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Neovascular glaucoma.

Neovascular glaucoma is a severe eye disorder classified as a secondary glaucoma and the most common of this type of disease. It is caused by a number of ocular and systemic conditions, which share the common element of retinal ischemia/hypoxia that initiates the subsequent release of angiogenesis factors. The most common causes of neovascular glaucoma are diabetic retinopathy and the occlusion of central retinal vein, of carotid artery, and of central retinal artery. More rarely, neovascular glaucoma can be secondary to eye tumors, traumas and uveitis. The present article reviews the stages of angiogenesis, forms of neovascularization and the clinical stages of the disease. Differential diagnosis is made and modern treatment of neovascular glaucoma is reviewed: treatment of iris neovascularisation, of extensive neovascular glaucoma and of end-stage neovascular glaucoma. Being a disease with poor prognosis, neovascular glaucoma should be well known not only by ophthalmologists but also by general practitioners, endocrinologists, neurologists, rheumatologist, and cardiologists. Only a timely diagnosis and adequate treatment can assure patients that they will preserve their vision and/or eye for a longer time.

Diagnosis, Differential↗

[Consensus on neovascular glaucoma].

Neovascular glaucoma is a dreadful pathology with a rapid spontaneous evolution responsible for painful and blind eye. The main cause is an anterior neovascular proliferation following a broad retinal ischemia. Early diagnosis and treatment are required in order to maintain a good visual status and a satisfactory IOP control with medical, surgical or cylodestructive procedures. In any case, the treatment of the retinal ischemia has to be performed. One must keep in mind that the most efficient way to avoid the incidence of neovascular glaucoma is a strict control of clinical situations potentially responsible for retinal ischemia, namely VRO in elderly patients and diabetic retinopathy in younger patients.

Adult↗

[Cyclocryocoagulation in treatment of neovascular glaucoma].

Neovascular glaucoma (NVG) is a pathological condition of the eye with fast deterioration, accompanied with eyeball pain and loosing sight. The aim of the study was to examine the efficacy of cryotherapy in the treatment of NVG which is resistant to medical and surgical therapy, concerning intraocular pressure (IOT) and eyeball pain immediately after the treatment and 6 months after. In the Department of Ophthalmology, Split University Scool of Medicine, during three years 70 patients with NVG, which were resistant to medical and surgical treatment, were included in the prospective study. There were 50 males and 21 women, average age 74 +/- 6.94 (45-87). The patients were treated with transconjuctival cyclocryocoagulation, machine ERBOKRYIO AE-ERBE was used. The average value of IOT was: at admission 44.8 mmHg, 7 days after the treatment 30.7 mmHg with the tendency of falling down 30 and 90 days later, to finally 19.9 mmHg 180 days after the treatment. The IOT was significantly lower after the treatment. At admission, the average value of eyeball pain intensity was high (4.2), 7 days after the treatment it was 2.1 with the tendency of falling down to finally 1.1 180 days after the treatment. The eyeball pain intensity was significantly lower after the treatment. Cyclocryocoagulation is a method of choice in the treatment of NVG resistant to medical and surgical treatment. Cyclocryocoagulation, as a treatment of noncontrolled progressive NVG, does not have any effect on the improvement of sight in these patient.

Aged↗

[Cyclocryotherapy in neovascular glaucoma and non-neovascular glaucoma].

