Neovascular Glaucoma

(NVG)
Saleh A. Al-Obeidan, MD
Department of Ophthalmology
College of Medicine
King Saud University

Neovascular Glaucoma
(NVG)
Neovascular Glaucoma is one of the most
Challenging forms of secondary glaucomas. It
occurs when the fibrovascular tissue proliferates
onto the chamber angle, obstructs the trabecular
meshwork, and produces peripheral anterior
synechiae and progressive angle closure. The
elevated intraocular pressure is often difficult to
control and frequently results in loss of vision.

NVG
1871

Pagenstetcher Hemorrhagic

1963

Weiss, et al.

NVG

NVG
Pathogenesis
Leading causes:
Retinal Ischemia Responsible for 97%

- Diabetic Retinopathy
- Central Retinal Vein Occlusion
Brown GC et al. Ophthalmology 1984

NVG
Pathogenesis
X-Factor
VEGF

- Vascular Endothelial Growth Factor

1 of 9 non polypeptide growth factors
Specific for endothelial cells (EC)
Causes EC migration and mitosis
Increases EC permeability

NVG
Pathogenesis
VEGF

(source in the eye)

Expressed and produced by: Corneal

endothelium, Iris pigment epithelium,
RPE, Ganglion cells, Astrocytes,
Muller cells, Uveal melanocyte, and
Choroidal fibroblasts.
J Glaucoma 2002

NVG
Pathogenesis
VEGF

Markedly elevated in aqueous

humor of patients with NVG.
Diabetes Care Nov. 1996
Ophthalmology 1998
J Glaucoma 2002

NVG
Pathogenesis

VEGF

(210 Vitrectomy samples)

- Vitreous (VEGF) PDR 36x NPDR

- Vitreous (VEGF) > Aqueous (VEGF)
- (VEGF) 75% post PRP

VEGF plays a major part in mediating

active intraocular neovascularization in
patients with ischemic retinal diseases.
N Engl J Med 1994;331:1480-7

NVG
Pathogenesis
Anti Angiogenic Therapy:
Intravitreal injection of crystalline
cortisone causes regression of iris
neovascularization
Jonas et al. J Glaucoma 2001

NVG
Pathogenesis
Anti-Angiogenic Therapy:
Anti VEGF (Ranibizumab, Lucentis)
Intravitreal injection prevented
formation of CNV in monkeys and
decreased leakage of already
formed
CNV with no significant
toxic effects
Arch Ophthalmol 2002
Kim, et al. Invest Ophthalmol. Vis Sci 2006

NVG
Pathogenesis
Anti Angiogenic Therapy:
Anti VEGF [SU 5416 (Semaxinib)]
Durable and rapid recovery of
visual functions in a patient with
von
Hippel-Lindau syndrome
Ophthalmology, Feb 2002
J Clin Oncol. May 2005

NVG
Pathogenesis
Anti Angiogenic Therapy:
Anti VEGF [Aptamer (Macugen)]
Remarkable reduction in the size of
CNV
Remarkable visual improvement
26.7% gained 3 lines or more
The Eye Tech Study Group, Retina 2002
Exp Eye Res. May 2006
Ophthalmology. Apr 2006

NVG
Pathogenesis
Anti Angiogenic Therapy:

Bevacizumab [Avastatin]
Davidorf, et al. Retina 2006
Kehook, et al. Ophtha Surg 2006

NVG
Pathogenesis
Panretinal Photocoagulation and Ocular
Neovascularization
PRP upregulate expression of
transforming growth factor-
(TGF)
TGF- is a powerful vascular
endothelial cell proliferation inhibitor.
Invest Ophthalmol Vis Sci 1998

NVG
Pathogenesis
Panretinal Photocoagulation and
Ocular Neovascularization
Photo coagulated cultured human
RPE & rat retinas upregulate expression of
high level of Pigment Epithelium
Derived Factor (PEDF)
PEDF has been shown to be a potent
inhibitor of ocular angiogenesis
Am J Ophthalmol, Sep 2001
Am J Ophthalmol Aug 2002
Invest Ophthalmol Vis Sci 2002

NVG
Pathogenesis
Panretinal Photocoagulation and
Ocular Neovascularization
Major benefit of PRP may be
destruction of VEGF source.

