes mellitus

Glaucoma and diabetes mellitus are two common chronic diseases in Europe and worldwide which require intensive therapy. Various pathophysiological mechanisms have been discussed which favour the development of glaucoma, especially in the presence of diabetes mellitus. Medicinal and surgical adjustment of intraocular pressure is associated with some limitations in patients with diabetes mellitus, for example, filtering interventions show lower success rates than in non-diabetic glaucoma patients. Besides pure ophthalmological endocrinological therapy, the psychological burden of two chronic diseases should also be considered and included in the individual therapy plan.

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

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

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.

Gonioscopy-assisted transluminal trabeculotomy in neovascular glaucoma: Salvaging the conventional outflow pathway

Purpose

To report a case of acute neovascular glaucoma with partial synechial angle closure secondary to central retinal vein occlusion that underwent gonioscopy-assisted transluminal trabeculotomy as well as near-monthly anti-vascular endothelial growth factor (VEGF) injections and panretinal photocoagulation (PRP) treatments.

Observations

Nine months after GATT, the patient had achieved intraocular pressure control on no medications. However, she was lost to follow up for 4 months and received no anti-VEGF or PRP during that time; she re-presented with acute NVG and complete synechial closure, and ultimately underwent aqueous shunt implantation.

Conclusions and Importance

To our knowledge, this is the first reported attempt of an ab interno angle surgery to successfully restore aqueous outflow through the conventional outflow pathway in an eye with acute NVG and partial synechial angle closure. We posit that this can be an effective approach to achieve IOP control in NVG with at least partially open angles, as long as sufficient anti-neovascular treatments are administered until the underlying neovascular drive achieves quiescence.

Updates on the Diagnosis and Management of Glaucoma

Glaucoma is the leading cause of blindness throughout the world (after cataracts); therefore, general physicians should be familiar with the diagnosis and management of affected patients. Glaucomas are usually categorized by the anatomy of the anterior chamber angle (open vs narrow/closed), rapidity of onset (acute vs chronic), and major etiology (primary vs secondary). Most glaucomas are primary (ie, without a contributing comorbidity); however, several coexisting ophthalmic conditions may serve as the underlying etiologies of secondary glaucomas. Chronic glaucoma occurs most commonly; thus, regular eye examinations should be performed in at-risk patients to prevent the insidious loss of vision that can develop before diagnosis. Glaucoma damages the optic nerve and retinal nerve fiber layer, leading to peripheral and central visual field defects. Elevated intraocular pressure (IOP), a crucial determinant of disease progression, remains the only modifiable risk factor; thus, all current treatments (medications, lasers, and operations) aim to reduce the IOP. Pharmacotherapy is the usual first-line therapy, but noncompliance, undesirable adverse effects, and cost limit effectiveness. Laser and surgical treatments may lower IOP significantly over long periods and may be more cost effective than pharmacotherapy, but they are plagued by greater procedural risks and frequent treatment failures. Traditional incisional procedures have recently been replaced by several novel, minimally invasive glaucoma surgeries with improved safety profiles and only minimal decreases in efficacy. Minimally invasive glaucoma surgeries have dramatically transformed the surgical management of glaucoma; nevertheless, large, randomized trials are required to assess their long-term efficacy.

A Paradigm Shift in the Management Approaches of Proliferative Diabetic Retinopathy: Role of Anti-VEGF Therapy

Diabetic retinopathy (DR) is considered one of the leading causes of vision loss globally. It principally causes upregulation of pro-angiogenic, proinflammatory, and vascular permeability factors such as vascular endothelial growth factor (VEGF), leading to neovascularisation. The advanced stage of DR or proliferative diabetic retinopathy (PDR) is of more concern, as it leads to vitreous haemorrhage and traction retinal detachment. Various risk factors associated with PDR include hyperglycemia, hypertension, neuropathy, dyslipidemia, anaemia, nephropathy, and retinal complications of drugs used for diabetes. Current management approaches for PDR have been stratified and involve pan-retinal photocoagulation, vitrectomy, and anti-VEGF agents. Given the emerging role of anti-VEGF agents as a favourable adjunct or alternative therapy, they have a critical role in the management of PDR. The review emphasises current management approaches for PDR focusing on anti-VEGF therapy. The review also highlights the risk/benefit evaluation of the various approaches employed for PDR management in various clinical scenarios.