BACKGROUND: There are conflicting reports on the value of cyclocryotherapy and it seems that the success rate is depending on glaucoma conditions, the period of follow-up and the technique. This retrospective study was carried out to assess the efficacy and complication rate of cyclocryosurgery for advanced glaucoma with and without neovascularization. PATIENTS AND METHODS: We induced 76 eyes of 75 patients with inadequately controlled glaucoma, which underwent cyclocryotherapy during the period of 1993 and 1996 (treatment time 60 seconds with -80 degrees C, 6-12 applications (mean 9.8 +/- 2.3), 180-360 degree (median 270 degree), diameter of the probe tip 2.5 mm, 1-2 mm distance from the limbus). Depending on the etiology we distinguished between neovascular (NVG) and non-neovascular glaucoma (nNVG). Pre- and postoperative data from all patients were studied retrospectively, for follow-up after 12-36 months patients were examined. RESULTS: Intraocular pressure (IOP) decreased in all patients from 44.7 +/- 12.6 mm Hg preoperatively to 15.6 +/- 6.5 mm Hg postoperatively after a follow-up of 12-36 months. In 88.2% IOP was lowered to < or = 25 mm Hg. NVG showed a mean IOP reduction from 49.1 +/- 12.5 mm Hg before cyclocryotherapy to 15.6 +/- 5.0 mm Hg at follow-up. In the nNVG group IOP was 40.5 +/- 11.3 mm Hg and 15.7 +/- 7.6 mm Hg after cyclocryotherapy. Pressure was controlled (< or = 25 mm Hg) for 83.8% of NVG and 92.3% of nNVG. A cyclocryotherapy-induced intense inflammation was seen more frequent in NVG (43.2%) than in nNVG (17.9%). 2 patients with NVG and 3 with nNVG developed phthisis postoperatively (total 6.7%). CONCLUSIONS: Cyclocryosurgery is an effective method to reduce IOP in advanced, refractory glaucoma, when other methods have failed. The risk/success rate seems to be acceptable.

Aged↗

[Current trends in neovascular glaucoma treatment].

Neovascular glaucoma is divided in three clinical stages: rubeosis iridis, secondary open-angle glaucoma, and synechia of the angle-closure glaucoma. 36% of neovascular glaucomas occurs after central retinal vein occlusion, 32% after diabetic proliferative retinopathy, and 13% occurs after carotid artery obstructive. The key of success in the treatment of neovascular glaucoma is the early and rightly diagnosis, the treatment is aimed mainly at relieving pain, as the prognosis for maintaining visual function is extremely poor. The most important surgical procedures are trabeculectomy, artificial drainage shunts and cyclo-distraction by trans-scleral diode laser. This essay presents a synthesis of modern principle data concerning neovascular glaucoma.

Antimetabolites↗

[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.

Carotid Stenosis↗

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.

Journal Article↗

[Vitreoretinal surgery in the treatment of neovascular glaucoma].

PURPOSE: Neovascular glaucoma develops on a background of ischemic ocular pathologies, such as diabetic eye diseases or central retinal vein occlusion. Development of neovascular membranes in the chamber angle leads to elevated intraocular pressure. Since treatment by cyclodestructive therapy or drainage surgery often fails, we have examined intense antiproliferative surgery as a treatment for advanced neovascular glaucoma. PATIENTS AND METHODS: Thirty-two patients with neovascular glaucoma subsequent to central vein occlusion or advanced diabetic retinopathy underwent antiproliferative surgery, which comprised vitrectomy, panretinal laser treatment and direct laser coagulation of the ciliary processes, followed by silicone oil tamponade. Patients were followed for a minimum of 1 year and as long as 3 years. RESULTS: After one week following surgery the intraocular pressure (IOP) was normal, ranging from 8 to 21 mm#Hg, in 52% (15/29 eyes), after 3 months the IOP was normal in 50% (16/32 eyes), after 6 months the IOP was normal in 59% (16/27 eyes) and after 1 year the IOP was normal in 72% (18/25 eyes). Of the 10 eyes that lost all sight after the surgery, 7 eyes had a history of central vein occlusion. Hypotony was observed in 6% (2/32) of the eyes 3 months following surgery; after 6 months hypotony was present in 15% (4/27) of the eyes and after 1 year hypotony was present in 12% (3/25) of the eyes. CONCLUSIONS: The theoretical premise of our surgical intervention (antiproliferative surgery) is based on the assumption that laser treatment interrupts the self enhancing pathway of retinal ischemia, release of proliferative factors and increase in intraocular pressure. The silicone oil endotamponade prevents postoperative complications and supports the rapid regression of rubeosis iridis by separating the anterior from the posterior segment.

Aged↗

Pars plana vitrectomy, endolaser coagulation of the retina and the ciliary body combined with silicone oil endotamponade in the treatment of uncontrolled neovascular glaucoma.

