Eyeworld

96 | EYEWORLD | SPRING 2024 G UCOMA by Ellen Stodola Editorial Co-Director About the physicians Emily Schehlein, MD Brighton Vision Center Brighton, Michigan Christina Y. Weng, MD, MBA Professor of Ophthalmology Fellowship Program Director, Vitreoretinal Diseases & Surgery Baylor College of Medicine Houston, Texas References 1. Shah SM, al. Risk, prevalence, and progression of glaucoma in eyes with age-related macular degeneration treated with intra- vitreal anti-vascular endothelial growth factor injections. Am J Ophthalmol. 2022;243:98–108. 2. Islam YFK, et al. Glaucoma drainage device erosions in patients receiving anti-vascular endothelial growth factor thera- py for diabetic retinopathy. Clin Ophthalmol. 2022;16:3681–3687. 3. de Vries VA, et al. The effects of intravitreal injections on intraocular pressure and retinal nerve fiber layer: a systematic review and meta-analysis. Sci Rep. 2020;10:13248. 4. Good TJ, et al. Sustained elevation of intraocular pressure after intravitreal injections of an- ti-VEGF agents. Br J Ophthalmol. 2011;95:1111–1114. 5. Bakri SJ, et al. Intraocular pres- sure in eyes receiving monthly ranibizumab in 2 pivotalage-re- lated macular degeneration clinical trials. Ophthalmology. 2014;121:1102–1108. 6. Eadie BD, et al. Association of repeated intravitreous bevacizumab injections with risk for glaucoma surgery. JAMA Ophthalmol. 2017;135:363–368. 7. Chang EK, et al. Effects of postoperative intravitreal injec- tions on outcomes of traditional glaucoma surgery in patients with preoperative intravitreal in- jections. Ophthalmol Glaucoma. 2022;5:219–228. A nti-VEGF intravitreal injections (IVI) may have some effect on the success of glaucoma procedures, and both retina specialist, Christina Weng, MD, MBA, and glaucoma specialist, Emily Schehlein, MD, agree that this is situation dependent on the patient with various scenarios and pathologies. Dr. Weng highlighted three specific situa- tions where there could be a relation between injections and glaucoma procedures. First, she brought up the ongoing debate regarding whether or not intravitreal injections impact IOP long term. "We know that in the short term, all intravitreal injections transiently elevate the IOP to the 30–40 mm Hg range, but for most patients, this will self-resolve within 30–60 minutes," she said. "That being said, there is some literature suggesting that recur- rent induced spikes could lead to persistent IOP elevation, especially in patients with glauco- ma. 1 So theoretically, this could counteract the effect of a procedure like MIGS, but additional research is needed." Additionally, approximately one-third of patients injected with intravitreal steroids will experience a significant rise in IOP approxi- mately 6–8 weeks later, so this should always be monitored closely. She said it is important to remember that, in general, there is no definitive evidence to support that intravitreal injections cause glaucoma or negatively impact the success of glaucoma procedures. 2,3 Dr. Schehlein echoed some of Dr. Weng's observations regarding transient increase in IOP with IVIs, conflicts in the literature, and the active research in this area. Patients with glau- coma are more likely to develop an IOP spike than are patients without glaucoma, she said, adding that a study by Good et al. found that 33% of glaucoma patients compared to 3.1% of non-glaucoma patients (p<0.001) had an IOP spike following injection. 4 While the increase in IOP with a spike from IVI is usually transient, Dr. Schehlein noted that some studies have shown long-term sustained IOP elevation can occur and lead to the patient requiring glauco- ma surgery. 5,6 Dr. Weng also mentioned that there are certain indications for glaucoma surgery, such as neovascular glaucoma, where intravitreal injec- tions may actually improve procedural success. 7 "Because steroids and anti-VEGF suppress in- flammation and neovascularization, their effects on patient pathology and perioperative fibrosis could theoretically be beneficial, although this remains unproven," she said. Finally, she noted concerns with the actual injection procedure. "I typically avoid giving intravitreal injections within the first few days following a glaucoma surgery," she said. It is also important to avoid injecting through involved areas such as a tube shunt plate or the bleb as this could result in erosion and ultimate- ly failure. 8 Dr. Schehlein added that anti-VEGF injec- tions have been linked to higher rates of recur- rent glaucoma tube erosions in patients with age-related macular degeneration (AMD). 9 She agrees that it is critical to inject the medication away from the tube shunt or trabeculectomy and take care with inserting and removing the eyelid speculum. "All patients, but especially glaucoma patients with a history of incisional surgery, should be instructed not to touch or rub their eye following an injection." The effect of intravitreal injections on glaucoma procedures Dr. Weng performs an intravitreal injection in a patient with wet macular degeneration. Source: Christina Y. Weng, MD, MBA/Credit: Agapito Sanchez, Jr.

• Blank Page
• Blank Page (1)