Rapid Onset Neovascular Glaucoma due to COVID-19-related Retinopathy

Aim

Background

Case description

Conclusion

Clinical significance

How to cite this article

Etiology, pathogenesis, and diagnosis of neovascular glaucoma

Neovascular glaucoma is defined as iris and/or anterior chamber angle neovascularization associated with increased intraocular pressure. It is a secondary glaucoma that is most frequently caused by severe retinal ischemia. The most common diseases responsible for the development of neovascular glaucoma are diabetic retinopathy, ischemic central retinal vein occlusion, and ocular ischemic syndrome. Uncommon causes include ocular radiation, ocular tumors, uveitis and other miscellaneous conditions. Vascular endothelial growth factor is an important and likely predominant agent involved in the pathogenesis of intraocular neovascularization and neovascular glaucoma. The evolution of clinical and histopathological changes from predisposing conditions to the occurrence of rubeosis iridis and neovascular glaucoma is divided into four stages: prerubeosis, preglaucoma, open angle glaucoma, and angle-closure glaucoma.

Review: The Development of Risk Factors and Cytokines in Retinal Vein Occlusion

Retinal vein occlusion (RVO) is the second most prevalent retinal disease. Despite this, the pathogenic mechanisms and risk factors are not entirely clear. In this article, we review recent publications on the classification, pathogenesis, risk factors, ischemic changes, cytokines, and vital complications of RVO. Risk factors and cytokines are important for exploring the mechanisms and new treatment targets. Furthermore, risk factors are interrelated, making RVO mechanisms more complex. Cytokines act as powerful mediators of pathological conditions, such as inflammation, neovascularization, and macular edema. This review aims to summarize the updated knowledge on risk factors, cytokines of RVO and signaling in order to provide valuable insight on managing the disease.

The Histopathology of Two Eyes Enucleated after Continuous Transscleral and Micropulse Transscleral Cyclophotocoagulation for Refractory Secondary Glaucoma

INTRODUCTION

Cyclodestructive procedures, which target the nonpigmented epithelium of the ciliary body, have been utilized to treat recalcitrant glaucoma since the early 1930s. There are now various types of cyclophotocoagulation (CPC) available. The authors provide a retrospective description that details the histopathologic findings in 2 patients who underwent CPC for uncontrolled uveitic and neovascular glaucoma (NVG) with subsequent enucleation.

CASE PRESENTATIONS

Two enucleated globes from 2 patients with secondary refractory glaucoma underwent cilioablative therapy: one with uveitic glaucoma and a remote history of micropulse transscleral CPC (MP-TSCPC) and the other with NVG and a recent history of traditional continuous transscleral CPC (CW-TSCPC). The clinical histories are summarized, and light microscopy reviewed for degree of coagulative necrosis and inflammation of the ciliary body and surrounding structures, as well as the underlying pathology of the glaucoma.

CONCLUSION

Both patients ultimately experienced pain and vision loss with either a recrudescence of elevated intraocular pressure or inflammatory hypotony and subsequently underwent enucleation of the affected eye. One globe was enucleated shortly after CW-TSCPC and found to have near full-thickness coagulative necrosis of the pigmented and nonpigmented ciliary epithelium and ciliary muscle as well as necrosis of adjacent nontarget tissues with fibrin in the anterior chamber. The second patient underwent enucleation many months after MP-TSCPC with partial healing fibrosis of the ciliary body and some remaining viable ciliary processes. The histopathologic findings post-CPC may vary based on the method used and evolve over time; additional study is needed.

Three-Year Outcomes of Pars Plana Ahmed and Baerveldt Glaucoma Implantations for Neovascular Glaucoma in Japanese Eyes

PRCIS

Tube shunt implantation through the pars plana was effective for neovascular glaucoma (NVG) for at least 3 years, with few serious postoperative complications observed.

PURPOSE

The aim was to report 3-year outcomes of pars plana Ahmed and Baerveldt glaucoma implantation for NVG in Japanese eyes.

