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

Association between stress hyperglycemia ratio and neovascular glaucoma in patients with proliferative diabetic retinopathy

OBJECTIVE

The purpose of this study was to investigate the association between the stress hyperglycemia ratio (SHR) and the occurrence of neovascular glaucoma (NVG) in patients with proliferative diabetic retinopathy (PDR). We aimed to explore the potential role of SHR as a biomarker for NVG risk and to identify demographic and clinical modifiers of this association.

METHODS

We conducted a retrospective cohort study using electronic health records from our hospital over a 10-year period from 2010 to 2020. Patients diagnosed with PDR were included, with exclusions for those without diabetes-related NVG or incomplete SHR data. The SHR was calculated using admission blood glucose and HbA1c levels. Logistic regression and Cox proportional hazards modeling were used to assess the association between SHR and NVG, adjusting for potential confounders.

RESULTS

A total of 1,245 patients were identified, of which 378 (30.3%) had PDR with NVG. The mean SHR for the entire cohort was 2.9, with a higher mean SHR observed in the PDR with NVG group (3.2 vs. 2.7, p < 0.001). Multivariate logistic regression analysis revealed a significant association between SHR and NVG (OR 2.5, 95% CI 1.9 to 3.3, p < 0.001). Subgroup analysis showed a stronger association between SHR and NVG risk in males (HR 1.4, 95% CI 1.1 to 1.7, p = 0.01) and patients over 65 years old (HR 1.5, 95% CI 1.2 to 1.9, p = 0.001). The association was also more pronounced in patients with a diabetes duration exceeding 15 years (HR 1.4, 95% CI 1.1 to 1.8, p = 0.01).

CONCLUSION

Our study demonstrated a significant association between SHR and NVG with PDR patients, with certain subgroups showing a stronger association. These findings suggest that glycemic variability, as measured by SHR, may play a critical role in the development of NVG and could inform tailored clinical strategies for the prevention and management of NVG in high-risk patients.

Changes in retinal capillary density in female with type 2 diabetes and gestational diabetes-an analysis based on OCTA technology

AIM

To evaluate alterations in conjunctival vascular density (CVD) and macular capillary density (MCD) in female patients with type 2 diabetes mellitus (T2DM) and gestational diabetes mellitus (GDM) using optical coherence tomography angiography (OCTA).

METHODS

A total of 60 female participants were recruited, comprising 20 patients with T2DM, 20 patients with GDM, and 20 healthy age-matched controls (HCs). OCTA was used to assess superficial and deep retinal and conjunctival capillary plexuses. Subsequently, changes in MCD were analyzed using a circular segmentation method (C1-C6), a hemispheric quadrant segmentation method [superior right (SR), superior left (SL), inferior left (IL), and inferior right (IR)], and the early treatment diabetic retinopathy study (ETDRS) segmentation method (S, I, R, L).

RESULTS

OCTA unequivocally demonstrated that the variations in CVD among HCs, T2DM, and GDM groups were statistically significant (P<0.001). In the superficial retinal capillary plexus (sRCP), significant differences were observed in the densities of total microvascular (TMI), microvasculature (MIR), and macrovascular (MAR) between patients with T2DM and HCs (P<0.05). Furthermore, the GDM group exhibited a more substantial reduction in MIR density compared to the T2DM group (P<0.01). In the deep retinal capillary plexus (dRCP), significant differences in the densities of TMI and MIR were identified between the T2DM group and HCs (P<0.05), with a notable difference in TMI density also observed between the GDM and T2DM groups (P<0.01). In the receiver operating characteristic (ROC) curve analysis, the area under the ROC curve (AUC) for TMI in sRCP between the T2DM group and HCs was 0.975, with a 95% confidence interval (CI) of 0.941-1. The AUC for MIR was highest in dRCP, with an AUC value of 0.914 and a 95%CI ranging from 0.847 to 0.981. In comparing the GDM and T2DM groups, the AUC for I region was maximized in sRCP, achieving a value of 0.978 with a 95%CI of 0.953-1. Additionally, the AUC for R region was maximized in dRCP, reaching a value of 0.99 with a 95%CI of 0.975 to 1.

CONCLUSION

The sRCP and dRCP densities show higher diagnostic sensitivity for T2DM and GDM. OCTA holds potential as a significant instrument for the early diagnosis and differentiation of T2DM and GDM.

