Early Vitrectomy Combined with Pan Retinal Photocoagulation, Anti-Vascular Endothelial Growth Factor, and Gradual Cyclophotocoagulation for Treatment of Neovascular Glaucoma
Neovascular glaucoma (NVG) is a severe and refractory form of glaucoma characterized by the development of neovascularization on the iris or in the anterior chamber angle. This condition often leads to a dramatic elevation in intraocular pressure (IOP) and can result in significant vision loss. Managing NVG is challenging due to its complex pathophysiology and the difficulty in controlling IOP and preventing further vision loss. This article presents a comprehensive treatment protocol that combines early vitrectomy, pan retinal photocoagulation (PRP), anti-vascular endothelial growth factor (VEGF) therapy, and gradual cyclophotocoagulation to manage NVG effectively.
The study was conducted as a prospective interventional case series at the China-Japan Friendship Hospital in Beijing, China. A total of 46 patients (52 eyes) were enrolled from January 2013 to December 2017, with a follow-up period of at least six months. The inclusion criteria for the study were: 1) IOP ≥ 21 mmHg, 2) observed neovascularization on the iris or anterior chamber angle, and 3) NVG caused by retinal ischemic diseases. Patients with severe systemic diseases that precluded surgery or those who had previously undergone anti-glaucoma surgeries were excluded from the study.
The treatment protocol aimed to achieve several key objectives: immediate control of IOP, completion of PRP as soon as possible, use of anti-VEGF as an adjuvant therapy, and management of residual glaucoma through gradual cyclophotocoagulation. The treatment schedule was designed to address the specific challenges associated with NVG, such as corneal edema, hyphema, and vitreous hemorrhage, which often hinder the early completion of PRP.
To lower IOP as quickly as possible, paracentesis was performed in patients with IOP higher than 40 mmHg. For patients with severe corneal edema, hyphema, cataract, or vitreous hemorrhage, a 25-gauge vitrectomy was performed. During the vitrectomy, PRP was completed using a wide-angle viewing system. Intravitreal injection of bevacizumab (Avastin, Roche, Switzerland) was administered in two scenarios: 1) at the end of vitrectomy when PRP could not be completed due to dense retinal hemorrhage, and 2) when neovascularization on the iris or anterior chamber angle recurred after complete PRP.
Transscleral cyclophotocoagulation (TCP) was performed if IOP remained higher than 30 mmHg despite medication. To prevent hypotony, TCP was conducted in a gradual manner, with the upper temporal quadrant of the ciliary body always reserved. Repeated TCPs were spaced at least one month apart.
The results of the study demonstrated significant improvements in IOP control and visual acuity. The mean IOP at the last follow-up was 15.41 ± 3.74 mmHg, significantly lower than the pre-treatment mean IOP of 39.67 ± 10.47 mmHg. IOP was reduced in all patients, with 48 eyes (92%) achieving an IOP lower than 21 mmHg. In 45 eyes (87%), IOP was controlled without the need for medication. Visual acuity improved in 32 eyes (62%), with 19 eyes (37%) achieving a best-corrected visual acuity (BCVA) of 0.1 or better. BCVA remained unchanged in 17 eyes (33%) and decreased in three eyes (6%), all of which had NVG secondary to proliferative diabetic retinopathy (PDR).
Logistic regression analysis identified several prognostic factors for final visual acuity. Eyes with better visual acuity at diagnosis, those that received more anti-VEGF injections, and those that did not require cyclophotocoagulation had a better prognosis for final visual acuity. The main complications associated with TCP included postoperative pain, transient IOP elevation, and hyphema. Transient IOP elevation typically occurred within the first three days post-surgery, and hyphema resolved within one week in all affected patients. Hypotony developed in three patients around one to two weeks after TCP, but IOP gradually recovered during follow-up.
The study concluded that the comprehensive treatment protocol was effective in controlling IOP and improving visual acuity in the majority of patients with NVG. However, the management of NVG remains challenging due to the potential for recurrence of retinal ischemia, necessitating close follow-up and monitoring of patients.
In summary, the combination of early vitrectomy, PRP, anti-VEGF therapy, and gradual cyclophotocoagulation offers a promising approach to managing NVG. This protocol addresses the immediate need for IOP control, ensures the timely completion of PRP, and provides a long-term strategy for managing residual glaucoma. The results of this study highlight the importance of a multifaceted treatment approach in improving outcomes for patients with this complex and challenging condition.
doi.org/10.1097/CM9.0000000000000482
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