A prospective study of xenon arc photocoagulation for central retinal vein occlusion.

Twenty patients with central retinal vein occlusion were randomly divided into two groups in a prospective study to evaluate the effects of xenon are photocoagulation in central retinal vein occlusion. The patients in one group were treated with 360 degrees scatter xenon photocoagulation and the others received no treatment. The average follow-up was 18 months. There were no cases of rubeosis or neovascular glaucoma in the treated group. Two patients in the untreated group developed rubeosis with subsequent neovascular glaucoma. There was no significant difference in the visual prognosis or in fundus neovascularization between the groups.     

Effects of argon laser photocoagulation on rubeosis iridis and angle neovascularization

Of 93 eyes with proliferative diabetic retinopathy treated by argon laser panretinal photocoagulation, two (2.2%) developed rubeosis. The incidence of rubeosis in five xenon-treated eyes was one (1.9%) and in an untreated group of 52 eyes, two (3.8%) developed rubeosis. The incidence of rubeosis in central retinal vein occlusion demonstrating retinal ischemia on fluorescein angiography was 60%, while in patients with central retinal vein occlusion and good capillary perfusion, the incidence of rubeosis only 1%. Panretinal photocoagulation was more effective in controlling rubeosis in diabetics than in patients with central retinal vein occlusion.     

A prospective follow-up study of panretinal photocoagulation in preventing neovascular glaucoma following ischaemic central retinal vein occlusion

Fifteen consecutive eyes with central retinal vein occlusion (CRVO) and extensive capillary non-perfusion were treated by panretinal photocoagulation using argon laser. Of these eyes six had chronic glaucoma and one had acute angle-closure glaucoma when first seen. One developed neovascular glaucoma before treatment. After photocoagulation iris new vessels appeared in two eyes with preexisting glaucoma. In one case the new vessels later regressed without further treatment. The prevalence of neovascular glaucoma was considerably less than has been reported in untreated eyes with ischaemic-type CRVO. Poor dilatation of the pupil due to pre-existing glaucoma, cataract and/or massive retinal oedema put a limit on the extent of treatment.     

Extracapsular cataract extraction in diabetic eyes

Cataract surgery may exacerbate preexisting diabetic retinopathy. Especially diabetics with active retinal neovascularisation are at high risk of rubeosis iridis after intracapsular cataract extraction. Thirty-five eyes previously treated with panretinal photocoagulation underwent extracapsular cataract extraction with posterior chamber lens implantation. Twenty-eight eyes with retinal neovascularisation required further Argon laser PRP after surgery. Fourteen eyes required YAG-laser capsulotomy. From the group of eyes without YAG-laser capsulotomy none developed neovascular glaucoma. From the YAG laser capsulotomy group six eyes developed rubeosis iridis and neovascular glaucoma. Our results indicate that eyes in which PRP has been performed, have an excellent prognosis after ECCE with posterior chamber lens implantation only if YAG Laser posterior capsulotomy is not performed.     

Rubeosis iridis: preoperative iris fluorescein angiography and periocular steroids

To study the risk of developing rubeosis iridis following vitrectomy, the use of preoperative iris fluorescein angiography was prospectively investigated on patients with diabetes mellitus, without any clinically detectable iris or angle neovascularization. With increasing severity of fluorescein leakage, the risk of iris neovascularization with or without glaucoma, six months after vitreous surgery, is significantly increased. It was also determined whether postoperative steroid therapy (periocular triamcinolone acetonide and topical prednisolone phosphate) reduces the risk of developing iris neovascularization after vitrectomy. Controlled and treated patient eyes did not differ significantly in the degree of rubeosis. However, neovascular glaucoma statistically occurred more frequently in the nonsteroid group.     

Preliminary report on effect of retinal panphotocoagulation on rubeosis iridis and neovascular glaucoma.

Eight eyes with central retinal vein occlusion one eye with old central retinal artery occlusion complicated by rubeosis iridis or increased intraocular pressure, or both; and one eye with diabetic retinopathy and rubeosis iridis were treated by retinal panphotocoagulation. Vision did not improve but intraocular pressure was lower and iris neovascularisation regressed in most cases, supporting the hypothesis that retinal hypoxia is a cause of iris neovascularisation and suggesting that retinal panphotocoagulation has a potential prophylactic and therapeutic role in rubeosis iridis and early neovascular glaucoma.     