The causal effect of glaucoma and diabetic retinopathy: a Mendelian randomization study

BACKGROUND

Previous research showed that there is an important association between glaucoma and diabetic retinopathy (DR). However, the relationship has not been clarified. In this study, we attempted to evaluate it.

METHODS

We conducted bidirectional Two-sample Mendelian randomization (MR), Multivariable Mendelian randomization (MVMR), and Mediation analysis. The Inverse-variance-weighted method was adopted as the main MR method, supplemented by MR-Egger, weighted median, weighted mode, and simple mode.

RESULTS

The results of forward MR analysis suggested that glaucoma [p = 0.001, odds ratio (OR) = 1.080] and intraocular pressure (IOP) (p = 0.019, OR = 1.100) as risk factors for DR. The reverse MR found that DR was a risk factor for glaucoma (p = 0.039, OR = 1.024) and IOP (p = 0.010, OR = 1.057). The results of MVMR analysis demonstrated that glaucoma (p = 0.046, OR = 1.069) remained an independent risk factor for DR. The bidirectional relationship between glaucoma and DR is mediated by IOP, according to the results of the Two-step MR analysis. Besides, glaucoma contributed to the positive causal link that exists between IOP and DR.

CONCLUSION

The findings demonstrated a reciprocal causal link between glaucoma and DR, with a possible mediating function for IOP. Moreover, glaucoma played an important mediator of IOP as a risk factor for DR. It offers recommendations for the early prevention of both DR and glaucoma.

Pharmacological adjuvants for diabetic vitrectomy surgery

Diabetic vitrectomy is a highly intricate surgical procedure performed during the advanced stages of diabetic retinopathy (DR). It is used to treat conditions such as tractional or combined retinal detachment, vitreous hemorrhage, and subhyaloid hemorrhage, which are all severe manifestations of proliferative DR. The results of the surgery are uncertain and variable. Vitreoretinal surgery has made significant progress since the early stages of vitrectomy. In the past ten years, advancements in intravitreal pharmacotherapy have emerged, offering new possibilities to improve the surgical results for our patients. Within the realm of medical terminology, an "adjunct" refers to a pharmaceutical or substance employed to aid or expedite the primary therapeutic intervention for a particular ailment. Their introduction has broadened the range of therapeutic choices that are accessible prior to, during, and following surgical procedures. This review article will specifically analyze the pharmacological adjuncts used in diabetic vitrectomy surgery, with a focus on their role in facilitating or aiding specific steps of the procedure. The implementation of this system of categorization offers benefits to the surgeon by allowing them to foresee potential difficulties that may occur during the surgical procedure and to choose the appropriate pharmacological agent to effectively tackle these challenges, thus enhancing surgical success rates.

Vitrectomy for cases of diabetic retinopathy

Microvascular complications of diabetic retinopathy (DR) may require surgical intervention in the form of vitrectomy. Since its inception, diabetic vitrectomy has evolved with introduction of better instruments, newer techniques, and smaller port sizes. Common indications for diabetic vitrectomy include nonresolving vitreous hemorrhage, tractional retinal detachment, epiretinal membrane, progression of fibrovascular membranes despite laser therapy, recalcitrant diabetic macular edema, and neovascular glaucoma. Preoperative systemic stabilization is essential prior to planning surgery. Surgical techniques commonly used in diabetic vitrectomy are segmentation, delamination, and rarely en-bloc dissection. Modification in surgical techniques such as chandelier-assisted bimanual dissection and pharmacological adjuvants improve surgical outcomes in these patients. Prognosis in these patients could be improved with early intervention. Studies evaluating the outcome of vitrectomy in patients with early proliferative DR are required to understand the appropriate time of intervention in patients. Treatment aimed at arresting the progression of DR and gene therapy are avenues that need further evaluation. The following review will focus on covering the epidemiology of DR, indications of vitrectomy, preoperative considerations, surgical procedures of diabetic vitrectomy, methods of membrane dissection, pharmacological adjuvants to vitrectomy, outcomes of diabetic vitrectomy, and future directions of diabetic vitrectomy.

Comparison of the Risk of Diabetic Retinopathy Between Sodium-Glucose Cotransporter-2 Inhibitors and Dipeptidyl Peptidase-4 Inhibitors in Patients with Type 2 Diabetes Mellitus in Japan: A Retrospective Analysis of Real-World Data

INTRODUCTION

Diabetic retinopathy (DR), a microvascular complication of type 2 diabetes mellitus (T2DM), is a leading cause of blindness and has detrimental effects on patients' quality of life. We compared the risk of DR diagnosis with sodium-glucose cotransporter-2 inhibitors (SGLT2i) versus dipeptidyl peptidase-4 inhibitors (DPP-4i) in patients with T2DM in Japan.

