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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

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Neovascular Glaucoma (NVG)


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neovascular glaucoma nvg

Neovascular Glaucoma(NVG)

Saleh A. Al-Obeidan, MD

Department of Ophthalmology

College of Medicine

King Saud University

neovascular glaucoma nvg2
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 pathogenesis
NVG Pathogenesis

Leading causes:

  • Retinal Ischemia Responsible for 97%

- Diabetic Retinopathy

- Central Retinal Vein Occlusion

Brown GC et al. Ophthalmology 1984

nvg pathogenesis6
NVGPathogenesis
  • 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 pathogenesis7
NVGPathogenesis
  • 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 pathogenesis8
NVGPathogenesis
  • VEGF

Markedly elevated in aqueous humor of patients with NVG.

Diabetes Care Nov. 1996

Ophthalmology 1998

J Glaucoma 2002

nvg pathogenesis9
NVGPathogenesis
  • 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 pathogenesis10
NVGPathogenesis

Anti Angiogenic Therapy:

Intravitreal injection of crystalline cortisone causes regression of iris neovascularization

Jonas et al. J Glaucoma 2001

nvg pathogenesis11
NVGPathogenesis

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 pathogenesis12
NVGPathogenesis

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 pathogenesis13
NVGPathogenesis

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 pathogenesis14
NVGPathogenesis

Anti Angiogenic Therapy:

Bevacizumab [Avastatin]

Davidorf, et al. Retina 2006

Kehook, et al. Ophtha Surg 2006

nvg pathogenesis15
NVGPathogenesis

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 pathogenesis16
NVGPathogenesis

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 pathogenesis17
NVGPathogenesis

Panretinal Photocoagulation and

Ocular Neovascularization

Major benefit of PRP may be destruction of VEGF source.

slide18

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)
slide19
NVG
  • Enucleation is only practical treatment
  • No means are known to prevent NVG
  • The treatment of NVG is disheartening

Duke Elder, 1969

Grant, 1974

Hoskins, 1974

slide20
NVG
  • Outcomes have improved dramatically.
  • New medical and surgical approaches.
  • Better understanding and control of angiogenesis.
slide21
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

slide22

NVG

Management

  • Recognition of patients at HIGH RISK
  • Recognition of NVI before angle closure is critical
  • Treatment
slide23

NVG

Management

  • Recognition high risk patients
    • Correction of the underlying pathology
    • Close observation (NVI & NVA)
    • Efficient & sufficient PRP
  • Prevention:
  • Treatment
slide24

NVG

Treatment

  • Visual potential
  • Clarity of the media

Determinants

slide25

NVG

Treatment (cont.)

  • Control inflammation & pain
    • Cycloplegia
    • Steroids

Medical Therapy

slide26

NVG

Treatment (cont.)

  • Control IOP
    • Aqueous suppressants
    • Avoid miotics & prostaglandines

Medical Therapy

slide27

NVG

Treatment (cont.)

  • Panretinal photocoagulation (PRP)
    • 1st line of therapy (if possible)
    • Reduces & can eliminate ant. seg. neovascularization.
  • Panretinal cryoablation

Laser Therapy

Cryo Therapy

slide28

NVG

Treatment (cont.)

  • Filteration surgery
  • Tube surgery
  • Cyclodystructive procedures
  • Others

Conventional Surgery

nvg treatment
NVGTreatment

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 treatment30
NVGTreatment

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

slide31

NVG

Treatment (cont.)

  • Filteration surgery
full prp improves the outcome of trabeculectomy in nvg
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 nvg33
Full PRP Improves the Outcome of Trabeculectomy in NVG
  • Short Term Complications:
      • - Transient hypotony - 14/23 (61%)
      • - Hyphema - 8/23 (35%)
      • - Choroidal Detachment - 2/23 (9%)
      • - Leaking Bleb - 1/23 (4%)
  • Long Term Complications:
    • - Cataract prog. – 2/23 (9%)
    • - NLP
    • - Hypotony Maculopathy Non
    • - Phthisis Bulbi
full prp improves the outcome of trabeculectomy in nvg34
Full PRP Improves the Outcome of Trabeculectomy in NVG

Results

Complete Success 20/23 (87%)

Qualified Success 3/23 (13%)

treatment
Treatment

NVG

NLP

- Medical Rx - Cyclodestructive procedure

Seeing eye

Vitreous hge Vitrectomy+ endolaser

Clear media PRP

Poor media Cryoablation

Trabeculectomy & Mitomycin

Not suitable for trab.

Tube shunts cyclophotocoagulation

nvg points to remember
NVGPoints to Remember

It is a preventable condition.

nvg points to remember37
NVGPoints to Remember

It is a treatable condition.