Neovascular glaucoma following central retinal vein obstruction

The results of a prospective clinical and fluorescein angiographic study of 155 patients with central retinal vein obstruction (CRVO) were analyzed to identify risk factors contributing to the subsequent development of iris neovascularization (NVI) and neovascular glaucoma (NVG). Of 144 untreated eyes, 20% developed NVG. The eyes were classified as having either an ischemic or a hyperpermeable type of CRVO according to the extent of retinal capillary nonperfusion demonstrated by the initial fluorescein angiogram. The risk of developing NVG was found to be approximately 60% in those eyes with extensive retinal ischemia. None of the 22 eyes with an ischemic CRVO treated with panretinal photocoagulation (PRP) prior to the onset of NVI developed NVG.     

Intracameral bevacizumab for iris rubeosis

PURPOSE: To determine whether intracameral bevacizumab decreases vascular leakage from iris rubeosis in patients with neovascular glaucoma. DESIGN: Interventional case series. METHODS: The study included six eyes of three patients with secondary neovascular glaucoma due to proliferative diabetic retinopathy (n = 2) or ischemic central retinal vein occlusion (n = 1). All patients received an intracameral injection of 1.0 mg bevacizumab. Morphologic changes and vascular leakage were investigated prospectively by iris fluorescein angiography. RESULTS: Decrease in leakage was detected as early as one day after injection. No inflammation was observed. No relapse was seen within the follow-up of four weeks. CONCLUSION: Intraocular injection of bevacizumab may provide an additional strategy for the treatment of iris rubeosis in neovascular glaucoma.     

Dynamics of vascular changes in neovascular glaucoma. I. Development of rubeosis iridis after cryosurgery]

The author is evaluating the influence of two cryosurgical methods for the development of the rubeosis of iris in neovascular glaucoma. The cyclocryocoagulation was used as a single method in 12 eyes, the combination of transscleral panretinal cryocoagulation and cyclocryocoagulation in 26 eyes. The results were clearly better if the combination of cryosurgical methods was used. The involution of rubeosis of iris was observed in 6 weeks in all patients after the transscleral panretinal photocoagulation in combination with cyclocryocoagulation. The author thinks that the non-satisfactory regression of the rubeosis in neovascular glaucoma after simple cyclocryocoagulation is caused by the fact, that by this method we affect just one factor in the pathogenesis of rubeosis. The author is suggesting that there are two factors influencing the pathogenesis of the rubeosis of iris: the primary disease, that is causing the development of proliferative retinopathy; and the high intraocular pressure, that is reducing the blood flow in retinal vessels and by this is increasing the hypoxia of the retina.     

Neovascular glaucoma and vitreous hemorrhage following cataract surgery in patients with diabetes mellitus

The potential complications of cataract surgery in the general population are well known. In addition, cataract extraction in the patient with diabetes mellitus is associated with other potential complications common to this disease: neovascular glaucoma and acceleration of proliferative diabetic retinopathy with or without vitreous hemorrhage. We analyzed the records of 154 patients with diabetes mellitus who had undergone standard intracapsular cataract extraction in one eye only with the other eye serving as the unoperated control eye. We were able to determine the status of the diabetic retinopathy before the operation and to note the development of vitreous hemorrhage and rubeosis iridis/neovascular glaucoma after the operation. If either event occurred within six weeks of the surgery, it was considered to be a complication of the cataract extraction. Intracapsular cataract extraction in this diabetic population, without regard of the preoperative status of the retinopathy, was associated with a statistically significant incidence of postoperative rubeosis iridis/neovascular glaucoma (7.8% vs 0%). In patients with preoperative active proliferative diabetic retinopathy, the risk of developing postoperative rubeosis iridis/neovascular glaucoma was even higher (40% vs 0%). There was also a statistically significant incidence of vitreous hemorrhage after surgery in eyes with no diabetic retinopathy or background diabetic retinopathy (6.5% vs 0%). In patients with active proliferative diabetic retinopathy, there was an increased incidence of vitreous hemorrhage after surgery (20% vs 6.5%), but this was not statistically significant due to the small number of patients studied. Possible explanations for these findings are explored and therapeutic and prophylactic measures recommended.     

