Intravitreal Bevacizumab (Avastin) Treatment of Neovascular Glaucoma in Ocular Ischemic Syndrome

We report a case of ocular ischemic syndrome accompanied by neovascular glaucoma that was successfully treated with Bevacizumab. A 70-year-old male patient diagnosed with neovascular glaucoma of the left eye 3-4 years prior complained of continuous left eye pain and declining visual acuity despite receiving the latest treatment methods. At the time of admission the patient had no light perception in the left eye and his intraocular pressure was 30 mmHg. Anterior segment and fundus examinations revealed neovascularization of the iris and stenosis of the retinal vessel. Hypofluorescence of the choroid and retinal vessels was observed on fluorescence fundus angiography. Left internal carotid artery stenosis was observed on a brain MRI. Despite being treated with eye solution and oral medication, intraocular pressure was not controlled. After 7 days, we performed an intravitreal Bevacizumab 1.25 mg/0.05mL injection. One day after the intravitreal Bevacizumab injection, the neovascularization had nearly regressed and intraocular pressure was 30 mmHg. Intravitreal Bevacizumab injection produced regression of neovascularization and proved effective for treatment of neovascular glaucoma in this case of ocular ischemic syndrome.     

小梁切除术联合视网膜光凝术治疗新生血管性青光眼

目的 探讨复合小梁切除术联合视网膜光凝术治疗新生血管性青光眼的疗效.方法 回顾性分析视网膜中央静脉阻塞继发新生血管性青光眼患者9例,行复合小梁切除术,术后1周予全视网膜光凝术.记录术前及术后3个月、12个月患者视力、眼压、虹膜及房角新生血管检查,眼底视网膜新生血管消退及无灌注区情况.结果 术后12个月患者视力提高8眼,1眼无明显提高.术后眼压：5例患者眼压控制在21mmHg以下;4例眼压控制欠佳,需要局部使用降眼压药物,其中2例使用一种局部降眼压药物后眼压控制在21mmHg以下,另外2例眼压不能控制.虹膜及房角新生血管消退.眼底3个月和12个月后行荧光血管造影显示新生血管消退,无水肿,毛细血管无灌注区消失.结论 复合小梁切除术联合全视网膜光凝术是一种治疗视网膜中央静脉阻塞继发的新生血管性青光眼的有效的方法.     

The efficacy of panretinal photocoagulation for neovascularization of the iris after central retinal artery obstruction

Panretinal photocoagulation (PRP) is widely used for a variety of ischemic ocular conditions. In diseases that produce neovascularization of the iris (NVI), such as diabetes mellitus and central retinal vein obstruction, a judiciously timed PRP can reduce the incidence of neovascular glaucoma. Neovascularization of the iris can occur after central retinal artery obstruction (CRAO) as well. In this article, the authors report the outcome of 17 patients who received PRP to treat rubeosis iridis secondary to CRAO. Eleven of the 17 patients (65%) showed regression of NVI after PRP. Although the uncontrolled and retrospective nature of this study precludes drawing definitive conclusions from these data, PRP appears to be effective in reducing the incidence of neovascular glaucoma, if it is delivered before the development of elevated intraocular pressure (IOP). Once neovascular glaucoma occurs, additional modalities appear to be necessary in order to adequately control the elevated IOP.     

Ocular neovascularization in a patient with Fanconi anemia

CASE REPORT: An 11-year-old girl diagnosed with Fanconi anemia was referred to us for redness and pain in her right eye. Findings in the right eye included visual acuity of counting fingers, neovascular glaucoma, vitreous hemorrhage, optic disc neovascularization, and features of peripheral ischemic retinopathy. Findings in the left eye included peripheral retinal neovascularization and areas of retinal capillary nonperfusion. COMMENTS: Patients with Fanconi anemia may develop ocular neovascularization with subsequent severe visual loss due to vitreous hemorrhage or neovascular glaucoma. Regular ophthalmic examination, including ophthalmoscopy and fluorescein angiography in selected cases, is recommended in such patients.     

Intravitreal bevacizumab (Avastin) injection for neovascular glaucoma

Neovascular glaucoma is a secondary glaucoma with grave prognosis which follows ischemic retinal disorders in the majority of cases. Mediators that induce new vessel formation such as the vascular endothelial growth factor-A seem to play a key role in the pathophysiology of this condition. Herein, we report 2 cases with neovascular glaucoma secondary to ischemic central retinal vein occlusion who received treatment with intravitreal bevacizumab (Avastin) a nonselective antibody against vascular endothelial growth factor-A. Both patients demonstrated dramatic short-term response in terms of intraocular pressure reduction and regression of neovascularization.     