METHODS

This Japanese retrospective cohort study used the JMDC Claims Database (data collected from January 2015 to September 2022). Patients with T2DM and no record of microvascular or macrovascular diseases who were newly treated with an SGLT2i (23,061 patients) or a DPP-4i (53,986 patients) were matched 1:1 using propensity score (10,166 per matched group). Incidence rates (IRs) and cumulative IRs of DR diagnosis were calculated for each treatment group; hazard ratio (HR) and its 95% confidence interval (CI) were calculated using Cox proportional hazard models to compare the risk between the groups.

RESULTS

The IR of DR diagnosis was 46.23 and 57.12 per 1000 person-years in the SGLT2i and DPP-4i groups, respectively, with a significantly lower risk in the SGLT2i group than in the DPP-4i group (HR 0.83, 95% CI 0.75-0.92, P = 0.0003).

CONCLUSIONS

In this study, the risk of DR diagnosis was lower with SGLT2i compared with DPP-4i in patients with T2DM without microvascular and macrovascular diseases in Japan. Findings suggest that early SGLT2i treatment may be beneficial in preventing DR development in early-stage T2DM. Graphical abstract available for this article.

The effect of leizumab on serum vascular endothelial growth factor, IL-6, MCP-1 inflammatory factors in neovascular glaucoma

This study aimed to assess Leizumab's effect on serum endothelial growth factor, interleukin-6 (IL-6), monocyte chemotactic protein-1 (MCP-1), and inflammatory factors in neovascular glaucoma patients. 80 eligible patients treated between January 2021 and April 2023 were enrolled, randomly divided into control and study groups. The control group underwent vitrectomy while the study group received preoperative intravitreal rituximab injection. Measurements included serum and aqueous humor VEGF/PEDF, IL-6/MCP-1 levels, postoperative rebleeding/retinal detachment, and visual acuity changes over 6 weeks. After surgery, patients showed reduced serum VEGF/PEDF levels (P < 0.05), with decreased VEGF and increased PEDF in aqueous humor (P < 0.05). The study group had lower VEGF and higher PEDF levels than the control (P < 0.05). Serum IL-6/MCP-1 levels reduced post-surgery, with the study group lower than control (P < 0.05). Intraocular rebleeding was lower in the study group (P < 0.05), while retinal detachment rates were similar (P > 0.05). Visual acuity differed significantly from week 1 to 6 post-surgery (P < 0.05), with higher acuity in the study group during weeks 1-4 (P < 0.05). Weeks 5-6 follow-up showed no significant difference (P > 0.05). Pre-vitrectomy ranibizumab injection effectively reduced bleeding, VEGF/PEDF levels, inflammatory factors, and improved visual recovery.

The Role of Immune Cells and Signaling Pathways in Diabetic Eye Disease: A Comprehensive Review

Diabetic eye disease (DED) encompasses a range of ocular complications arising from diabetes mellitus, including diabetic retinopathy, diabetic macular edema, diabetic keratopathy, diabetic cataract, and glaucoma. These conditions are leading causes of visual impairments and blindness, especially among working-age adults. Despite advancements in our understanding of DED, its underlying pathophysiological mechanisms remain incompletely understood. Chronic hyperglycemia, oxidative stress, inflammation, and neurodegeneration play central roles in the development and progression of DED, with immune-mediated processes increasingly recognized as key contributors. This review provides a comprehensive examination of the complex interactions between immune cells, inflammatory mediators, and signaling pathways implicated in the pathogenesis of DED. By delving in current research, this review aims to identify potential therapeutic targets, suggesting directions of research for future studies to address the immunopathological aspects of DED.