PATIENTS AND METHODS

This study examined 41 eyes of 39 patients who underwent tube shunt implantation through the pars plana with the Baerveldt glaucoma implant (BGI group, 26 eyes) or Ahmed glaucoma valve (AGV group, 15 eyes) for NVG and who were followed up for over 3 years at Osaka Medical College between January 2009 and April 2016. Outcome measures were intraocular pressure (IOP, mm Hg) at presurgery and at 6 months and 1, 2, and 3 years postoperative. Postoperative failure was defined as an IOP of >21 mm Hg or <5 mm Hg, further glaucoma surgery, or no light perception.

RESULTS

Mean IOPs at presurgery and at 3 years postoperative were 34.8±9.1 and 15.6±4.6 in the AGV group, and 36.9±9.2 and 12.8±5.5 in the BGI group. Mean antiglaucoma medication scores at 3 years postoperative were 1.3±1.4 in the AGV group and 0.4±0.8 in the BGI group (P=0.05). The number of eyes with a probability of failure at 6 months and at 2 and 3 years postoperative was 2, 3, and 4, respectively, in the BGI group, and 0, 1, and 2, respectively, in the AGV group.

CONCLUSION

Findings for NVG cases showed tube shunt implantation through the pars plana was effective. Equivalent good IOP reductions were noted in both groups, with the BGI group requiring fewer postoperative antiglaucoma medications compared with the AGV group. Furthermore, both groups exhibited few serious postoperative complications.

Harnessing the Neuroprotective Behaviors of Müller Glia for Retinal Repair

Progressive and irreversible vision loss in mature and aging adults creates a health and economic burden, worldwide. Despite the advancements of many contemporary therapies to restore vision, few approaches have considered the innate benefits of gliosis, the endogenous processes of retinal repair that precede vision loss. Retinal gliosis is fundamentally driven by Müller glia (MG) and is characterized by three primary cellular mechanisms: hypertrophy, proliferation, and migration. In early stages of gliosis, these processes have neuroprotective potential to halt the progression of disease and encourage synaptic activity among neurons. Later stages, however, can lead to glial scarring, which is a hallmark of disease progression and blindness. As a result, the neuroprotective abilities of MG have remained incompletely explored and poorly integrated into current treatment regimens. Bioengineering studies of the intrinsic behaviors of MG hold promise to exploit glial reparative ability, while repressing neuro-disruptive MG responses. In particular, recent in vitro systems have become primary models to analyze individual gliotic processes and provide a stepping stone for in vivo strategies. This review highlights recent studies of MG gliosis seeking to harness MG neuroprotective ability for regeneration using contemporary biotechnologies. We emphasize the importance of studying gliosis as a reparative mechanism, rather than disregarding it as an unfortunate clinical prognosis in diseased retina.

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.

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.

Visual Outcomes in Eyes With Neovascular Glaucoma and Anterior Segment Neovascularization Without Glaucoma

PURPOSE

To find predictive factors of neovascular glaucoma (NVG) development in eyes with anterior segment neovascularization without glaucoma (ASNVWG), and poor visual outcomes in eyes that have already developed NVG.

DESIGN

Retrospective, clinical cohort studies.

METHODS

A retrospective chart review was performed on 106 eyes of 94 patients with ASNVWG and 245 eyes of 225 patients with NVG. Measured outcomes included the development of NVG at any time point of the disease for the ASNVWG arm, and a visual acuity of ≤20/200 at 6 months after initial presentation for the NVG arm.

RESULTS

Overall, 25% of ASNVWG eyes progressed to NVG. Progression was associated with retinal vein occlusion (RVO) (P < .01), lower median presenting BCVA (P < .01), and concurrent traction retinal detachments (TRDs) (P = .025). Sixty-eight percent of NVG eyes had a BCVA of ≤20/200 by 6-month follow-up, which was associated with RVO (P = .005), vitreous hemorrhage on presentation (P = .001), and no panretinal photocoagulation (PRP) treatments (P < .001). BCVA >20/200 at 6 months was associated with ≥1 PRP or intravitreal bevacizumab (IVB) treatment within 1 week of presentation or ≥3 PRP or IVB treatments overall (P < .001).