Retinal ischemia and risk of neovascularization following central retinal vein obstruction

The predominant risk factor for the development of neovascular complications involving the retina (NVR), the optic disc (NVD), and iris (NVI) following central retinal vein obstruction (CRVO) is the extent, location, and duration of retinal ischemia (ischemic drive). The extent of retinal capillary nonperfusion (ischemic index) was quantitated by microcomputer analysis of 200 standard fundus-iris fluorescein angiograms. The results were correlated with the development of neovascularization in eyes not receiving prophylactic argon laser panretinal photocoagulation (PRP). Of the 85 eyes with intact capillary perfusion (hyperpermeable group), none developed NVR/NVD and only one eye (1%) developed neovascular glaucoma (NVG). Twenty-nine eyes exhibited moderate degrees of retinal ischemia (indeterminate group), and three eyes (10%) developed NVR/NVD, with two eyes (7%) developing NVG. Of the 86 eyes with extensive retinal capillary nonperfusion (ischemic group), 28 eyes (33%) developed NVR/NVD and NVG occurred in 39 eyes (45%). The inherent difficulties in following high risk patients clinically and angiographically at frequent intervals over extended periods of time, the tendency for rapid progression of early NVI to NVG, and the relatively poor results following treatment in advanced cases make the early recognition of eyes at high risk to develop NVG essential and the initiation of prophylactic PRP as the treatment of choice in this disorder.     

雷珠单抗治疗视网膜中央静脉阻塞引起的眼前段新生血管

目的：探讨雷珠单抗治疗视网膜中央静脉阻塞（ central retinal vein occlusion , CRVO ）引起的眼前段新生血管（ anterior segment neovascularization ,ASNV）的疗效。方法：回顾性研究,选取2013－01／2014－12我院门诊及住院的因CRVO引起的ASNV并经过雷珠单抗玻璃体腔注射治疗的连续病例18例18眼。观察患者的最佳矫正视力、眼压、虹膜情况、房角镜检查等,随访时间6～13（平均9．1±2．9）mo。结果：患者18例18眼都接受了雷珠单抗治疗,15例15眼行视网膜光凝,3例3眼因玻璃体混浊仅行抗VEGF治疗,1例1眼行青光眼阀植入。其中6例6眼为仅有虹膜新生血管而没有眼压升高的患者,这6例6眼患者经过雷珠单抗联合全视网膜光凝（ panretinal photocoagulation ,PRP）后视力提高,眼压控制。已经伴有新生血管性青光眼的患者中,经过雷珠单抗及PRP治疗后,眼压可以控制者4例4眼;另有7例7眼眼压在雷珠单抗治疗后可以降低,但仍需药物控制;1例1眼药物控制不良者植入青光眼阀治疗,术后眼压控制,但视力较注射雷珠单抗前变差。所有患者的虹膜新生血管均可以消退。结论：雷珠单抗可以有效地使虹膜新生血管消退并对眼压控制有所帮助,在早期没有眼压升高的时候效果更好,提示要早期发现虹膜血管并尽早干预。     

Development and classification of rubeosis iridis in diabetic eye disease.

The evolution and characteristics of diabetic rubeosis were studied in 33 eyes, and the following vascular abnormalities were found: (1) Dilated leaking capillaries around the pupil; (2) irregular or slow filling of the radial arteries; (3) superficial arborising newly formed vessels, usually starting in the chamber angle; and (4) dilatation and leakage of the radial vessels either before or after the development of neovascular glaucoma. None of the vascular changes was specific for diabetes. Four grades of diabetic iridopathy were distinguished on the extent of rubeosis: I, peripupillary vessel dilatations with leakage; II, early neovascularisation mainly in the chamber angle; III, prominent rubeosis with or without neovascular glaucoma; and IV, florid rubeosis.     