Cytomegalovirus retinitis with panretinal occlusive vasculopathy concealed by hypertensive uveitis: a case report

Cytomegalovirus (CMV) retinitis is a rare disease, and overlapping manifestations involving the anterior segment are extremely uncommon. We report a patient who initially presented with persistent corneal edema and was later diagnosed with CMV retinitis. A 72-year-old man with uncontrolled intraocular pressure (IOP) in his right eye visited a tertiary hospital. At initial presentation, the IOP was 36 mmHg and the fundus was not clear due to corneal edema. Spectral domain optical coherence tomography revealed paracentral acute middle maculopathy (PAMM). Panretinal obstructive vasculopathy was observed on ultra-widefield fluorescein angiography. Three weeks later, trabeculectomy was performed to resolve the persistently high IOP. Once corneal edema improved, a white patch-like peripheral lesion and silver wire-like retinal vasculature were observed. Polymerase chain reaction of the aqueous humor was positive for CMV. Oral valganciclovir and intravitreal ganciclovir were administered as antiviral therapies. Despite treatment for 4 months, the final visual acuity was no light perception, with persistent corneal edema and neovascularization of the iris. We describe a rare case of the simultaneous occurrence of hypertensive uveitis and CMV retinitis. The presence of PAMM could be an initial identifiable sign of CMV retinitis, even in the presence of media opacity.

Global trends in diabetic eye disease research from 2012 to 2021

JOURNAL/nrgr/04.03/01300535-202410000-00032/figure1/v/2024-02-06T055622Z/r/image-tiff Diabetic eye disease refers to a group of eye complications that occur in diabetic patients and include diabetic retinopathy, diabetic macular edema, diabetic cataracts, and diabetic glaucoma. However, the global epidemiology of these conditions has not been well characterized. In this study, we collected information on diabetic eye disease-related research grants from seven representative countries--the United States, China, Japan, the United Kingdom, Spain, Germany, and France--by searching for all global diabetic eye disease journal articles in the Web of Science and PubMed databases, all global registered clinical trials in the ClinicalTrials database, and new drugs approved by the United States, China, Japan, and EU agencies from 2012 to 2021. During this time period, diabetic retinopathy accounted for the vast majority (89.53%) of the 2288 government research grants that were funded to investigate diabetic eye disease, followed by diabetic macular edema (9.27%). The United States granted the most research funding for diabetic eye disease out of the seven countries assessed. The research objectives of grants focusing on diabetic retinopathy and diabetic macular edema differed by country. Additionally, the United States was dominant in terms of research output, publishing 17.53% of global papers about diabetic eye disease and receiving 22.58% of total citations. The United States and the United Kingdom led international collaborations in research into diabetic eye disease. Of the 415 clinical trials that we identified, diabetic macular edema was the major disease that was targeted for drug development (58.19%). Approximately half of the trials (49.13%) pertained to angiogenesis. However, few drugs were approved for ophthalmic (40 out of 1830; 2.19%) and diabetic eye disease (3 out of 1830; 0.02%) applications. Our findings show that basic and translational research related to diabetic eye disease in the past decade has not been highly active, and has yielded few new treatment methods and newly approved drugs.

Metabolomics combined with intestinal microbiota reveals the mechanism of compound Qilian tablets against diabetic retinopathy

Background

Diabetic retinopathy (DR) is one of the common chronic complications of diabetes mellitus, which has developed into the leading cause of irreversible visual impairment in adults worldwide. Compound Qilian tablets (CQLT) is a traditional Chinese medicine (TCM) developed for treating DR, but its mechanism is still unclear. This study explored the mechanism of action of CQLT in treating DR through metabolomics and intestinal microbiota.

Methods

Histopathologic examination of the pancreas and retina of Zucker diabetic fatty (ZDF) rats and immunohistochemistry were used to determine the expression levels of retinal nerve damage indicators ionized calcium binding adaptor molecule-1 (Iba-1) and glial fibrillary acidic protein (GFAP). Rat fecal samples were tested by LC-MS metabolomics to search for potential biomarkers and metabolic pathways for CQLT treatment of DR. Characteristic nucleic acid sequences of rat intestinal microbiota from each group were revealed using 16S rDNA technology to explore key microbes and related pathways for CQLT treatment of DR. At the same time, we investigated the effect of CQLT on the gluconeogenic pathway.

Results

After CQLT intervention, islet cell status was improved, Iba-1 and GFAP expression were significantly decreased, and abnormal retinal microvascular proliferation and exudation were ameliorated. Metabolomics results showed that CQLT reversed 20 differential metabolites that were abnormally altered in DR rats. Intestinal microbiota analysis showed that treatment with CQLT improved the abundance and diversity of intestinal flora. Functional annotation of metabolites and intestinal flora revealed that glycolysis/gluconeogenesis, alanine, aspartate and glutamate metabolism, starch and sucrose metabolism were the main pathways for CQLT in treating DR. According to the results of correlation analysis, there were significant correlations between Iba-1, GFAP, and intestinal microbiota and metabolites affected by CQLT. In addition, we found that CQLT effectively inhibited the gluconeogenesis process in diabetic mice.