PURPOSE: Neovascular glaucoma develops on a background of ischemic ocular pathologies, such as diabetic eye diseases or central retinal vein occlusion. Development of neovascular membranes in the chamber angle leads to elevated intraocular pressure (IOP). Since cyclodestructive therapy or drainage surgery often fails, we have examined intense antiproliferative surgery as a treatment for advanced neovascular glaucoma. PATIENTS AND METHODS: Thirty-two patients with uncontrolled neovascular glaucoma (mean IOP 45.5 mmHg) subsequent to central retinal vein occlusion or advanced diabetic retinopathy underwent antiproliferative surgery, which comprised pars plana vitrectomy, panretinal laser treatment and direct laser coagulation of the ciliary processes, followed by silicone oil tamponade. Patients were followed up for a minimum of 1 year and as long as 3 years. RESULTS: One week following surgery the IOP was normal, ranging from 8 to 21 mmHg, in 52% of eyes (15/29). After 3 months the IOP was normal in 50% (16/32); after 6 months, in 59% (16/27); and after 1 year, in 72% (18/25). Of the 10 eyes that lost all sight after the surgery, 7 eyes had a history of central retinal vein occlusion. Hypotony was observed in 6% of the eyes (2/32) 3 months after surgery; after 6 months hypotony was present in 15% (4/27), and after 1 year hypotony was present in 12% (3/25). CONCLUSIONS: The theoretical premise of our surgical intervention (antiproliferative surgery) is that laser treatment interrupts the self-enhancing pathway of retinal ischemia, release of proliferative factors and increase in intraocular pressure. The silicone oil endotamponade prevents postoperative complications and supports the rapid regression of rubeosis iridis by separating the anterior from the posterior segment.

Aged↗

Experience with the Baerveldt glaucoma implant in treating neovascular glaucoma.

PURPOSE: The authors present a retrospective study designed to assess the effectiveness of the Baerveldt glaucoma implant in controlling intraocular pressure (IOP) and maintaining visual function in eyes with neovascular glaucoma. METHODS: The medical records of all 36 patients (36 eyes) who underwent Baerveldt glaucoma implantation for medically uncontrolled neovascular glaucoma between February 1991 and December 1992 were reviewed. RESULTS: Eighteen patients received Model 350 implants, 16 received Model 500 implants, and 2 received Model 200 implants. The 12- and 18-month life-table success rates (success defined as 6 mmHg < or = final IOP < or = 21 mmHg without additional glaucoma surgery or devastating complication) were 79% and 56%, respectively. Visual acuity remained stable or improved in 10 (31%) patients. Postoperative complications included flat anterior chamber, serous choroidal detachment, and obstruction of the proximal tube tip with fibrovascular tissue, each of which occurred in four (11%) patients. Eleven (31%) patients lost light perception. There were no significant differences between the groups receiving the Model 350 and Model 500 implants with respect to life-table success rates, percentage of postoperative IOP reduction, or complication rates. Patients in the Model 500 implant group required significantly fewer antiglaucoma medications post-operatively, but also demonstrated a significantly greater mean visual acuity reduction. Better preoperative visual acuity and increased patient age were positively correlated with a successful outcome. CONCLUSIONS: Baerveldt implantation is effective in controlling IOP elevation associated with neovascular glaucoma. Postoperative visual loss, despite adequate IOP control, is common. Young patient age and poorer preoperative visual acuity are significant predictors of surgical failure.

Adult↗

Clinical experience in the management of neovascular glaucoma.

BACKGROUND: Neovascular glaucoma (NVG) is a devastating ocular disease with poor prognosis. The ideal surgical procedure has yet to be determined. In this study, the clinical course and visual outcome of NVG and their fellow eyes were investigated and the most appropriate management was also evaluated. METHODS: The study was conducted retrospectively consisting of NVG in-patients of Taipei Veterans General Hospital who were under the care of the same glaucoma specialist between January, 1998 and September, 2000. All patients had a minimal follow-up period of 6 months. RESULTS: The total number of patients enrolled was 35 (number of eyes enrolled was 35) with mean age of 66.4 +/- 12.3 years. The underlying cause was diabetes mellitus in 29 patients and central retinal vein occlusion in 6 patients. Twelve (34.3%) eyes had initial intraocular pressure (IOP) of over 60 mmHg. Only 1 (2.9%) eye had initial visual acuity better than 6/60. Four lesion eyes were able to receive panretinal photocoagulation whereas 31 eyes received panretinal cryotherapy. For IOP reducing procedures, 15 eyes received trabeculectomy, and 16 received Diode trans-scleral cyclophotocoagulation (TSCP). At the final visit, 20 eyes (trabeculectomy group: 11 and Diode TSCP group: 9) were able to maintain an IOP < or = 21 mmHg. Of these eyes, 15 (trabeculectomy group: 8 and Diode TSCP group: 7) were able to maintain or improve their vision. Of the remaining 4 eyes, 2 had cyclocryotherapy and 2 had trabeculectomy followed by Diode TSCP. IOP were controlled in these 4 eyes but none were able to maintain stable vision. Among the 34 fellow eyes with stable IOP, 32 were able to maintain stable vision. CONCLUSIONS: Trabeculectomy and Diode TSCP provided no statistically significant difference in IOP control (p = 0.32) and visual outcome (p = 0.59) in our patient group. More randomized, prospective trials are needed to define the most effective treatment for NVG.