NVG
Clinical Presentation

Reduced vision
Injected eye
A/C reaction
Elevated IOP < 40 mmHg
Middilated, non reactive pupil
Rubeosis irides (NVI)
Neovascularization of the angle (NVA)

NVG
Enucleation

is only practical treatment

Duke Elder, 1969

No

means are known to prevent NVG

Grant, 1974

The

treatment of NVG is disheartening

Hoskins, 1974

NVG
Outcomes

have improved
dramatically.

New

medical and surgical

approaches.

Better

understanding and
control of angiogenesis.

NVG
If the neovascular element can be
removed and further neovascularisation
prevented, then we are left with an
uncomplicated angle-closure problem
which should be amenable to classical
drainage surgery.
Flanagan D.W. & Blach R.K.
Br J. Ophtamol 1983;67,526-8

NVG
Management

Recognition of patients at HIGH RISK

Recognition of NVI before angle

closure is critical

Treatment

NVG
Management
Prevention:

Recognition high risk patients

Correction of the underlying pathology
Close observation (NVI & NVA)
Efficient & sufficient PRP

Treatment

NVG
Treatment
Determinants

Visual potential

Clarity of the media

NVG
Treatment (cont.)
Medical Therapy

Control inflammation & pain

Cycloplegia
Steroids

NVG
Treatment (cont.)
Medical Therapy

Control IOP
Aqueous suppressants
Avoid miotics & prostaglandines

NVG
Treatment (cont.)
Laser Therapy

Panretinal photocoagulation (PRP)

1st line of therapy (if possible)
Reduces & can eliminate
ant. seg. neovascularization.

Cryo Therapy

Panretinal cryoablation

NVG
Treatment (cont.)
Conventional Surgery

Filteration surgery

Tube surgery

Cyclodystructive procedures

Others

NVG

Treatment
Cyclodestructive procedures:
High rate of serious complications and visual loss

Cyclophotocoagulation
Visual loss up to 46.6%
Shields & Shields 1994

Cyclocryotherapy
Visual loss of up to 70%
Caprioli et al. Ophthalmology 1985

Phthisis Bulbi 34%

Krupin T et al. Am J Ophthalmol 1978;86:24-6

NVG
Treatment
Tube shunts:

Variable success rates

Probably more suitable
for previously operated
eyes (e.g. failed filter
proced. Aphakia)
High rate of visual loss
(19-48%) and phthisis
bulbi (11-25%)
Mermoud et al. Ophthalmology 1993

NVG
Treatment (cont.)

Filteration surgery

Full PRP Improves the Outcome

of Trabeculectomy in NVG
Surgical Technique
Procedure - Standard Trabeculectomy
- Mitomycin C 0.2mg/ml/2mins.
Precautions - Gradual decompression
of the eye

Full PRP Improves the Outcome

of Trabeculectomy in NVG
Short Term Complications:
- Transient hypotony - 14/23
- Hyphema - 8/23
- Choroidal Detachment - 2/23
- Leaking Bleb - 1/23
Long Term Complications:
- Cataract prog. 2/23
- NLP
- Hypotony Maculopathy
Non
- Phthisis Bulbi

(61%)
(35%)
(9%)
(4%)
(9%)

Full PRP Improves the Outcome

of Trabeculectomy in NVG
Results
Complete Success

20/23

(87%)

Qualified Success

3/23

(13%)

Treatment
NVG
NLP

Seeing eye

- Medical Rx
Clear
media PRP

Poor media
Cryoablation

Vitreous hge
Vitrectomy+
endolaser

Trabeculectomy & Mitomycin

Tube shunts
cyclophotocoagulation

- Cyclodestructive
procedure

NVG
Points to Remember

It is a preventable condition.

NVG
Points to Remember

It is a treatable condition.