Conclusion

In conclusion, CQLT could potentially reshape intestinal microbiota composition and regulate metabolite profiles to protect retinal morphology and function, thereby ameliorating the progression of DR.

The efficacy and safety of anti-vascular endothelial growth factor combined with Ahmed glaucoma valve implantation in the treatment of neovascular glaucoma: a systematic review and meta-analysis

Background

The intraocular injections of anti-vascular endothelial growth factor (anti-VEGF) demonstrates significant efficacy in inhibiting the formation of ocular neovascularization in neovascular glaucoma (NVG). Ahmed glaucoma valve implantation (AGVI) is extensively employed for the management of diverse glaucoma types.

Objective

To further evaluate the efficacy and safety of anti-VEGF combined with AGVI in the treatment of neovascular glaucoma.

Methods

A thorough search for randomized controlled trials (RCTs) was conducted across eight databases: PubMed, EMBASE, the Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang, SinoMed, and VIP. The search period was set from the inception of each database until March 2, 2024, to identify RCTs investigating the effectiveness and safety of combining AGVI with anti-VEGF therapy for NVG. We used the Cochrane Risk of Bias Assessment Tool to evaluate the quality of the literature and performed statistical analysis using Stata 15.0 software.

Results

Fourteen RCTs were included in this study. Compared with AGVI alone, the combination of anti-VEGF drugs and AGVI can reduce postoperative intraocular pressure (IOP) at 1 week [WMD = -4.03, 95% CI (-5.73, -2.34), p < 0.001], 1 month [WMD = -5.39, 95% CI (-7.05, -3.74), p < 0.001], 3 months [WMD = -6.59, 95% CI (-7.85, -5.32), p < 0.001], 6 months [WMD = -4.99, 95% CI (-9.56, -0.43), p = 0.032], and more than 12 months [WMD = -3.86, 95% CI (-6.82, -0.90), p = 0.011], with a higher Effective rate [RR = 1.27, 95% CI (1.18, 1.37), p < 0.001], decreased incidence of postoperative hyphema [RR = 0.24, 95% CI (0.15, 0.39), p < 0.001], reduced use of postoperative antiglaucoma medications [WMD = -0.48, 95% CI (-0.61, -0.35), p < 0.001], and decreased aqueous humor VEGF levels [SMD = -2.84, 95% CI (-4.37, -1.31), p < 0.001].

Conclusion

In comparison to AGVI alone, the combination of AGVI with anti-VEGF therapy has better effects in reducing IOP at various time intervals, diminishing postoperative antiglaucoma medication requirements and reducing aqueous humor VEGF levels. Furthermore, it effectively minimizes the incidence of postoperative hyphema. Nevertheless, due to the variability in the quality of the trials included, further high-quality experiments will be required in the future to substantiate this conclusion.

Systematic review registration

PROSPERO, identifier CRD42024519862, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024519862.

A neural network model for predicting the effectiveness of treatment in patients with neovascular glaucoma associated with diabetes mellitus

Introduction

The study hypothesizes that neural networks can be an effective tool for predicting treatment outcomes in patients with diabetic neovascular glaucoma (NVG), considering not only baseline intraocular pressure (IOP) values but also inflammation and intraocular microcirculation indicators.

Objective

To investigate the diagnostic significance of inflammation and intraocular blood circulation indicators in a neural network model predicting the effectiveness of transscleral cyclophotocoagulation (TSC CPC) treatment in patients with NVG of diabetic origin.

Methods

This retrospective cohort study included 127 patients (127 eyes; aged Me 65.0 years) with painful diabetic NVG and 20 healthy individuals (aged Me 61.5 years) as an immunological control. All patients underwent TSC CPC with a diode laser. Treatment success was defined as achieving an IOP level of ≤ 21 mmHg and maintaining or improving best-corrected visual acuity (BCVA) after 12 months of observation. Preoperative systemic immune-inflammation index (SII = platelets × [neutrophils/lymphocytes]) and systemic inflammation response index (SIRI = neutrophils × [monocytes/lymphocytes]) were calculated. We assessed the values of volumetric pulse blood filling, determined by the rheographic coefficient (RQ, 0/00), using the rheoophthalmography (ROG) method. Multiple regression analysis was used to conclude the significance of treatment efficacy based on initial clinical and laboratory indicators, followed by constructing a prediction model in the neural network.

