Secondary Neovascular Glaucoma in the Course of Diabetes in a Kidney Transplant Recipient: Case Report and Review of the Literature.

BACKGROUND: The increase in intraocular pressure during hemodialysis challenges nephrologists and ophthalmologists. It most often affects patients with previously diagnosed glaucoma and is particularly dangerous in the setting of diabetic retinopathy. Hypoperfusion and hypoxia of the retina may occur, leading to pathologic neovascularization in the retina and the anterior chamber angle. Changes in the filtration angle block the outflow of aqueous humor and cause secondary glaucoma. A special type of glaucoma is neovascular glaucoma, developing among others in patients with diabetic retinopathy. This study describes a patient with secondary neovascular glaucoma in whom a significant increase in intraocular pressure was observed during hemodialysis, not responding to the applied topical treatment. METHODS: The patient experienced severe pain, and her cornea was constantly injured by paracentesis. Ultimately, secondary glaucoma led to a significant decrease in vision in both eyes. The patient was enrolled on a transplant waiting list and transplanted with priority. RESULTS: The patient experienced some urologic and infectious complications, although 7 months after transplantation, her creatinine concentration was 1.2 mg/dL, and the ocular disease was stabilized. The intraocular pressure decreased, but there were still values above the norm, which required periodic injections of anti-vascular endothelial growth factor into the vitreous chamber and 5-fluorouracil injections under the conjunctiva. CONCLUSIONS: Patients with diabetes and secondary neovascular glaucoma on dialysis constitute an extremely difficult therapeutic problem and require the involvement of several specialists. Successful kidney transplantation, besides ameliorating general clinical conditions, may increase the chance of successful ophthalmologic treatment.

Analysis aqueous humor lipid profile of neovascular glaucoma secondary to diabetic retinopathy and lipidomic alteration response to anti-VEGF treatment.

The objective of this study was to examine the lipid spectrum of aqueous humor (AH) in patients with neovascular glaucoma (NVG) secondary to proliferative diabetic retinopathy and to investigate the lipid alteration response to anti-vascular endothelial growth factor (anti-VEGF) treatment. Lipidomic analysis using ultra-high performance liquid chromatography-tandem mass spectrometry was conducted to compare the lipid profiles of the AH in NVG patients with those of a control group. Lipid changes in the AH of NVG patients before and after intravitreal conbercept injections were also evaluated. The identification of lipids showing differential expression was accomplished through both multivariate and univariate analyses. This study included 13 NVG patients and 20 control subjects. Based on LipidSearch software, 639 lipid species across 33 lipid classes were detected in the participants' AH. The combination of univariate and multivariate statistical analyses yielded 53 differentially expressed lipids (VIP >1 and P < 0.05). In addition, 9 lipids were found to be differentially expressed before and after the intravitreal conbercept injections in the NVG patients. Significant alterations in the metabolic pathways of glycerophospholipid and glycerolipid exhibited notable changes. Our results highlighted the lipid changes in patients' AH in relation to the progression of NVG, and indicated that the modified lipids could potentially be utilized as therapeutic targets for NVG.

Retrospective Analysis of Radiation-Induced Complications of Uveal Melanoma Patients Treated With Brachytherapy in the Era of Anti-VEGF.

PURPOSE: To associate clinical factors and radiation doses delivered by iodine-125 plaque brachytherapy to visual outcomes and development of radiation-induced ocular complications in patients with uveal melanoma in the era of anti-vascular endothelial growth factor (anti-VEGF) injections. DESIGN: Retrospective cohort study. METHODS: A retrospective chart review was performed for 225 patients treated with iodine-125 brachytherapy for uveal melanoma. The effects of radiation doses (focal doses, average dose to the entire eye, and integral dose) on visual outcomes and development of radiation complications (radiation retinopathy, radiation optic neuropathy, vitreous hemorrhage, and neovascular glaucoma) were analyzed using multivariate Cox regression snalysis. RESULTS: Median follow-up was 33.6 months (range, 12-105.6 months). Radiation retinopathy was associated with younger age, tumor distance to optic nerve <6 mm, and maximum radiation dose to fovea. Radiation optic neuropathy was associated with White race, tumor distance to optic nerve <6 mm, and integral radiation dose. Vitreous hemorrhage was associated with White race and integral radiation dose. Incidence of neovascular glaucoma was low in our study, with 2 patients (0.9%) developing the complication. Of the 123 patients who developed radiation retinopathy, 82 patients (66.7% of radiation retinopathy patients, 37.3% of total patients) received anti-VEGF injections. CONCLUSIONS: Our study found multiple associations between radiation doses and complications as well as visual outcomes on multivariate analysis. Given that the majority of our patients who developed radiation retinopathy received anti-VEGF injections, our study helps to illustrate the course and progression of radiation-induced complications in the new era of anti-VEGF.