Vitrectomy for Proliferative Diabetic Retinopathy Associated with Vitreous Hemorrhage

This paper describes experience gained with 663 eyes of patients with diabetic vitreous hemorrhage treated by closed vitrectomy with a follow-up period of six months. Hemorrhages were nearly always associated with proliferative retinopathy (97%) and were thought to be caused always by ruptured proliferative vessels. Membrane removal was performed in 42% of all cases but in 60% when the retina was detached. The most common surgical complication was creation of retinal holes; more common when the posterior retina was detached (32%) than when it was attached (18%). The lens was removed in 73% of the cases. Eighty-two percent of the retained clear lenses remained clear at the six months follow-up period. Therefore, clear lenses should not be removed. Visual improvement could be achieved in 59% of the cases where the posterior retina was attached but only in 25% where it was detached resulting in an overall major visual improvement in 46% of the cases. If one adds to this group the cases that retained reasonable vision of 20/200 or better, the overall success rate was 51%. Posterior retinal detachment and rubeosis of the iris were the main factors for a bad prognosis. Forty-two percent of all eyes had at least some degree of rubeosis iridis. Most of the preoperative rubeotic eyes had rubeosis postoperatively (71%). Twenty-three percent of all eyes ended up with neovascular glaucoma.     

Panretinal cryotherapy in neovascular disease.

Panretinal cryotherapy (PRC) was used to treat 15 eyes with rubeosis, nine of which had established neovascular glaucoma, and seven eyes with proliferative diabetic retinopathy. The rubeosis regressed, with preservation of vision and return to normal of intraocular pressure, in all but one eye. With one exception all eyes with proliferative retinopathy also showed new vessel regression after treatment. PRC may be considered an effective alternative to retinal photocoagulation in the treatment of advanced rubeosis, early rubeotic glaucoma, and in certain circumstances proliferative diabetic retinopathy.     

Life expectancy of patients with neovascular glaucoma drained by Molteno implants

PURPOSE: To determine the survival of patients with sighted eyes who had Molteno implants inserted for neovascular glaucoma. METHODS: Patients who had Molteno implants inserted for neovascular glaucoma between October 1977 and March 2001 at Dunedin Hospital, New Zealand, were reviewed. Relative survival analysis was then used to compare survival in this group to survival of the New Zealand population of the same age. RESULTS: A total of 114 patients had 131 Molteno implants inserted for neovascular glaucoma. Neovascular glaucoma was secondary to central retinal vein occlusion in 66 eyes (50%) and diabetes in 42 eyes (32%), and patients lost 52% or 6.53 years of their expected remaining life span. Age, sex and postoperative intraocular pressure control did not predict survival. The only predictor of improved survival was a preoperative visual acuity of 6/48 or better. These patients lost 21% (or 2.43 years) of expected remaining life compared to 62% (or 10.78 years) in those patients who had a presenting visual acuity of 6/60 or worse. CONCLUSIONS: Patients with neovascular glaucoma had a markedly reduced life expectancy, which has improved in recent years when compared to that of the normal sex and age-matched New Zealand population. Patients presenting with better vision (6/48 or better) survived significantly longer than those presenting with poorer vision.     

Ranibizumab as adjuvant in the treatment of rubeosis iridis and neovascular glaucoma—results from a prospective interventional case series

Background

To evaluate the capability of adjuvant intraocular ranibizumab (Lucentis®) injections in the treatment of rubeosis and intraocular pressure in patients with rubeosis and neovascular glaucoma.

Methods

Ten eyes with rubeosis (R) and ten eyes with neovascular glaucoma (NVG) received Lucentis® injections (ranibizumab 0.5 mg/0.05 ml) in this prospective, monocenter, 12-months, interventional case series. The primary efficacy outcome measure was the change of degree of iris rubeosis as documented by iris fluorescein angiography measured after 12 months. Secondary outcomes were intraocular pressure (IOP), best-corrected visual acuity (BCVA, logMAR), numbers of additional interventions or antiglaucoma medications administered after injection, the gonioscopic status of the anterior chamber angle, and central retinal thickness.

