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Neovascular glaucoma
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.
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Neovascular glaucoma
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- 2. Secondary Glaucoma dueto fibrovascular membrane on the surface of the iris and the angle. Thrombotic glaucoma, hemorrhagic glaucoma, rubeotic glaucoma.
- 3. Nettleship et alnoted 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 vesselsarise 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 ANGIOGENICFACTORS RELEASED & DIFFUSED NEOVASCULARISATION ON IRIS AND IN THE ANGLE. NEOVASCULAR GLAUCOMA
- 10. CAUSES Ischaemic Central retinalvein 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 Hazycornea 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 Uniformsize 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 byreducing 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 topanretinal 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 visualpotential,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 Topicalbeta blocker Carbonic anhydrase inhibitor
- 21. CYCLODESTRUCTIVE PROCEDURES In painfuleyes ,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 burnspots ,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.
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