CONCLUSION

RVO, presenting visual acuity, and concurrent TRD are risk factors for NVG in eyes with ASNVWG. In eyes with NVG, RVO and concurrent vitreous hemorrhage are risk factors for ≤20/200 vision at 6 months, whereas treatment with ≥1 PRP or IVB within 1 week of presentation, or ≥3 treatments of PRP or IVB within 6 months are protective.

Intravitreal anti-vascular endothelial growth factor injections to treat post-trabeculectomy Swan syndrome

Purpose

To report a case of wound neovascularization (Swan syndrome) one year after trabeculectomy favorably treated with two intravitreal ranibizumab injections.

Observations

A 79-year-old woman under coumadin treatment for atrial fibrillation experienced relapsing decreased vision in her left eye due to vitreous hemorrhage. She had had a past history of ocular hypertension corneal decompensation after phacoemulsification that required a Descemet Membrane Endothelial Keratoplasty and a subsequent trabeculectomy. After clearance of the hemorrhage, examination showed neovascularization not in the retina but surrounding the sclerostomy wound of the trabeculectomy, being diagnosed as a Swan syndrome. After two intravitreal injections of ranibizumab, gonioscopy showed complete resolution of the new vessels. No further recurrences have been reported and IOP has remained controlled without glaucomatous changes 7 months after the last injection. Clinical features and patient characteristics are described.

Conclusion and importance

Anti-vascular endothelial growth factor intravitreal injections may be a good and safe alternative to manage vitreous hemorrhage secondary to wound neovascularization of the trabeculectomy site.

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.

Detection of signs of disease in external photographs of the eyes via deep learning

Retinal fundus photographs can be used to detect a range of retinal conditions. Here we show that deep-learning models trained instead on external photographs of the eyes can be used to detect diabetic retinopathy (DR), diabetic macular oedema and poor blood glucose control. We developed the models using eye photographs from 145,832 patients with diabetes from 301 DR screening sites and evaluated the models on four tasks and four validation datasets with a total of 48,644 patients from 198 additional screening sites. For all four tasks, the predictive performance of the deep-learning models was significantly higher than the performance of logistic regression models using self-reported demographic and medical history data, and the predictions generalized to patients with dilated pupils, to patients from a different DR screening programme and to a general eye care programme that included diabetics and non-diabetics. We also explored the use of the deep-learning models for the detection of elevated lipid levels. The utility of external eye photographs for the diagnosis and management of diseases should be further validated with images from different cameras and patient populations.

Anterior chamber enhancement predicts optic nerve infiltration in retinoblastoma

OBJECTIVES

As described recently, intravenously injected gadolinium-based contrast agent (GBCA) penetrates into the anterior eye chamber (AC) and is drained from the retina to the distal optic nerve (ON) along perivascular spaces, which serves retinal homeostasis and was termed the orbital glymphatic system (GS). Independently, AC enhancement predicted ON infiltration, a major risk factor for advanced retinoblastoma (RB), in a small RB patient cohort. We aimed to review the supposed imaging biomarker for ON infiltration in a large RB cohort and with respect to the recently described orbital GS.

METHODS

This IRB-approved retrospective single-center study encompassed 539 orbital MRIs performed with an orbital coil and with the children under general anesthesia. Differences of signal intensity ratios (∆SIRs) of the AC to the lens were determined between non-contrast and GBCA-enhanced T1-weighted images and were correlated with histopathologic presence of ON infiltration.

RESULTS

∆SIR of the RB eye was an independent, significant predictor for ON invasion in multivariate analysis with adjustment for tumor size (p < 0.05) and increased with infiltration level.

CONCLUSIONS

GBCA enhancement of the AC predicts ON infiltration. This might be caused by impairment of the orbital glymphatic system, which is supposed to clear toxic metabolites from the retina to the postlaminar ON. In RB with ON infiltration, this efflux path is likely to be inhibited, which is supposed to result in disturbed retinal homeostasis, release of vascular endothelial growth factor, and iris neovascularization, which increases penetration of GBCA into the AC.

KEY POINTS

• Infiltration of the optic nerve can be predicted by anterior chamber enhancement after intravenous MRI contrast agent administration. • Increased anterior chamber enhancement in retinoblastoma with optic nerve infiltration might result from dysfunction of the orbital glymphatic system with disturbance of retinal homeostasis and consecutive iris neovascularization.