Results

The development of the neural network model identified the most significant "input" parameters: SIRI (100%), RQ (85.7%), and SII (80.7%), which significantly influenced treatment success. The sensitivity of the neural network model was 100%, specificity was 30%, and the percentage of correctly predicted events during testing on the control group was 92.9%.

Conclusions

Neural network-based prediction of transscleral cyclophotocoagulation effectiveness for patients with diabetic neovascular glaucoma allows for a sufficiently accurate forecast of treatment success with a probability of 92.9%. We believe the in-time correction of systemic inflammation and intraocular blood circulation can significantly reduce intraocular pressure, preserve visual acuity, and improve the quality of life in patients with diabetic NVG after TSC CPC. Further research is required to support these findings.

Vascular Endothelial Growth Factor C and D Signaling Pathways as Potential Targets for the Treatment of Neovascular Age-Related Macular Degeneration: A Narrative Review

The development of treatments targeting the vascular endothelial growth factor (VEGF) signaling pathways have traditionally been firstly investigated in oncology and then advanced into retinal disease indications. Members of the VEGF family of endogenous ligands and their respective receptors play a central role in vasculogenesis and angiogenesis during both development and physiological homeostasis. They can also play a pathogenic role in cancer and retinal diseases. Therapeutic approaches have mostly focused on targeting VEGF-A signaling; however, research has shown that VEGF-C and VEGF-D signaling pathways are also important to the disease pathogenesis of tumors and retinal diseases. This review highlights the important therapeutic advances and the remaining unmet need for improved therapies targeting additional mechanisms beyond VEGF-A. Additionally, it provides an overview of alternative VEGF-C and VEGF-D signaling involvement in both health and disease, highlighting their key contributions in the multifactorial pathophysiology of retinal disease including neovascular age-related macular degeneration (nAMD). Strategies for targeting VEGF-C/-D signaling pathways will also be reviewed, with an emphasis on agents currently being developed for the treatment of nAMD.

Factors Affecting the Results of Ahmed Glaucoma Valve Implantation in Diabetic Neovascular Glaucoma With or Without Previous Pars Plana Vitrectomy

Objectives

The aim of this study was to compare the outcomes of Ahmed glaucoma valve implantation (AGVI) in neovascular glaucoma (NVG) due to proliferative diabetic retinopathy (PDR) with or without a pars plana vitrectomy (PPV) history and to analyze the factors affecting surgical failure.

Methods

Patients with NVG secondary to PDR undergoing AGVI at a single center were reviewed retrospectively. The surgical failure rates and post-operative complications were compared between eyes with (PPV-AGVI group) and without previous PPV (AGVI group). Failure was defined as loss of light perception or intraocular pressure (IOP) >17 mmHg despite maximum medication, or need of additional intervention for IOP control or for the management of complications. Survival analysis was investigated by Kaplan-Meier test. The possible factors for failure were analyzed with logistic regression analysis.

Results

The failure rates were 21.9% during the mean follow-up of 27.56±15.38 months and 14.3% during 23.63±12.38 months, in PPV-AGVI group (n=32) and in AGVI group (n=49), respectively (p=0.37). The frequency of complications and surgical intervention need for management of post-operative complications was similar between groups (p>0.05). There was no significant difference in survival analysis (p=0.13). The history of intravitreal anti-vascular endothelial growth factor (anti-VEGF) injection before AGVI was significantly associated with failure (odds ratio = 26.941, p=0.02).

Conclusion

The results of AGVI performed with long scleral tunnel technique were comparable in terms of failure rates, between NVG patients with and without previous diabetic vitrectomy. The only significant factor for failure was intravitreal anti-VEGF pre-treatment. This may be related to the necessity of anti-VEGF therapy in aggressive PDR, and also, anti-VEGF agents may increase fibrosis in the anterior chamber angle.

Surgical Treatment of Neovascular Glaucoma Secondary to Proliferative Diabetic Retinopathy in Japanese Patients without the Use of Glaucoma Drainage Devices