Results

In the R group, 3.6 injections and in the NVG group 2.3 injections of Lucentis® were administered. Additional treatments were photocoagulation (n?=?19), cyclodestructive procedures (n?=?9), cryopexy (n?=?3), and vitrectomy (n?=?1). The mean stage of rubeosis was 3.4?±?0.7 in the R group and 3.6?±?0.8 in the NVG group at baseline. At month 12, the rubeosis was almost resolved in the R group (0.1?±?0.3, p?<?0.001), and decreased significantly in the NVG group (0.7?±?1.1, p?<?0.001). In the NVG subgroup, mean IOP was 41.4?±?13.4 mmHg at baseline, which decreased rapidly (18.2?±?12.3, day-14, p?=?0.005) and stabilized during the follow-up (15.6?±?2.0 mmHg, p?<?0.05). BCVA improved significantly in both groups (p?<?0.05, at month 12).

Conclusions

Injection of 0.5 mg ranibizumab appears to be beneficial as an adjuvant treatment in neovascular glaucoma and rubeosis due to its anti-angiogenic properties and its ability to prevent establishment or progression of anterior chamber angle obstruction. Conventional therapeutic procedures addressing the retinal ischemia are still required in a stage-wise treatment approach.     

Value and limitations of cyclocryotherapy

We studied a consecutive series of 114 eyes of 102 patients that were treated with cyclocryotherapy by one surgeon. Intraocular pressure reduction sufficient to avoid further surgical intervention was achieved in two-thirds of the cases. However, the postoperative visual acuity was worse than the preoperative level in 60% of the cases, and 12% of the eyes developed phthisis. Factors which influenced these results included the type of glaucoma and the age of the patient. Eyes with neovascular glaucoma had the worst results, while those having glaucoma in aphakia without neovascular glaucoma had the most favorable response to cyclocryotherapy. Findings further showed that younger patients required more cryotherapy to achieve pressure reduction. Phthisis developed significantly more often following initial treatments than in eyes undergoing one or more repeat cyclocryotherapy procedures.     

Neovascular glaucoma, endophthalmitis and evisceration

A retrospective study of 35 patients undergoing evisceration at Moorfields Eye Hospital, London between 1982 and 1987, revealed that 60% were known to be suffering from neovascular glaucoma, the majority as a result of a central retinal vein occlusion. 76% of these rubeotic eyes subsequently developed an endophthalmitis and required evisceration. 81% of this rubeotic, infected group were being treated with topical steroids prior to developing a suppurative keratitis and ensuing endophthalmitis. Every patient (9) with neovascular glaucoma that was debilitated (due to a variety of underlying medical conditions--4 were diabetic) developed an endophthalmitis and 78% of these were also using topical steroids. This study reveals that there may be a specific group of patients with absolute neovascular glaucoma, i.e. being debilitated and using topical steroids, who might appear to be susceptible to developing severe intraocular infection.     

Retinal and disc neovascularization in Behçet's disease and efficacy of laser photocoagulation

Background: The vasoocclusive episodes resulting from Behçet's disease can cause capillary dropout and vascular remodeling. Retinal and disc neovascularizations, which occur as a result of occlusive vasculitis, can cause recurrent vitreal hemorrhages and neovascular glaucoma leading to severe visual impairment. Methods: 1080 eyes of 540 patients with Behçet's disease were examined between 1973 and 1993. Of the 912 eyes with posterior segment involvement, laser photocoagulation could be performed in 13 of 25 eyes with disc neovascularization (NVD), 12 of 22 eyes with retinal neovascularization (NVE), and 4 of 6 eyes with NVD and NVE. Laser was directed at areas of NVE and retinal capillary nonperfusion. In cases of NVD, panretinal photocoagulation was performed. Results: The rate of regression of NVD was significantly greater in laser-treated eyes than in the untreated group. The results were similar in cases of NVD with NVE. In eyes with NVE which underwent laser photocoagulation, the NVE regressed. None of the treated eyes developed neovascular glaucoma during the follow-up period. Vitreous hemorrhage occurred in two laser-treated eyes. Conclusion: Laser photocoagulation is successful in preventing complications of retinal and disc neovascularizations. Thus, in cases of occlusive vasculitis associated with Behçet's disease, laser photocoagulation should be considered for prevention of complications such as vitreous hemorrhage and neovascular glaucoma.Presented at the meeting of the Club Jules Gonin, Versaille, France, 8-13 September 1994