Clinical Manifestations of Supra-Large Range Nonperfusion Area in Diabetic Retinopathy

OBJECTIVE

We describe the clinical manifestations of supra-large range nonperfusion area (SLRNPA) in diabetic retinopathy (DR).

METHODS

This was a retrospective case-control study. A total of 260 eyes of 236 patients with DR who underwent pars plana vitrectomy in the Department of Ophthalmology of Qingdao Municipal Hospital from February 2016 to June 2019 were enrolled. Fundus fluorescein angiography was performed after surgery to determine whether SLRNPA or non-SLRNPA in DR was present. All demographic and clinical data were carefully collected.

RESULTS

Forty-one eyes of 22 patients were diagnosed with SLRNPA in DR (15.77% of all eyes). Compared to non-SLRNPA, SLRNPA patients were more likely to be male and younger with earlier DR onset, a smoking history, other comorbidities, and a higher HbA1c level. SLRNPA in DR eyes exhibited more neovascular glaucoma (NVG) and diabetic keratopathy (DK) than did other eyes. Such eyes were more likely to require anti-VEGF therapy before surgery or a silicone oil or a gas tamponade during surgery and to suffer from persistent corneal epithelial erosion and NVG recurrence after surgery.

CONCLUSIONS

SLRNPA in DR is a severe status of DR. Treatment for DR patients with SLRNPA is difficult, and the prognosis is poor, so clinicians must thus pay more attention to SLRNPA in DR.

MicroRNAs and the HIF/VEGF axis in ocular neovascular diseases

Ocular neovascular diseases, such as proliferative diabetic retinopathy, retinopathy of prematurity and neovascular age-related macular degeneration, are the leading causes of visual impairment worldwide. The hypoxia-inducible factors and vascular endothelial growth factors are key molecular promoters of ocular neovascularization. Moreover, the role of microRNAs as regulators of angiogenesis has been expanding, particularly hypoxia-associated microRNA; hypoxamiRs. This review provides a summary of hypoxamiRs that directly and specifically target HIF1A and VEGF mRNAs, thus critically involved in the regulation of ocular neovascular pathologies. The discussed microRNAs highlight putative diagnostic markers and therapeutic agents in choroidal and retinal angiogenic diseases, including proliferative diabetic retinopathy, retinopathy of prematurity and neovascular age-related macular degeneration.

Trabeculectomy for neovascular glaucoma in proliferative diabetic retinopathy, central retinal vein occlusion, and ocular ischemic syndrome: Surgical outcomes and prognostic factors for failure

PURPOSE

To evaluate the outcomes of trabeculectomy in the eyes with neovascular glaucoma (NVG), caused by proliferative diabetic retinopathy (PDR), central retinal vein occlusion (CRVO), and ocular ischemic syndrome (OIS).

METHODS

A retrospective review of NVG eyes that underwent trabeculectomy between 1991 and 2019. Complete success was defined as intraocular pressure (IOP) between 6 and 21 mmHg without antiglaucoma medications (AGM). The risk factors were analyzed by Cox's proportional hazard model.

RESULTS

The study included 100 eyes of 100 subjects with a mean age of 58 ± 9.8 years and a median follow-up of 1.27 years (interquartile range: 0.63, 2.27). The cause of NVG was PDR in 59 eyes (59%), CRVO in 25 eyes (25%), and OIS in 16 eyes (16%). Trabeculectomy with mitomycin-C was performed in 88 eyes and trabeculectomy in 12 eyes. The cumulative complete success probability of trabeculectomy in PDR was 50% (95% confidence interval [CI]: 38, 65) at 1 year, 8% (1, 46) at 3-5 years. In OIS, it was 64% (43, 96) from 1 to 5 years. In CRVO, it was 75% (59, 94) at 1 year, 45% (23, 86) from 2 to 5 years. The PDR was associated with a higher risk of surgical failure compared to OIS (P = 0.04) and CRVO (P = 0.004). Other significant risk factors were increasing age (P = 0.02), persistent neovascularization of iris (NVI) (P = 0.03), higher number of anti-vascular endothelial growth factor (VEGF) injections prior to trabeculectomy (P = 0.02), and delay in performing trabeculectomy (P = 0.02).