Purpose: The purpose of this study is to investigate outcomes of visual acuity (VA) and intraocular pressure (IOP) in proliferative diabetic retinopathy (PDR)-associated neovascular glaucoma (NVG) in Japanese patients treated with surgical therapies without the use of glaucoma drainage devices. Methods: A retrospective analysis of medical records was conducted for 31 consecutive PDR-associated NVG patients who underwent surgical treatments in our institution between 2013 and 2022. Patient demographics, clinical characteristics, VA, and IOP were recorded at the first and last visits, and surgical procedures, including pars plana vitrectomy with extensive panretinal and ciliary photocoagulation (PPV-PRCP), diode laser trans-scleral cyclophotocoagulation (DCPC), and trabeculectomy with mitomycin C (TLE-MMC), with or without a prior intravitreal bevacizumab (IVB) injection, were reviewed. Results: Of the thirty-one PDR patients with NVG, two patients received PPV-PRCP or DCPC alone (6.5%), respectively, three patients received TLE-MMC alone (9.7%), two patients received TLE-MMC after IVB (6.5%), six patients received PPV-PRCP and TLE-MMC (19.4%), seven patients received PPV-PRCP and TLE-MMC after IVB (22.6%), five patients received PPV-PRCP and DCPC and TLE-MMC (16.1%), and four patients received PPV-PRCP and DCPC and TLE-MMC after IVB (12.9%). The VA of two patients (6.5%) deteriorated to no light perception. In all patients, the mean logMAR VA was 1.28 ± 1.05 at the first visit and remained at 1.26 ± 1.08 at the last visit, with no significant change; the mean IOP was 33.0 ± 15.2 mmHg at the initial visit and decreased significantly to 14.0 ± 7.4 mmHg at the last visit. The number of eyes with IOP ≥ 21 decreased from twenty-eight (90.3%) to three (9.7%). Although IOP in patients with IOP > 30 mmHg at the initial visit reduced to a level comparable to that of patients with IOP ≤ 30 mmHg, the IOP > 30 mmHg group received IVB more frequently and had significantly higher logMAR VA at the last visit compared to the IOP ≤ 30 mmHg group. Hypotony (<6 mmHg) was observed in four eyes (12.9%). Conclusions: In PDR patients with NVG, various combinations of PPV-PRCP, DCPC, and TLE-MMC after adjunctive IVB without the use of glaucoma drainage devices lowered IOP sufficiently; for these patients, neovascular regression was observed, with no further deterioration of VA. However, surgical procedures should be performed for PDR patients with NVG before visual impairment occurs. On the other hand, approximately less than 15% of patients developed blindness or low IOP.

Construction and validation of a neovascular glaucoma nomogram in patients with diabetic retinopathy after pars plana vitrectomy

BACKGROUND

Neovascular glaucoma (NVG) is likely to occur after pars plana vitrectomy (PPV) for diabetic retinopathy (DR) in some patients, thus reducing the expected benefit. Understanding the risk factors for NVG occurrence and building effective risk prediction models are currently required for clinical research.

AIM

To develop a visual risk profile model to explore factors influencing DR after surgery.

METHODS

We retrospectively selected 151 patients with DR undergoing PPV. The patients were divided into the NVG (NVG occurrence) and No-NVG (No NVG occurrence) groups according to the occurrence of NVG within 6 months after surgery. Independent risk factors for postoperative NVG were screened by logistic regression. A nomogram prediction model was established using R software, and the model's prediction accuracy was verified internally and externally, involving the receiver operator characteristic curve and correction curve.

RESULTS

After importing the data into a logistic regression model, we concluded that a posterior capsular defect, preoperative vascular endothelial growth factor ≥ 302.90 pg/mL, glycosylated hemoglobin ≥ 9.05%, aqueous fluid interleukin 6 (IL-6) ≥ 53.27 pg/mL, and aqueous fluid IL-10 ≥ 9.11 pg/mL were independent risk factors for postoperative NVG in patients with DR (P < 0.05). A nomogram model was established based on the aforementioned independent risk factors, and a computer simulation repeated sampling method was used to internally and externally verify the nomogram model. The area under the curve (AUC), sensitivity, and specificity of the model were 0.962 [95% confidence interval (95%CI): 0.932-0.991], 91.5%, and 82.3%, respectively. The AUC, sensitivity, and specificity of the external validation were 0.878 (95%CI: 0.746-0.982), 66.7%, and 95.7%, respectively.

CONCLUSION

A nomogram constructed based on the risk factors for postoperative NVG in patients with DR has a high prediction accuracy. This study can help formulate relevant preventive and treatment measures.

