A paradigm shift in the management of neovascular glaucoma

Abstract

Neovascular glaucoma (NVG) secondary to proliferative diabetic retinopathy (PDR) is a potentially devastating condition. The commonest cause of treatment failure in NVG is underlying systemic disease progression. The underlying ischemia is often refractory to medical treatment. Surgical options have evolved to include Bevacizumab in the Ophthalmologist's armamentarium. Visual prognosis can be guarded in these patients who additionally have reduced life expectancy. Thus, early diagnosis and aggressive treatment is imperative to avert visual loss, and improve their prognosis. We present a case of NVG secondary to PDR which was challenging to treat. The patient adherent to his treatment plan and achieved unusually successful results, maintaining good vision.

The mechanism and therapeutic strategies for neovascular glaucoma secondary to diabetic retinopathy

“…Besides, NVG is more likely to occur after cataract surgery and vitreoretinal surgery due to surgery-induced inflammation cascade, retinal hypoxia, and the lack of anti-neovascular factors ( 14 , 15 ). Furthermore, clinical studies have shown that posterior surgery might help the diffusion of vascular endothelial growth factor (VEGF) into the anterior chamber ( 18 ). Taking the above risk factors, the incidence of NVG in diabetic patients after ocular surgery raised to 80% ( 19 ).…”

Optic Nerve Changes in Diabetic Retinopathy

“…Diabetic retinopathy is often associated with neovascular proliferation due to ischemia in the retina and release of angiogenic factors. These conditions cause neovascularization of the optic disc (NVD), also neovascularization elsewhere (NVE) [70,71]. Patients with NVD have a poor visual prognosis due to high incidence of complication, such as vitreous hemorrhage, fibrous proliferation, and traction retinal detachment.…”

“…In DR, capillary occlusion and reduced perfusion in retina provoke cascade events related to hypoxia and lead to angiogenesis. Normally, pro-angiogenic factors (VEGF and angiopoietin-2) and antiangiogenic factors (pigment epithelium-derived growth factor) are in equilibrium [71]. Imbalance between those factors might trigger activation, proliferation, and migration of endothelial cells and pericytes and lead to neovascularization [71][72][73].…”

“…Normally, pro-angiogenic factors (VEGF and angiopoietin-2) and antiangiogenic factors (pigment epithelium-derived growth factor) are in equilibrium [71]. Imbalance between those factors might trigger activation, proliferation, and migration of endothelial cells and pericytes and lead to neovascularization [71][72][73]. VEGF is produced in a variety of neuroretinal cells and plays a major part in promoting intraocular neovascularization.…”

“…In early stages of neovascularization, patients may be asymptomatic or may present with low vision. Ocular findings can be subtle in early stage, so case history and complete ocular examination are important to make early diagnosis [71][72][73].…”