Neovascular glaucoma is a secondary glaucoma caused by the growth of new blood vessels on the iris and in the anterior chamber angle due to underlying retinal ischemia or disease. The new vessels are stimulated by hypoxic factors and can contract, pulling the iris forward and occluding the drainage angle. This leads to increased eye pressure and vision loss if not treated. Treatment options aim to reduce the stimulus for new vessel growth such as panretinal photocoagulation laser or anti-VEGF injections, lower eye pressure through filtration surgeries or cyclodestructive procedures, and manage pain.

1. NEOVASCULAR
GLAUCOMA

2. Secondary Glaucoma due to fibrovascular
membrane on the surface of the iris and the
angle.
 Thrombotic glaucoma, hemorrhagic
glaucoma,
rubeotic glaucoma.


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. 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.


9. PATHOGENESIS
CHRONIC RETINAL ISCHAEMIA
ANGIOGENIC FACTORS RELEASED &
DIFFUSED
NEOVASCULARISATION ON IRIS AND
IN THE ANGLE.
NEOVASCULAR GLAUCOMA

10. CAUSES
Ischaemic Central retinal vein occlusion
 Diabetic Retinopathy
 Retinal detachment
 Chronic uveitis
 Malignant melanoma
 Retinoblastoma
 Cataract excision
 Vitrectomy


11. PRESENTATION

SYMPTOMS
- Sudden pain
- Headache ,vomiting
- Redness
- Watering
- Defective vision
- Photophobia

12. 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


13. NORMAL IRIS VESSELS




Uniform size
Radial course
No branching
Located in stroma
NEW VESSELS




Irregular size
Irregular course
Branching
Located on surface

14. TREATMENT
Panretinal photocoagulation
 Goniophotocoagulation
 Intra Vitreal Anti -VEGF
 Mydriatics
 Corticosteroids
 Filtering surgeries
 Cyclodestructive procedures
 Enucleation


15. 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.


17. 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.


18. 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.


19. 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.


20. MEDICATIONS
Mydriatics
 Corticosteroids
 Topical beta blocker
 Carbonic anhydrase inhibitor


21. 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.


23. LASER CYCLOABLATION

12-24 burn spots ,posterior to limbus over
360 degrees , 1500-2000 MW, 1.5-2 secs.

24. 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.

25. THANK YOU