The effect of the intercellular adhesion molecule-1 and glycated haemoglobin on the management of diabetic neovascular glaucoma

Introduction: The study hypothesizes that some patients with diabetic neovascular glaucoma (NVG) do not fully respond to transscleral (TSC) cyclophotocoagulation (CPC) due to significant inflammation and insufficient glucose control. Objective: The study aimed to determine the effect of baseline blood levels of intercellular adhesion molecule-1 (ICAM-1) and glycated haemoglobin (HbA1c) on the management of patients with diabetic NVG by TSC CPC. Methods: This open prospective study included 70 diabetic patients (75 eyes; aged Ме 63.0 years) with painful NVG and 20 healthy individuals (aged Ме 61.5 years) as an immunological control. All patients underwent TSC СPC with a diode laser. Baseline HbA1c levels and ICAM-1 expression in blood samples were determined. Follow-up was 12 months. Results: One month after TSC CPC, IOP decreased by 28% compared to baseline. The effectiveness of laser treatment after 12 months of follow-up was 63% with IOP decrease by 46%. In patients with NVG, the initial level of ICAM-1 was 2.5 times higher than in the control group. Patients who did not fully respond to the first TSC CPC (30 eyes) and required additional laser procedure, had high initial HbA1c (9.5%) and high expression values of the ICAM-1 (609.0 cells/μL). Conclusions: Repeated procedures of TSC CPC at high IOP in diabetic patients with NVG are associated with high initial values of expression of ICAM-1 in peripheral blood and high HbA1c. The strategy of management of patients with diabetic NVG should be aimed at intensive glucose control and local anti-inflammatory treatment. Abbreviations: PDR = proliferative diabetic retinopathy, DR = diabetic retinopathy, NVG = neovascular glaucoma, TSC CPC = transscleral cyclophotocoagulation, ICAM-1 = intercellular adhesion molecule-1, HbA1c = glycated haemoglobin, IOP = intraocular pressure.

Clinical Efficacy of Preoperative and Intraoperative Intravitreal Ranibizumab as Adjuvant Therapy of Ahmed Glaucoma Valve Implantation Combined with Vitrectomy in the Management of Neovascular Glaucoma with Diabetic Vitreous Hemorrhage

Neovascular glaucoma (NVG) secondary to proliferative diabetic retinopathy (PDR) is a devastating ocular disease with poor prognosis. Intravitreal ranibizumab injection (IVR) has been used as adjuvant therapy of surgical interventions preoperatively or intraoperatively. This study aimed to determine the efficacy and safety of combined IVR as adjuvant therapy in treating NVG with vitreous hemorrhage (VH) in PDR. A total of 39 NVG patients with VH (39 eyes) received IVR 3 to 5 days before surgery, and then they were assigned to either pars plana vitrectomy (PPV) + Ahmed glaucoma valve (AGV) implantation (Group 1, n = 22) or PPV + AGV implantation + intraoperative IVR (Group 2, n = 17). Patients were followed up for at least 9 months. Intraocular pressure (IOP), anti-glaucoma medications, best corrected visual acuity (BCVA), surgical success rates and postoperative complications were compared. Results showed that IOP decreased promptly after surgery and was notably maintained at a mid-term follow-up in both groups, and no significant differences were observed (all p > 0.05). Additional intraoperative IVR significantly reduced postoperative recurrent VH and iris neovascularization (p = 0.047, p = 0.025, respectively). There was no remarkable difference in postoperative anti-glaucoma medications, BCVA and complications between two groups (all p > 0.05). In conclusion, preoperative and intraoperative IVR as adjuvant therapy of AGV implantation combined with PPV could be a safe and effective treatment for NVG with VH in PDR. An additional intraoperative anti-VEGF injection could significantly reduce postoperative VH and iris neovascularization.

Oxidative Stress and Its Regulation in Diabetic Retinopathy

Diabetic retinopathy is the retinal disease associated with hyperglycemia in patients who suffer from type 1 or type 2 diabetes. It includes maculopathy, involving the central retina and characterized by ischemia and/or edema, and peripheral retinopathy that progresses to a proliferative stage with neovascularization. Approximately 10% of the global population is estimated to suffer from diabetes, and around one in 5 of these individuals have diabetic retinopathy. One of the major effects of hyperglycemia is oxidative stress, the pathological state in which elevated production of reactive oxygen species damages tissues, cells, and macromolecules. The retina is relatively prone to oxidative stress due to its high metabolic activity. This review provides a summary of the role of oxidative stress in diabetic retinopathy, including a description of the retinal cell players and the molecular mechanisms. It discusses pathological processes, including the formation and effects of advanced glycation end-products, the impact of metabolic memory, and involvements of non-coding RNA. The opportunities for the therapeutic blockade of oxidative stress in diabetic retinopathy are also considered.