Intravitreal bevacizumab for neovascular glaucoma following central retinal artery occlusion

PURPOSE: To report a case of neovascular glaucoma due to central retinal artery occlusion treated with a single intravitreal injection of bevacizumab. METHODS: A 68-year-old patient with a 10-week history of central retinal artery occlusion presented with neovascularization of the iris and the angle and intraocular pressure of 30 mm Hg. The patient received a single injection of 1.25 mg bevacizumab in 0.1 mL intravitreally. RESULTS: Iris and angle neovascularization regressed within 48 hours of the injection. Intraocular pressure dropped from 30 to 15 mm Hg, and there was marked improvement in patient comfort. Panretinal photocoagulation was applied 4 weeks after the injection. CONCLUSIONS: Bevacizumab seems to be a useful adjunct to panretinal photocoagulation in the treatment of neovascular glaucoma.     

Neovascular glaucoma diagnosed following carotid endarterectomy

We report a case of bilateral asymptomatic rebeosis iridis related to a bilateral obstruction of the carotid arteries. The iridocorneal angles were closed by a neovascular membrane and intraocular pressures were normal within both eyes (normotensive neovascular glaucoma). After left carotid endarterectomy, the increased perfusion of the ciliary body and the increased secretion of aqueous humor resulted in a sudden bilateral ocular hypertension. Management of ocular neovascularization related to carotid artery obstruction may involve the destruction of areas of retinal ishchemia (laser panretinal photocoagulation or cryotherapy) before carotid surgery.     

联合手术治疗新生血管性青光眼疗效比较

目的 比较两组治疗新生血管性青光眼方法的效果.方法 前瞻性随机对照研究.41例(41只眼)新生血管性青光眼随机分2组.A组(20只眼)行手术区域虹膜、房角新生血管光凝及小梁切除联合前视网膜冷凝术.B组(21只眼)行睫状体冷凝术联合前部视网膜冷凝术.观察1周内眼压及眼内情况;随访1年眼压及并发症情况.结果 术后1周A组眼压明显低于B组,差异有统计学意义(t=7.12P<0.01);A组疼痛消失明显,差异有统计学意义(χ2=7.15 P<0.01).术后1年A组眼压有90%(18/20)正常,B组有49%(10/21)正常,差异有统计学意义(t=2.37 P<0.05),两组病例中虹膜新生血管均有减退,A组优于B组,差异有统计学意义(χ2=5.53 P<0.05).结论 手术区域虹膜、房角新生血管光凝及小梁切除联合前视网膜冷凝术效疗更优越.     

新生血管性青光眼的联合手术治疗观察

目的:探讨视网膜光凝或视网膜冷凝联合小梁切除术治疗新生血管性青光眼的疗效。方法:新生血管性青光眼64例64眼,首先行视网膜光凝或视网膜冷凝,再行小梁切除术,术后观察视力、眼压、虹膜新生血管、球结膜滤过泡及手术并发症等。结果:术后随访6～12mo,视力均无明显改善,平均眼压自术前47.89±6.74mmHg随访末降至18.41±2.16mmHg,控制在21mmHg以下者53眼(73%)。结论:视网膜光凝或视网膜冷凝联合小梁切除术治疗新生血管性青光眼有较好的长期疗效。     

Anterior segment ischemia secondary to carotid occlusive disease

The ischemic signs of carotid occlusive disease in the anterior segment can be summarized as follows: vasodilation in the conjunctiva, episclera, and iris; neovascularization in the iris and the anterior chamber angle with consequent neovascular glaucoma, with or without elevation of intraocular pressure; and noninflammatory uveitis with corneal edema, keratitic precipitates, flare and cells in the anterior chamber, and late development of cataract. A questionnaire was sent to neuro-ophthalmology and glaucoma specialists regarding their perceptions of this condition. On average, approximately 1 case per specialist per year was seen. One third of the respondents had seen significant ocular pressure increase in patients with rubeosis following successful vascular surgery. Most felt that panretinal photocoagulation, though not as effective as in diabetic rubeosis, did cause regression of iris and angle neovascularization. The visual prognosis following all types of treatment was not good and was insufficient to justify a clear recommendation about the advisability of aggressive management of this condition.     

The role of gonio-photocoagulation in neovascularization of the anterior chamber angle

Gonio-photocoagulation is a name applied to direct laser therapy to neovascular vessels in the anterior chamber angle in progressive anterior segment neovascularization. The technique is useful not in altering the stimulus to anterior segment neovascularization, but in immediately altering the product of the stimulus, the new vessels in the angle. The goal is to halt immediately progression toward angle closure and severe neovascular glaucoma. A recommended protocol is presented for incorporation of this technique into a prophylactic regimen for neovascular glaucoma in conjunction with retinal therapy to alter the stimulus.     