CONCLUSION

Compared to CRVO and OIS, the eyes with NVG secondary to PDR had poor success with trabeculectomy. Older age, persistent NVI, need for a higher number of anti-VEGF injections, and delayed surgery were associated with a higher risk for trabeculectomy failure.

Neovascular Glaucoma Progress and Impact of Therapeutic Intervention in Saudi Arabia

Purpose: This study aimed to present the outcomes of the therapeutic interventions for neovascular glaucoma (NVG) between 2002 and 2012 at a tertiary eye hospital in Saudi Arabia.

Methods: A retrospective chart review of the patients with NVG treated in the last 10 years at King Khaled Eye Specialist Hospital was carried out. The demographics, visual acuity, and intraocular pressure (IOP) at the baseline were compared to that, at last, follow-up. The clinical course of treated eyes and causes for poor vision were reviewed.

Results: Among 597 eyes with NVG, the mean IOP at presentation was 32 mmHg. A total of 335 eyes (56.1%) were treated with pan-retinal photocoagulation (PRP). In 459 (77%) eyes, IOP was controlled with medications or different surgeries. The vision on the last follow-up was 20/20 to 20/40 in 19 (3%) eyes, 20/50 to 20/200 in 67 (11%) eyes, <20/200 to 20/400 in 267 (45%) eyes, and <20/400 in 225 (38%) eyes. Nineteen eyes were soft/enucleated. In 45 (8%, 95% CI 6-10) eyes vision improved. The IOP was reduced to <22 mmHg in 369 (62%, 95% CI 58.2-65.9) eyes, 23-30 mmHg in 69 (12%) eyes and was > 31 mmHg in 102 (17%) eyes. In 26 (3.7%) eyes, ocular hypotony was noted. The causes of poor vision included retinal ischemia (n=75, 13%), optic nerve head cupping (n=104, 17%), retinal detachment (n= 42, 7%) and other (n=17, 3%).

Conclusion: The NVG is a serious ocular ischemic complication. Prompt therapy maintained or improved the vision and controlled IOP in 50% and more cases.

A review of neovascular glaucoma. Etiopathogenesis and treatment

Neovascular glaucoma (NVG) is a type of secondary glaucoma, refractory to treatment, often incurable, with very poor visual prognosis. It is characterized by the appearance of new vessels over the iris and iridocorneal angle and frequently associates the presence of a fibrovascular membrane which limits the aqueous humor outflow from the anterior chamber. The most common causes of NVG are: central retinal vein occlusion, proliferative diabetic retinopathy, and ocular ischemic syndrome. Once the gonioscopy developed as a part of clinical examination, it became possible to visualize the new vessels of the anterior segment of the eye in early stages and to understand the mechanisms of increased intraocular pressure (IOP), including narrowing and closing of the iridocorneal angle. Also, the modern imaging techniques, such as optical coherence tomography angiography and fluorescein angiography became indispensable for the clinician. Thus, an early diagnosis, followed by starting an appropriate therapy: panretinal photocoagulation or administration of anti-VEGF drugs, with or without hypotensive ocular therapy, allows the preservation of visual functions for patient's better quality of life. However, one or more surgeries will often be required, especially in the advanced stages of the disease, which do not respond to drug therapy. Managing the NVG we should aim to: 1) reduce ocular ischemia and treat its underlying cause, 2) reduce elevated IOP, once installed and 3) control the inflammatory process. Anyway, the best treatment is prevention, so we must be very attentive at patients with risk factors for developing the NVG. Abbreviations: NVG = neovascular glaucoma, ICA = iridocorneal angle, IOP = intraocular pressure, TM = trabecular meshwork, AH = aqueous humor, AC = anterior chamber, PRP = panretinal photocoagulation, VEGF = vascular endothelial growing factor, Anti-VEGF = anti- vascular endothelial growing factor, PAS = peripheral anterior synechiae, CRVO = central retinal vein occlusion, PDR = proliferative diabetic retinopathy, DR = diabetic retinopathy, OIS = ocular ischemic syndrome, CRAO = central retinal artery occlusion, ROP = retinopathy of prematurity, FEVR = familial exudative vitreoretinopathy, PVR = proliferative vitreoretinopathy, MMPs = matrix metalloproteinases, VEGFR = vascular endothelial growing factor receptor, PDGF = platelet-derived growth factor, PIGF = placental growth factor, NRP = neuropilins, HIF = hypoxia-inducible factor, SDF1 = stromal cell-derived factor 1, DDL4 = delta like ligand 4, NICD = Notch intracellular domain, TIMMPs = tissue inhibitors of matrix metalloproteinases, ANGPT = angiopoietin, Tie 2 = tyrosine-protein kinase receptor for angiopoietins, IGF-1 = insulin-like growth factor 1, RPE = retinal pigment epithelium, IL = interleukin, TNF = tumor necrosis factor, bFGF = basic fibroblast growth factor, TGF = transforming growth factor, HGF = hepatocyte growth factor, TNFR 2 = tumor necrosis factor receptor 2, OIR = oxygen induced retinopathy, NVI = neovascularization of the iris, NVA = neovascularization of the iridocorneal angle, FA = fluorescein angiography, RAPD = relative afferent pupillary defect, CNP = capillary non-perfusion, NVE = neovascularization elsewhere in the retina, NVD = neovascularization of the optic disc, FFA = fundus fluorescein angiography, OCTA = optical coherence tomography angiography, B-scan US = B-scan ocular ultrasound, AS-OCT = anterior segment optical coherence tomography, ARC = anterior retinal cryotherapy, FDA = food and drug administration, United States of America, BVZ = bevacizumab, RBZ = ranibizumab, AFB = aflibercept, AMD/ ARMD = age related macular degeneration, DME = diabetic macular edema, GDDs = glaucoma drainage devices, MMC = mitomycin C, 5-FU = 5-fluorouracil, AGV = Ahmed glaucoma valve, AADI = Aurolab aqueous drainage implant, MIGS = minimally invasive glaucoma surgery, BCVA = best corrected visual acuity, TVT = Tube versus Trabeculectomy study, MPC = micro-pulse cyclophotocoagulation.