Widefield swept-source optical coherence tomography angiography metrics associated with neovascular glaucoma in patients with proliferative diabetic retinopathy.

PURPOSE: To explore the association between widefield swept-source optical coherence tomography angiography (WF SS-OCTA) metrics, including nonperfusion area (NPA) and neovascularization (NV), and presence of neovascular glaucoma (NVG) in patients with proliferative diabetic retinopathy (PDR). METHODS: A prospective, cross-sectional study was conducted from November 2018 to February 2020. A total of 85 eyes of 60 PDR patients without NVG and 9 eyes of 8 PDR patients with NVG were included. Retinal ischemic parameters (NPA; ischemia index [NPA/total retinal area]) and NV features (NV number; NV area; NV vessel density) were evaluated. Foveal avascular zone (FAZ), macular thickness/volume, and choroidal thickness/volume were obtained using the Zeiss ARI Network. WF SS-OCTA retinal and choroidal metrics, systemic, and ocular parameters were screened using Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression for variable selection. Firth's bias-reduced logistic regression (outcome: presence of NVG) was subsequently used to identify parameters associated with NVG. RESULTS: After LASSO variable selection, 8 variables were significantly associated with the presence of NVG: DM duration (years), insulin (yes/no), best-corrected visual acuity (BCVA) (logMAR), IOP, ischemia index, skeletonized vessel density, macular thickness (inner inferior, outer temporal regions). Firth's bias-reduced logistic regression showed ischemia index (odds ratio [OR]=13.2, 95% confidence interval [CI]:5.3-30.7, P<0.001) and BCVA (OR=5.8, 95%CI:1.2-28.8, P<0.05) were associated with the presence of NVG. NV metrics, FAZ, and choroidal parameters were not related to NVG. CONCLUSIONS: Retinal ischemia but not NV was associated with the presence of NVG in patients with PDR using WF SS-OCTA. Larger, longitudinal studies are needed to validate imaging biomarkers associated with diabetic NVG.

Glaucoma neovascular causado por metástasis de carcinoma microcítico de pulmón. Presentación de un caso / Neovascular glaucoma caused by small-cell lung cancer iris metastasis: A case presentation

El carcinoma microcítico de pulmón puede afectar al ojo directamente mediante proliferación metastásica o indirectamente a través de síndromes paraneoplásicos. La coroides es el lugar más afectado entre las metástasis uveales; no obstante, el iris puede estar envuelto en una proporción pequeña de casos (<10%). Visión borrosa, dolor, hiperemia, fotofobia, glaucoma, hipema o defectos en el campo visual pueden originarse por la afectación metastásica. La mediana de supervivencia en pacientes con metástasis iridianas es de 4 meses. El glaucoma secundario que se origina puede ser manejado con tratamiento tópico y oral, ciclo fotoablación transescleral, trabeculoplastia con láser, anti-VEGF, MIGS, cirugía filtrante o enucleación. Se presenta un caso único que desarrolló un cáncer microcítico de pulmón primario con metástasis iridianas. Las metástasis provocaron un cierre angular, refractario al tratamiento tópico. Se realizó radioterapia local para conseguir una respuesta local (AU)

Small-cell lung cancer may directly affect the eye by metastatic proliferation or indirectly by paraneoplastic syndromes. The choroid is the most common site for uveal metastasis (90%); however, the iris can be involved in a smaller proportion of cases (incidence <10%). Blurred vision, pain, redness, photophobia, glaucoma, hyphema and visual field defects can arise from this metastatic involvement. The median survival time for patients with iris metastasis is reported to be 4 months. Secondary glaucoma can be managed with topical and oral treatment, transscleral cyclophotocoagulation, laser trabeculoplasty, anti-VEGF, minimally invasive glaucoma surgery (MIGS), filtering surgery, shunting surgery or enucleation. A case of primary small-cell lung cancer with iris metastasis is presented. The metastases produced an angle-closure glaucoma, which was refractory to topical treatment. Local radiotherapy was administered, obtaining a good local response (AU)

Neovascular glaucoma caused by small-cell lung cancer iris metastasis: A case presentation.

Small-cell lung cancer may directly affect the eye by metastatic proliferation or indirectly by paraneoplastic syndromes. The choroid is the most common site for uveal metastasis (90%); however, the iris can be involved in a smaller proportion of cases (incidence <10%). Blurred vision, pain, redness, photophobia, glaucoma, hyphema and visual field defects can arise from this metastatic involvement. The median survival time for patients with iris metastasis is reported to be 4 months. Secondary glaucoma can be managed with topical and oral treatment, transscleral cyclophotocoagulation, laser trabeculoplasty, anti-VEGF, Minimally Invasive Glaucoma Surgery (MIGS), filtering surgery, shunting surgery or enucleation. A case of primary small-cell lung cancer with iris metastasis is presented. The metastases produced an angle-closure glaucoma, which was refractory to topical treatment. Local radiotherapy was administered, obtaining a good local response.