Primate model of neovascular glaucoma

Iris neovascularization has been reproducibly created in cynomolgus monkey eyes by argon laser occlusion of retinal veins. Pre-treatment of the eyes with lensectomy and vitrectomy (before the retinal vein occlusion) led to a more rampant development of the iris neovascularization in all eyes, as well as development of neovascular angle closure glaucoma in two of the 12 eyes. Histopathologic examination confirmed the finding of neovascular angle closure. This primate model may allow further investigation into the causes and therapy of neovascular glaucoma.     

A case report of neovascular glaucoma due to carotid artery occlusive disease--diagnosis of neovascular glaucoma and histological characteristics

PURPOSE: The methods of diagnosing neovascular glaucoma were evaluated in a case with carotid artery occlusive disease. A trabeculectomy specimen taken from this patient was examined histologically to find the characteristic picture of this slowly progressive neovascular glaucoma. MATERIALS AND METHODS: The left eye of a 48-year old man with neovascular glaucoma due to carotid artery occlusive disease had been previously diagnosed as uveitis with ocular hypertension. His left eye was examined by fluorescein fundus and gonioangiography. Trabeculectomy was performed because of uncontrolled intraocular pressure and the trabeculectomy specimen was examined histologically including immunohistochemistry with antibodies against von Willebrand factor antigen. RESULTS: The characteristic picture of fluorescein fundus angiography was filling delay in the choroid and stained walls of the retinal arteries and veins. Fluorescein gonioangiography using a fundus camera clearly demonstrated new vessels in the pupil and angle with intense fluorescein leak in spite of faint neovascularization in those areas when observed by slit lamp with gonioscopy. Histological examination of the trabeculectomy specimen revealed proliferation of new vessels in the spaces of the trabecular meshwork and focal occlusion of Schlemm's canal. CONCLUSION: Fluorescein fundus angiography and gonioangiography by fundus camera is very useful for diagnosis of neovascular glaucoma due to carotid artery occlusive disease. Neovascular proliferation in the trabecular meshwork with slight of peripheral anterior synechia and focal occlusion of Schlemm's canal may be peculiar to such slowly progressive neovascular glaucoma.     

Neovascular glaucoma: aetiology, pathogenesis and treatment

Neovascular glaucoma, as a typical secondary glaucoma, is due to ocular or (earlier) systemic diseases. The formation of a fibrovascular membrane on the anterior surface of the iris (rubeosis iridis) and extending into the chamber angle leads to irreversible obliteration of the outflow system, with a corresponding rise in intraocular pressure. The most frequent cause is retinal ischaemia resulting either from vascular occlusion or from diabetic alterations. The differential diagnosis must include acute angle-closure glaucoma and uncontrolled open-angle glaucoma. Treatment is aimed at eliminating the actual cause or at least reducing the risk factors (e.g. by retinal laser coagulation), or consists in cyclodestructive procedures. Medicamentous therapy comprises anti-inflammatory agents (steroids, cycloplegic agents) and substances that reduce the production of aqueous humour (carbonic anhydrase antagonists, beta blockers). In the near future, antiangiogenic medication might be another effective option. For end-stage neovascular glaucoma, the implantation of drainage devices is also discussed.     

A Case Report of Neovascular Glaucoma Due to Carotid Artery Occlusive Disease. Diagnosis of Neovascular Glaucoma and Histological Characteristics

Purpose: The methods of diagnosing neovascular glaucoma were evaluated in a case with carotid artery occlusive disease. A trabeculectomy specimen taken from this patient was examined histologically to find the characteristic picture of this slowly progressive neovascular glaucoma.Materials and Methods: The left eye of a 48-year old man with neovascular glaucoma due to carotid artery occlusive disease had been previously diagnosed as uveitis with ocular hypertension. His left eye was examined by fluorescein fundus and gonioangiography. Trabeculectomy was performed because of uncontrolled intraocular pressure and the trabeculectomy specimen was examined histologically including immunohistochemistry with antibodies against von Willebrand factor antigen.Results: The characteristic picture of fluorescein fundus angiography was filling delay in the choroid and stained walls of the retinal arteries and veins. Fluorescein gonioangiography using a fundus camera clearly demonstrated new vessels in the pupil and angle with intense fluorescein leak in spite of faint neovascularization in those areas when observed by slit lamp with gonioscopy. Histological examination of the trabeculectomy specimen revealed proliferation of new vessels in the spaces of the trabecular meshwork and focal occlusion of Schlemm's canal.Conclusion: Fluorescein fundus angiography and gonioangiography by fundus camera is very useful for diagnosis of neovascular glaucoma due to carotid artery occlusive disease. Neovascular proliferation in the trabecular meshwork with slight of peripheral anterior synechia and focal occlusion of Schlemm's canal may be peculiar to such slowly progressive neovascular glaucoma.     