Comparison of Efficacy and Safety between Conbercept and Ranibizumab in Neovascular Age-Related Macular Degeneration: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Conbercept, as a novel vascular endothelial growth factor (VEGF) inhibitor, was approved for the treatment of neovascular age-related macular degeneration (nAMD) in China.

OBJECTIVE

This study aimed to compare the efficacy and safety between conbercept and ranibizumab in patients with nAMD.

METHODS

Several databases (PubMed, Web of Science, China National Knowledge Infrastructure, and WANFANG) were searched for the results of studies describing conbercept and ranibizumab for the treatment of nAMD. Sixteen randomized controlled trials including 1,224 eyes met our search criteria and were assessed.

RESULTS

Conbercept and ranibizumab had comparable effects on improving visual acuity at 3 months (standardized mean difference [SMD]: -0.19; 95% confidence interval [CI]: -0.46 to 0.08; p = 0.17) and 6-12 months (SMD: -0.01; 95% CI: -0.20 to 0.18; p = 0.90). At 3 months and 6-12 months, the differences in the change of central macular thickness in conbercept and ranibizumab groups were 1.06 μm (95% CI: -3.52 to 5.64; p = 0.65) and -0.12 μm (95% CI: -9.26 to 9.02; p = 0.98). In the short term, there was no significant difference between the 2 groups with respect to ocular adverse events (odds ratio [OR]: 0.86; 95% CI: 0.46-1.61; p = 0.63). No significant differences were observed in the recovery rate of choroidal neovascularization leakage between conbercept and ranibizumab at both 3 months (OR: 1.49; 95% CI: 0.83-2.68; p = 0.18) and 6-12 months (OR: 0.66; 95% CI: 0.18-2.43; p = 0.53). There were significant differences between conbercept and ranibizumab in terms of decreasing intraocular pressure (weighted mean difference [WMD]: -1.74; 95% CI: -2.28 to -1.20; p < 0.00001), the plasma VEGF level (WMD: -21.49; 95% CI: -26.28 to -16.70; p < 0.00001), and the C-reactive protein level (WMD: -1.16; 95% CI: -1.45 to -0.87; p < 0.00001) in the short term.

CONCLUSION

Conbercept was similar to ranibizumab in terms of efficacy and safety for the treatment of nAMD in China. Further studies with longer term observation are needed to support this conclusion.

