Clinical Efficacy of Preoperative and Intraoperative Intravitreal Ranibizumab as Adjuvant Therapy of Ahmed Glaucoma Valve Implantation Combined with Vitrectomy in the Management of Neovascular Glaucoma with Diabetic Vitreous Hemorrhage

Abstract

Neovascular glaucoma (NVG) secondary to proliferative diabetic retinopathy (PDR) is a devastating ocular disease with poor prognosis. Intravitreal ranibizumab injection (IVR) has been used as adjuvant therapy of surgical interventions preoperatively or intraoperatively. This study aimed to determine the efficacy and safety of combined IVR as adjuvant therapy in treating NVG with vitreous hemorrhage (VH) in PDR. A total of 39 NVG patients with VH (39 eyes) received IVR 3 to 5 days before surgery, and then they were assigned to either pars plana vitrectomy (PPV) + Ahmed glaucoma valve (AGV) implantation (Group 1, n = 22) or PPV + AGV implantation + intraoperative IVR (Group 2, n = 17). Patients were followed up for at least 9 months. Intraocular pressure (IOP), anti-glaucoma medications, best corrected visual acuity (BCVA), surgical success rates and postoperative complications were compared. Results showed that IOP decreased promptly after surgery and was notably maintained at a mid-term follow-up in both groups, and no significant differences were observed (all p > 0.05). Additional intraoperative IVR significantly reduced postoperative recurrent VH and iris neovascularization (p = 0.047, p = 0.025, respectively). There was no remarkable difference in postoperative anti-glaucoma medications, BCVA and complications between two groups (all p > 0.05). In conclusion, preoperative and intraoperative IVR as adjuvant therapy of AGV implantation combined with PPV could be a safe and effective treatment for NVG with VH in PDR. An additional intraoperative anti-VEGF injection could significantly reduce postoperative VH and iris neovascularization.

Anti-vascular endothelial growth factor therapies in ophthalmology

“…Given VEGF’s pivotal role in promoting angiogenesis and fibroblast activation, intravitreal administration of anti-VEGF agents has been suggested as an adjunctive treatment for neovascular glaucoma [ 139 ]. Preoperative use has been associated with rapid regression of neovessels in the iris and angle, leading to reduced intraoperative bleeding, a lower incidence of postoperative hyphemia and fibrovascular occlusion of the drainage tube, and improved surgical outcomes with the Ahmed Glaucoma Valve [ 140 ] ( Figure 4 ).…”

Anti-vascular endothelial growth factor therapies in ophthalmology

“…Given VEGF’s pivotal role in promoting angiogenesis and fibroblast activation, intravitreal administration of anti-VEGF agents has been suggested as an adjunctive treatment for neovascular glaucoma [ 139 ]. Preoperative use has been associated with rapid regression of neovessels in the iris and angle, leading to reduced intraoperative bleeding, a lower incidence of postoperative hyphemia and fibrovascular occlusion of the drainage tube, and improved surgical outcomes with the Ahmed Glaucoma Valve [ 140 ] ( Figure 4 ).…”

Comparison of the effectiveness of ranibizumab monotherapy vs. combined panretinal photocoagulation on the regression of neovascularization in proliferative diabetic retinopathy

“…This can be plausibly explained by the mechanism of action. Anti-VEGF agents cause rapid contraction and involution of neovascular fronds but may not always lead to complete fibrosis and obliteration of the vascular channel ( 24 , 25 ). If treatment intervals are extended or if there is a rebound in VEGF levels, these fragile vessels may recanalize and bleed ( 26 , 27 ).…”

Intravitreal ranibizumab as an adjunct to conventional surgery for neovascular glaucoma: a retrospective observational study of efficacy and clinical characteristics of surgical failure cases

“…The anti-VEGF agent (Lucentis ® , 10 mg/ml, Novartis) was administered intravitreally one week preoperatively ( Liu et al., 2016 ). This interval was selected based on previous studies demonstrating significant regression of iris neovascularization within 5–7 days after ranibizumab injection, which creates favorable conditions for subsequent surgery ( Lüke et al., 2013 ; Gao et al., 2023 ). A one-week interval also allowed sufficient time for clinical reassessment of NVI regression and surgical planning.…”

Anti-vascular endothelial growth factor therapies in ophthalmology

“…Given VEGF’s pivotal role in promoting angiogenesis and fibroblast activation, intravitreal administration of anti-VEGF agents has been suggested as an adjunctive treatment for neovascular glaucoma [ 139 ]. Preoperative use has been associated with rapid regression of neovessels in the iris and angle, leading to reduced intraoperative bleeding, a lower incidence of postoperative hyphemia and fibrovascular occlusion of the drainage tube, and improved surgical outcomes with the Ahmed Glaucoma Valve [ 140 ] ( Figure 4 ).…”

Comparison of the effectiveness of ranibizumab monotherapy vs. combined panretinal photocoagulation on the regression of neovascularization in proliferative diabetic retinopathy

“…This can be plausibly explained by the mechanism of action. Anti-VEGF agents cause rapid contraction and involution of neovascular fronds but may not always lead to complete fibrosis and obliteration of the vascular channel ( 24 , 25 ). If treatment intervals are extended or if there is a rebound in VEGF levels, these fragile vessels may recanalize and bleed ( 26 , 27 ).…”

Intravitreal ranibizumab as an adjunct to conventional surgery for neovascular glaucoma: a retrospective observational study of efficacy and clinical characteristics of surgical failure cases

“…The anti-VEGF agent (Lucentis ® , 10 mg/ml, Novartis) was administered intravitreally one week preoperatively ( Liu et al., 2016 ). This interval was selected based on previous studies demonstrating significant regression of iris neovascularization within 5–7 days after ranibizumab injection, which creates favorable conditions for subsequent surgery ( Lüke et al., 2013 ; Gao et al., 2023 ). A one-week interval also allowed sufficient time for clinical reassessment of NVI regression and surgical planning.…”

Anti-vascular endothelial growth factor therapies in ophthalmology

“…Given VEGF’s pivotal role in promoting angiogenesis and fibroblast activation, intravitreal administration of anti-VEGF agents has been suggested as an adjunctive treatment for neovascular glaucoma [ 139 ]. Preoperative use has been associated with rapid regression of neovessels in the iris and angle, leading to reduced intraoperative bleeding, a lower incidence of postoperative hyphemia and fibrovascular occlusion of the drainage tube, and improved surgical outcomes with the Ahmed Glaucoma Valve [ 140 ] ( Figure 4 ).…”

Comparison of the effectiveness of ranibizumab monotherapy vs. combined panretinal photocoagulation on the regression of neovascularization in proliferative diabetic retinopathy

“…This can be plausibly explained by the mechanism of action. Anti-VEGF agents cause rapid contraction and involution of neovascular fronds but may not always lead to complete fibrosis and obliteration of the vascular channel ( 24 , 25 ). If treatment intervals are extended or if there is a rebound in VEGF levels, these fragile vessels may recanalize and bleed ( 26 , 27 ).…”

Intravitreal ranibizumab as an adjunct to conventional surgery for neovascular glaucoma: a retrospective observational study of efficacy and clinical characteristics of surgical failure cases

“…The anti-VEGF agent (Lucentis ® , 10 mg/ml, Novartis) was administered intravitreally one week preoperatively ( Liu et al., 2016 ). This interval was selected based on previous studies demonstrating significant regression of iris neovascularization within 5–7 days after ranibizumab injection, which creates favorable conditions for subsequent surgery ( Lüke et al., 2013 ; Gao et al., 2023 ). A one-week interval also allowed sufficient time for clinical reassessment of NVI regression and surgical planning.…”