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Neovascular glaucoma

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Neovascular glaucoma

  1. 1. NEOVASCULAR GLAUCOMA
  2. 2. Secondary Glaucoma due to fibrovascular membrane on the surface of the iris and the angle.  Thrombotic glaucoma, hemorrhagic glaucoma, rubeotic glaucoma. 
  3. 3.  Nettleship et al noted an association between Neovascular glaucoma and diabetes mellitus.  Kurtz described the gonioscopic appearance of new vessels at the angle and a fibrovascular contracted to form PAS in 1937.  The term Neovascular glaucoma was proposed by Weiss et al in 1963.
  4. 4. RUBEOSIS IRIDIS  New vessels arise from the microvascular bed in the iris and ciliary body.  Appearance as endothelial buds from capillaries of minor arterial circle as tufts. Fibrous membrane contains myofibroblasts that have contractile properties.  Pulls the posterior pigment layer of the iris epithelium anteriorly - ectropion uvea  Pulls the peripheral iris into the chamber angle producing PAS. 
  5. 5. PATHOGENESIS CHRONIC RETINAL ISCHAEMIA ANGIOGENIC FACTORS RELEASED & DIFFUSED NEOVASCULARISATION ON IRIS AND IN THE ANGLE. NEOVASCULAR GLAUCOMA
  6. 6. CAUSES Ischaemic Central retinal vein occlusion  Diabetic Retinopathy  Retinal detachment  Chronic uveitis  Malignant melanoma  Retinoblastoma  Cataract excision  Vitrectomy 
  7. 7. PRESENTATION  SYMPTOMS - Sudden pain - Headache ,vomiting - Redness - Watering - Defective vision - Photophobia
  8. 8. SIGNS Ciliary injection  Hazy cornea from epithelial edema  Deep anterior chamber with moderate flare,  Hyphema, a small pupil, and new vessels on the iris and in the angle(Gonioscopy)  Ectropion uveae  Fixed dilated pupil  Raised IOP 
  9. 9. NORMAL IRIS VESSELS     Uniform size Radial course No branching Located in stroma NEW VESSELS     Irregular size Irregular course Branching Located on surface
  10. 10. TREATMENT Panretinal photocoagulation  Goniophotocoagulation  Intra Vitreal Anti -VEGF  Mydriatics  Corticosteroids  Filtering surgeries  Cyclodestructive procedures  Enucleation 
  11. 11. PANRETINAL PHOTOCOAGULATION Performed by reducing stimulus for new vessel formation. in Diabetic retinopathy & Ischaemic CRVO.  200 -500 um spot size , 1500 -2000 burns  Use of Argon laser  To prevent the onset of NVG. 
  12. 12. GONIOPHOTOCOAGULATION Useful adjunct to panretinal photocoagulation.  Performed directly to NVI before development of NVG ,Absence of synechia.  Low-energy argon laser treatments (0.2 seconds, 50-100 um, 100 - 200 mW) are applied to the neovascular tufts as they cross the scleral spur. 
  13. 13. INTRAVITREAL ANTI - VEGF Bevacizumab (Avastin) at dose of 1.25 mg /0.05 ml .  It inhibits the VEGF – receptor interaction and blocks vascular permeability and angiogenesis. 
  14. 14. FILTRATION SURGERIES Good visual potential,IOP not reduced by medical treatment and if the neovascular membrane has regressed.  To prevent pressure –induced injury to optic nerve and improve vascular perfusion.  To control pressures and preserve vision. 
  15. 15. MEDICATIONS Mydriatics  Corticosteroids  Topical beta blocker  Carbonic anhydrase inhibitor 
  16. 16. CYCLODESTRUCTIVE PROCEDURES In painful eyes ,poor visual potential it is performed to destroy secretory ciliary epithelium,reduces aqueous secretion.  Cyclocryotherapy is usually applied at 60 degrees C to 80 degrees C, using a large-tip probe with its anterior edge 2.5 mm posterior to the limbus. Six to eight 60-second freezes are placed over half of the circumference of the ciliary body. 
  17. 17. LASER CYCLOABLATION  12-24 burn spots ,posterior to limbus over 360 degrees , 1500-2000 MW, 1.5-2 secs.
  18. 18. REFERENCES 1. Becker – Shaffer Diagnosis and therapy of the glaucomas , 8 th edition. 2. American academy of Ophthalmology ,Glaucoma , Section 10 , 2011-12. 3. Jack J Kanski and Brad Bowling , Clinical Ophthalmology ,7 th edition.
  19. 19. THANK YOU

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