Eyeworld

98 | EYEWORLD | SPRING 2024 G UCOMA Contact Schehlein: emschehlein@gmail.com Weng: Christina.Weng@bcm.edu being followed for their condition and suggests having a low threshold to directly reach out to the glaucoma specialist. "Research shows that higher frequency of intravitreal injections may impact the need for glaucoma medication use and glaucoma surgery. 6,15 Therefore, patients should routine- ly have their pressure checked whenever they present for an injection to monitor for IOP spikes and trends over time," she said. Glau- coma patients should also be monitored with OCT and visual field testing with a glaucoma specialist. Dr. Schehlein said that IOP spikes should be prevented in patients with advanced glaucoma- tous disease, especially as large IOP fluctuations in these cases may worsen disease. "In patients with advanced disease, we know that repeated IOP fluctuations may worsen glaucoma. 11,16 In an advanced glaucoma patient newly requir- ing IVI for neovascular AMD with demonstrated IOP spikes following injection, I am proactive in preventing progression," she said. "Sometimes this will mean adding an additional drop (as this has been known to decrease post-IVI IOP spikes), but if the IOP elevation is sustained or the fluctuation is significant, I will also talk to patients about the risks and benefits of pur- suing a minimally invasive glaucoma surgery to decrease IOP fluctuations and lower IOP in the long term. 17 In the case of glaucomatous progression in any patient, I will consider both minimally invasive and incisional surgery as an option to reduce IOP." While there are not many other compli- cations associated with performing glaucoma procedures in patients who receive intravitreal injections, Dr. Weng did note the possibility of zonulopathy. "In those with an extensive history of intravitreal injections, because some glauco- ma procedures nowadays are combined with cataract surgery, the surgeon should be aware of potential loss of zonular integrity," she said. "One large registry study from Sweden found a 1.45 odds ratio for cataract surgery complica- tions among patients with a history of intravitre- al injections compared to those with none." 18 There have been recent advancements in drugs available in the retina space, as well as drugs being used in higher doses. It's important to consider and monitor the impacts that these may have as they are being used and studied more. In 2023, the first two drugs for the treatment of geographic atrophy (GA) were approved by the FDA. These are complement in- hibitors given as intravitreal injections either ev- ery month or every other month, Dr. Weng said. "Because of this frequency, along with the fact that the drug volume is 0.1 cc (double the typi- cal injection volume), it is important to remain vigilant for any post-marketing adverse effects that may emerge," she said. "The rate of IOP rise reported in the pivotal trials for pegcetaco- plan and avacincaptad pegol ranged from 2–9% but were thought to be related to the injection procedure rather than the drug itself, and the majority were transient and self-resolved." 19 Dr. Weng added that some recently-ap- proved and investigational drugs are adminis- tered in a greater volume than what has typi- cally been injected. "High-dose aflibercept is a four-fold dose of standard aflibercept delivered in a 0.07 cc volume," she said. "Given concerns for possible effects on IOP by these drugs and others, some retina specialists are applying pressure to the globe pre-injection to potential- ly prevent post-injection spikes, although the benefits of doing this are unproven." She added that it will be important for retina specialists to monitor all patients' IOP over time and work closely with their glaucoma colleagues as more is learned about the relationship between intra- vitreal injections and glaucoma. Dr. Schehlein said the effect on intraocular pressure after intravitreal injections occurs in two phases. First is the initial IOP spike from additional fluid injected into the eye, which is typically transient and resolves. However, patients can undergo a more chronic form of IOP elevation over time with multiple injec- tions. "Newer treatment options for dry AMD/ GA, which inhibit the complement system, are administered very similarly to current anti-VEGF IVIs and will be familiar to ophthalmologists who perform these injections," she said. "There- fore, it is very likely that a subset of patients will undergo a transient IOP spike following injection, as shown in clinical trials." She added that there is little data on the long-term effects of these medications, so it is important to mon- itor these patients by checking the intraocular pressure at each injection and clinic visits. 17,20 "With these newer medications, the cur- rent guidelines are to inject them monthly or continued from page 97 References (continued) 17. El Chehab H, et al. Effect of topical pressure-lowering medication on prevention of intraocular pressure spikes after intravitreal injection. Eur J Oph- thalmol. 2013;23:277–283. 18. Hård Af Segerstad P. Risk model for intraoperative compli- cation during cataract surgery based on data from 900,000 eyes: previous intravitreal injection is a risk factor. Br J Oph- thalmol. 2022;106:1373–1379. 19. Khanani AM, et al. Efficacy and safety of avacincaptad pegol in patients with geograph- ic atrophy (GATHER2): 12-month results from a randomised, double-masked, phase 3 trial. Lancet. 2023;402:1449–1458. 20. Jaffe GJ, et al. C5 inhibi- tor avacincaptad pegol for geographic atrophy due to age-related macular degen- eration: a randomized pivotal phase 2/3 trial. Ophthalmology. 2021;128:576–586. Relevant disclosures Schehlein: Perceptron Health, Glaukos, Allergan Weng: AGTC, Allergan/Abbvie, Alcon, Alimera Sciences, Apellis Pharmaceuticals, Iveric Bio, No- vartis, REGENXBIO, Regeneron, DORC, DRCR Retina Network, Genentech, EyePoint, Springer Publishers continued on page 100

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