Eyeworld

62 | EYEWORLD | SEPTEMBER 2023 G UCOMA References 1. Vancea PP, Abu-Taleb A. Current trends in neovascular glaucoma treatment. Rev Med Chir Soc Med Nat Iasi. 2005;109:264–268. 2. Aboobakar IF, Lin MM. Clinical diagnosis of neovascular glauco- ma in the ophthalmology office. In: Qiu, M. (eds) Neovascular Glaucoma. Essentials in Ophthal- mology. 2022. 3. Kanter J, et al. Gonioscopy-as- sisted transluminal trabeculot- omy in neovascular glaucoma: Salvaging the conventional out- flow pathway. Am J Ophthalmol Case Rep. 2022;28:101668. 4. Viruni N, Cai CX. Anti-vascular endothelial growth factor for neovascular glaucoma. In: Qiu, M. (eds) Neovascular Glaucoma. Essentials in Ophthalmology. 2022. 5. Grisanti S, et al. Intracameral bevacizumab for iris rubeosis. Am J Ophthalmol. 2006;142:158– 160. 6. Olmos LC, et al. Long-term outcomes of neovascular glau- coma treated with and without intravitreal bevacizumab. Eye (Lond). 2016;30:463–472. 7. Qiu M, et al. Improving outcomes in neovascular glau- coma. Ophthalmol Glaucoma. 2022;5:125–127. shunt with a 3-0 Prolene ripcord to prevent ear- ly and late hypotony." There are many different ways to approach surgical management of eyes with NVG, Dr. Qiu said, and we need more data to learn which way results in the best patient outcomes. Dr. Sun stressed that addressing the un- derlying disease requires working with retinal colleagues. "These patients generally need anti-VEGF injections and/or panretinal photoco- agulation (PRP), depending on the underlying condition," she said. "They may need systemic work-up and control of their systemic disease, too." For NVG, immediate anti-VEGF injection at the time of presentation is often helpful to save any portion of the angle that is still open because anti-VEGF injections work faster than PRP to regress neovascularization. Dr. Wang said that patients with NVG require a multidisciplinary treatment approach. Patients must be followed closely from the retina perspective to treat the underlying retinal pathology causing the ischemia and neovascu- larization. This includes a combination of intrav- itreal anti-VEGF injections to rapidly regress the neovascularization, as well as PRP to address the ischemia more permanently, she said. Simultaneously, patients require prompt and close follow-up with a glaucoma specialist to normalize the IOP. "How this is achieved de- pends largely on the angle anatomy at presen- tation. In patients with completely open or even partially open angles, the IOP responds fairly well to medical therapy. This means that topical IOP-lowering medications and/or oral carbonic anhydrase inhibitors can be used first, providing some leeway and time for anti-VEGF agents to regress the active neovascularization so that surgery can be performed in a more controlled context with a lower bleeding risk." Since the angle is still fully or partially open, Dr. Qiu and Dr. Wang suggest that per- forming an angle surgery to restore the con- ventional outflow pathway can be considered. There are treatment protocols being piloted that may allow this to be successful, Dr. Qiu said. In patients with completely closed angles, the IOP doesn't decrease appreciably with medical ther- apy or correlate with the regression of active neovascularization following anti-VEGF therapy. "Patients in this category will require surgical intervention, but in an eye with active anterior segment neovascularization, risk of bleeding- associated complications remain high," she said. One strategy that can rapidly lower the IOP while also allowing the neovascularization to regress before performing incisional surgery is to implement a staged approach consisting of prompt gentle cyclophotocoagulation to rapidly normalize the IOP and prevent ongoing glauco- matous optic neuropathy, followed by implan- tation of a tube shunt at a later date, if needed, once the eye is quiescent. How does MIGS fit into the treatment paradigm? There was a case report in a patient with a partially open angle who successfully under- went gonioscopy-assisted transluminal trabec- ulotomy (GATT) to restore aqueous outflow from her conventional outflow pathway, 3 but more research is needed in this area, Dr. Qiu said. "The rationale for possible angle surgery in the earlier stages of NVG is that the trabecular meshwork is at least partially open without ex- tensive peripheral anterior synechiae. Since fi- brovascular proliferation and tissue contraction has not yet completely blocked the angle, the angle can still be potentially salvaged by cutting through the fibrovascular membrane that is blocking the trabecular meshwork and restoring aqueous outflow. However, if there are active anterior segment neovessels, angle surgery is not advised because the rate of bleeding-associ- ated complications is very high. We recommend anti-VEGF injections to regress the neovessels first, and angle surgery should only be consid- ered in eyes that have quiescent disease with no active anterior segment neovessels." She added that the underlying disease pro- cess needs to be aggressively treated by the reti- na team to prevent the neovessels from return- ing, which can be challenging. These patients need to understand that if GATT fails, they will need a subsequent, more definitive surgery, such as an aqueous shunt to control the IOP. MIGS may be an option for patients with neovascular glaucoma with completely or par- tially open angles, Dr. Wang said. Rather than "giving up" on the conventional outflow path- way when the angle is still functioning, glauco- ma specialists can utilize MIGS to restore the conventional outflow pathway. Dr. Wang noted GATT as a potential option because it requires access to only a small portion of the angle in order to access Schlemm's canal but can then continued from page 61

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