Panretinal photocoagulation and photodynamic therapy for anterior segment neovascularization secondary to ischemic central retinal vein occlusion.

BACKGROUND AND OBJECTIVE: To compare the effects of panretinal photocoagulation (PRP) and photodynamic therapy (PDT) for anterior segment neovascularization secondary to ischemic central retinal vein occlusion (CRVO). PATIENTS AND METHODS: Fifty-seven eyes were randomized to receive standard PRP (19 eyes), selective PRP (20 eyes), or PDT (17 eyes). Selective PRP was performed only when iris neovascularization and/or angle neovascularization showed progression on weekly follow-up. Primary outcome measures were the extension of anterior segment neovascularization and the rate of neovascular glaucoma development. Secondary outcome measures included visual acuity results. RESULTS: After 12 months of follow-up, iris neovascularization extension was 0.52, 2.55, and 2.27 in the PRP, selective PRP, and PDT groups, respectively. Anterior segment neovascularization extension was 0.57, 1.50, and 1.27 in the PRP, selective PRP, and PDT groups, respectively. Both showed a statistically significant difference in the PRP group. The rate of neovascular glaucoma development was similar in the three groups. CONCLUSIONS: Although PRP was better at determining iris neovascularization and anterior segment neovascularization regression, the similar rate of neovascular glaucoma development found in the three groups indicates that anterior segment neovascularization secondary to ischemic CRVO can also be safely managed using selective PRP or PDT.     

Photocoagulation in diabetic rubeosis iridis and neovascular glaucoma

This retrospective study was performed to examine the effect of retinal coagulation on the course of iris neovascularization and neovascular glaucoma in patients with diabetic retinopathy. Sixty-four eyes in 42 patients were examined. Following retinal coagulation iris neovascularization regressed in 47 eyes (73%), while 17 eyes (27%) showed no improvement. In eyes with neovascular glaucoma, a drop in intraocular pressure was noted. Visual acuity decreased in 60% of the treated eyes. Regression of iris neovascularization was related to the number of burns applied.     

眼缺血性疾病对预测颈动脉狭窄发生的意义

目的:探讨眼缺血性疾病对于预测颈动脉狭窄存在的临床意义。方法:选取70例眼缺血性疾病患者,使用颈动脉超声方法检查其是否存在颈动脉狭窄,结果进行统计学分析。结果:视网膜中央(分支)动脉、眼外肌麻痹、眼缺血综合征、新生血管性青光眼组发生颈动脉狭窄的比例显著升高,具有显著性差异(P<0.05),缺血性视神经病变组颈动脉狭窄的发生比例无明显升高。结论:在各类眼缺血性疾病中,视网膜中央(分支)动脉、眼外肌麻痹、眼缺血综合征、新生血管性青光眼对于颈动脉狭窄的发生有着较好的预测性,而缺血性视神经病变与颈动脉狭窄的发生缺乏一致性。     

Bevacizumab in conjunction with panretinal photocoagulation for neovascular glaucoma

BackgroundNeovascular glaucoma (NVG) is a type of secondary angle-closure glaucoma that can result from severe retinal ischemia, such as proliferative diabetic retinopathy. Vascular endothelial growth factor (VEGF) plays a role in ocular neovascularization, which can result in NVG. The use of bevacizumab, an anti-VEGF antibody, has been shown to lead to the rapid resolution of ocular neovascularization and may be used off-label in conjunction with panretinal photocoagulation in the treatment of neovascular glaucoma.1, 2, 3, 4Case ReportA 71-year-old man presented with neovascular glaucoma in both eyes secondary to proliferative diabetic retinopathy and was treated with both panretinal photocoagulation and an intravitreal injection of bevacizumab, which led to the rapid resolution of his iris neovascularization. A follow-up examination after 12 months showed that there was no recurrence of neovascularization.ConclusionThis case shows the possible beneficial effects of bevacizumab in conjunction with panretinal photocoagulation as a treatment option for neovascular glaucoma.     

Arterial obstruction and ocular neovascularization

A series of 12 patients (13 eyes) with neovascular glaucoma in association with arterial obstructive disease is presented. Appropriately characterized as having an ocular ischemic syndrome, the anterior segment findings in each included aqueous flare and rubeosis iridis. Posterior segment manifestations included midperipheral intraretinal hemorrhages (venous stasis retinopathy), narrowed retinal arteries, often a cherry red spot, and neovascularization of the disc and/or retina. Most eyes with the ocular ischemic syndrome have either ipsilateral common carotid artery obstruction or severe bilateral obstruction of the internal carotid arteries.