Neovascular glaucoma is a form of secondary open-angle glaucoma caused by the growth of new blood vessels in the eye in response to retinal ischemia. The blood vessels are accompanied by a membrane that can obstruct aqueous outflow and pull the iris forward, restricting access to the angle and leading to synechial angle closure. Treatment involves controlling intraocular pressure with medications, performing panretinal photocoagulation, and using anti-VEGF drugs or surgeries like trabeculectomy to dry up the neovascularization when possible. Long-term follow up is important due to risks of uncontrolled pressure, hyphema, and vision loss.
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2. INTRODUCTION
•A form of secondary open angle with
subsequent progression to secondary synechial
angle closure.
•Caused by new blood vessels forming in
response to retinal ischemia
•Vessels are associated with a membrane
•The membrane can obstruct aqueous outflow
•The contraction of membrane can lead to PAS
formation
3. PATHOPHYSIOLOGY
•Ischemic retina produces vasogenic substances
that stimulate the growth of new vessels
(VEGF)
•Vessels are accompanied by a membrane that
restricts aqueous access to the angle (even
areas that aren’t closed by synechiae)
•The membrane pulls the iris forward
4. PATHOPHYSIOLOGY
•Intraocular surgery – like cataract surgery – can
breakdown the natural barriers and increase the
risk for anterior segment neovascularization
5. CAUSES
•Ischemic central retinal vein occlusion (90 day
glaucoma)
•Diabetes mellitus
•Arterial retinal vascular disease
- Such as CRAO and ocular ischemic syndrome
• Miscellaneous causes ie. retinal detachment, chronic
intraocular inflammation
13. SIGNS - ANGLE
• Sometimes a red blush to the trabecular meshwork
• The membrane that accompanies the vessels impairs
outflow
• Note that angle vessels can be present without iris
vessels
14. SIGNS- ANGLE
• Later the membrane pulls the iris over the angle and
causes synechial angle closure
• Elevated IOP > 60mmHg
15. SIGNS - ANGLE
• Because the corneal endothelium is normal the
synechiae don’t extend pass Schwalbe line
- Unlike ICE (irido corneal endothelium syndrome)
22. TREATMENT
• Where possible treat the underlying pathology
• Frequent review (specially first few months after
CRVO)
Medical treatment
• Aqueous suppressants
• Miotics are contraindicated, prostaglandin derivatives
used with caution
• Topical steroids and cycloplegics
23. TREATMENT
Panretinal photocoagulation for proliferative diabetic
retinopathy
For other conditions such as CRVO, PRP without
delay
If retinal view poor one can
use indirect ophthalmoscopy or
in operating room with iris hooks
Trans-scleral cryotherapy
24. TREATMENT
• Intraocular VEGF inhibitors like bevacizumab (Avastin
®) or Ranibizumab (Patizra ®) have proven to be
effective in drying up anterior segment
neovascularization
• Intracameral injection is an alternative to intravitreal
route
- CRAO in ocular ischemic syndrome
25. TREATMENT
Other treatment options
•Ciliary body ablative procedures ie. Cyclodiode or
cyclocryotherapy ; if visual prognosis is poor
• Filtration Surgery if visual acuity is hand movement
(HM) or better
Trabeculectomy with active NVG has a poor
prognosis
Tube shunts
• Pars plana vitrectomy and retinal detachment repair
26. FOLLOW UP
• Long term follow up is needed
Complications :
• Uncontrolled IOP
• Hyphema
• Loss of vision
27. KEY POINTS
• A common secondary open angle glaucoma with
progression to synechial angle closure
• Should not be confused with pupillary block
• Can have NVA without NVI
Need to do regular gonioscopy
• Treat the underlying cause