CLINICAL SIGNIFICANCE OF RETINAL VASCULAR OCCLUSION IN MOYAMOYA DISEASE: Case Series and Systematic Review

PURPOSE

Although moyamoya disease primarily affects the carotid artery in the ophthalmic artery bifurcation area, retinal vascular abnormalities in moyamoya disease have rarely been reported. The purpose of this report is to describe clinical findings of patients with retinal vascular occlusion in patients with moyamoya disease and present its clinical significance.

METHODS

We reviewed and analyzed patients with moyamoya disease with retinal vascular occlusions. For this, a retrospective medical chart review was performed in a tertiary medical center and a literature search was performed using PubMed and EMBASE until September 2020.

RESULTS

Patients with retinal artery occlusion (RAO) were significantly younger than patients with retinal vein occlusion (25.0 vs. 40.1 years, P = 0.023). Of 14 patients, retinal vascular occlusion was the presenting sign of moyamoya disease in 8 (57.1%) patients. The occlusion site at the carotid artery was proximal to the ophthalmic artery bifurcation area in 8 (57.1%) patients. Legal blindness occurred in 8 (57.1%) patients at final visits.

CONCLUSION

Retinal vascular occlusion is a rare but sight-threatening ocular complication in patients with moyamoya disease. Overall, younger age may be a risk factor for RAO, whereas older age for retinal vein occlusion. Retinal vascular occlusion can be an important indicator of moyamoya disease screening, especially in relatively younger and healthy patients.

Presentation, etiology and treatment outcome of neovascular glaucoma in Ekiti state, South Western Nigeria

Background

Neovascular glaucoma (NVG), a form of secondary glaucoma has varying causes across geographical locations.

Objective

The objective of this study was to determine the presentation, aetiology, and outcome of treatment of patients with NVG in a Nigerian tertiary hospital.

Method

A retrospective review of records of all cases of NVG seen over a 5year period was carried out. Demographic characteristics, presenting visual acuity and coexisting ocular and systemic conditions were noted. Data were analysed with Statistical Package for Social Sciences (SPSS) version 25.

Results

29 eyes of patients with NVG were analysed. Most of the patients (89.70%) presented with visual acuity less than 3/60 in the affected eye. All patients except one were treated with anti-glaucoma medications while only 9(31%) consented to and received anti-vascular endothelial growth factor. No patient had improvement in visual acuity despite resolution of other symptoms at 12week follow up.

Conclusion

NVG though not as common as other forms of glaucoma accounted for a large proportion of monocular blindness in the affected eyes at presentation. There is need for health promotion and education among our people on the need for early preventive eye check practices.

Neovascular Glaucoma after Diabetic Vitrectomy: Incidence and Risk Factors

Purpose: The prevalence and risk factors of neovascular glaucoma (NVG) after diabetic vitrectomy were evaluated. Methods: This retrospective study included 171 eyes of 141 patients who underwent diabetic vitrectomy in-hospital between March 2013 and July 2019 and were followed for >12 months postoperatively. Regardless of the presence or absence of neovascularization in the anterior segment, all patients received injections of intravitreal bevacizumab during vitrectomy. Patients with preoperative neovascularization in iris (NVI) or angle (NVA) received both intracameral and intravitreal bevacizumab injections. Data were collected regarding baseline demographics, preoperative best-corrected visual acuity, intraocular pressure, hypertension, NVG in the fellow eye, panretinal photocoagulation history, iris and angle neovascularization, and postoperative findings (e.g., rebleeding and residual retinal detachment). Results: In total, 141 patients and 171 eyes were included in the study, and the incidence of postoperative NVG was 5.85% (10 patients). Five patients (27.78%) with preoperative NVI or NVA developed postoperative NVG. Significant risk factors for postoperative NVG were preoperative NVA or NVI (odds ratio [OR] = 16.428, p = 0.003), shorter diabetic duration (OR = 0.853, p = 0.033), and the absence of preoperative panretinal photocoagulation (OR = 0.006, p = 0.035). Conclusions: There is a high possibility of postoperative NVG in patients with preoperative NVI or NVA, a short duration of diabetes, and no preoperative panretinal photocoagulation. In such patients, close monitoring is required after diabetic vitrectomy.