Adult↗

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.

Animals↗

Neovascular glaucoma. Current management.

Neovascular glaucoma is one the most difficult forms of glaucoma to treat successfully. Recent advances modifying filtration surgery can result in up to 77% success. Utilization of anterior and posterior segment photocoagulation can maintain an open angle in up to 80% of eyes when they are treated prior to angle closure by peripheral anterior synechiae. Destruction of the ciliary body can be performed more selectively utilizing argon and ruby lasers. This paper presents a rational approach to the management of neovascular glaucoma incorporating these recent advances.

Ciliary Body↗

The development and management of neovascular glaucoma.

Patients with neovascular glaucoma (NVG) often present with neovascularisation of the iris (NVI) already established and prompt energetic treatment of these patients is needed to reverse or stabilise the condition with possible retention of some visual function. In this series if the ocular media were still clear panretinal photocoagulation (PRP) caused regression of NVI in about 60% of cases and if a persistent rise in intraocular pressure (IOP) were still present this could be dealt with by drainage operation, Molteno implant or cyclophotocoagulation. If the media were already opaque or NVI did not regress then a Molteno implant or cyclophotocoagulation was used to reduce the IOP, preserving corneal endothelial function so that a comfortable eye could be obtained. Some regression of the NVI process was likely with time if the IOP were controlled by surgical treatment. Of 32 patients reviewed here, 20 patients developed NVG following a central retinal vein occlusion; in six patients NVG followed diabetic proliferative retinopathy, in five it followed arterial occlusion, and in one it followed an old traumatic retinal detachment. In those patients where NVG followed venous or arterial occlusion the common risk factors were always present. Patients were usually under treatment for their systemic condition but this treatment should be reviewed.

Adult↗

[Results of a survey on the occurrence of neovascular glaucoma after central retinal vein occlusion].

A prospective study, ten years long, has been conducted in 147 cases of retinal central vein occlusion without any photocoagulation treatment, in order to evaluate the frequency and the delay of occurrence of neovascular glaucoma. Neovascular glaucoma occurred in 28 cases (19%) occurrence rate of neovascular glaucoma increases in the first four years and then remains stable during the 10 years of observation. Connections between occurrence of neovascular glaucoma and initial association to ware hypertony of chronic glaucoma or to hypertony are discussed.

Glaucoma↗

Long-term results of Ahmed glaucoma valve and Molteno implant in neovascular glaucoma.

AIMS: To evaluate the surgical success results of Ahmed glaucoma valve (AGV) and Molteno single-plate implant (MSPI) in cases of neovascular glaucoma (NVG). METHODS: Between May 1997 and May 2002, 38 of 38 NVG patients that underwent implantation of AGV and 27 eyes of 27 NVG patients that underwent MSPI (a total 65 eyes of 65 patients) included to the study. RESULTS: The cumulative probabilities of success were 63.2% at 1 year, 56.2% at 2 years, 43.2% at 3 years, 37.8% at 4 years, and 25.2% at 5 years in AGV group whereas the cumulative probabilities of success were 37.0% at 1 year, 29.6% at 2 years, 29.6% at 3 years, 29.6% at 4 years, and 29.6% at 5 years in MSPI group (P=0.141). Preoperative visual acuity <2/200 (P=0.003), diagnosis of diabetes mellitius (P=0.050), and preoperative IOP>or=35 mmHg (P=0.038) were found to be poor prognostic factors for surgical success. CONCLUSIONS: Both AGV and single plate MSPI were successful for early and intermediate-term of IOP control but in long term both implants were failed to achieve control of IOP in patients with NVG.

Adolescent↗