Retinal vein occlusions associated or complicated with glaucoma. Aspects of prediction and paths of progression.

Background and Objectives: The aim of the study is to evaluate prediction factors and progression paths when retinal vein occlusions are associated with preexisting glaucoma or complicated with neovascular glaucoma. Materials and Methods: The study included 111 patients diagnosed with retinal vein occlusions, of whom 21 with preexisting open angle glaucoma and 12 with neovascular glaucoma as complication. The study was conducted from September 2020 to September 2022 in Timisoara, Romania. We assessed intraocular pressure, cup-disc ratio and retinal nerve fiber layer from the moment of retinal vein occlusion diagnosis until at least one year of follow-up, considering these aspects as values of prediction concerning the paths of progression when glaucoma and retinal vein occlusions come together. Results: The mean initial IOP for the affected eyes was higher (15.89 ± 2.73) than for fellow eyes (15.20 ± 3.11), with an increase of the IOP after one year, but with no statistically significant differences for the affected eyes (p=0.116) or for the other eyes (p=0.684), neither for the affected eyes associated with glaucoma in comparison with affected eyes without glaucoma association. The mean cup-disc ratio was higher for the affected eyes in comparison with the fellow eyes (0.4812 ± 0.219 for the affected eyes and 0.4738 ± 0.229 for the fellow ones in cases without associated glaucoma and 0.681 ± 0.157 for the affected eyes and 0.600 ± 0.241 for the fellow eyes in cases with associated glaucoma), with statistical significant differences in the evolution for both groups in comparison with the unaffected eyes (p=0.0056 for the first group and p=0.0003 for the second group). Comparing the evolution of the affected eyes with the preexisting glaucoma and the affected eyes without preexisting glaucoma, no statistical difference has been found (p=0.1104). The mean retinal nerve fiber layer decreased significantly in affected eyes without glaucoma (from 96 ± 14.71 to 89.16 ± 13.07) and in affected eyes with associated glaucoma (from 78.50 ± 4.23 to 75.50 ± 5.83), but with no significant differences (p=0.182). The level of decreasing was significantly more consistent in association with a venous occlusion (p= 0.0001). Conclusions: The findings of the current study fortify the correlation between glaucoma as a risk factor for retinal venous occlusion development, the intraocular pressure and optic nerve cupping as prediction factors in retinal venous occlusions, the association of a well-controlled preexisting glaucoma with no effect on the progression of the retinal venous occlusions and the development of a neovascular glaucoma with a much aggressive and different path of disease progression.

Neovascular glaucoma with combined retinal vascular occlusion in carotid cavernous fistula.

Carotid cavernous fistulas (CCFs) can present with varied ophthalmic manifestations. The most important vision-threatening complications of CCF include glaucoma and retinal vascular occlusions. We report a case of a man in his early 30s who developed a post-traumatic direct CCF. The patient denied undergoing embolisation therapy. This resulted in aggravation of his condition with onset of combined retinal venous and artery occlusion leading to neovascular glaucoma and severe vision loss. He was treated with medical management followed by diode laser photocoagulation to control intraocular pressure. Diagnostic cerebral angiography done 3 months later showed complete closure of the fistula; hence, no further intervention was advocated. Combined vascular occlusion is a rare vision-threatening occurrence in cases of CCF. Timely intervention with closure of the fistula can prevent the development of vision-threatening complications.

Visual prognosis and surgical timing of Ahmed glaucoma valve implantation for neovascular glaucoma secondary to diabetic vitrectomy.

BACKGROUND: Evaluate the visual outcomes of Ahmed glaucoma valve implantation (AGVI) in patients with neovascular glaucoma (NVG) who underwent diabetic vitrectomy and suggest appropriate AGVI timing. METHODS: Medical records of patients who underwent AGVI due to NVG after diabetic vitrectomy were reviewed. Successful intraocular pressure (IOP) control was defined as an IOP between 6 and 21 mmHg. Visual outcome was compared before NVG diagnosis and after AGVI, and the "favorable" visual outcome was defined as a postoperative deterioration in BCVA of less than 0.3 logMAR units compared to those before the development of NVG. Various factors including surgical timing were evaluated to identify the risk factors associated with unfavorable visual outcome. RESULTS: A total of 35 eyes were enrolled and divided into group 1(medically uncontrolled NVG group, IOP more than 30mmHg, 16 eyes) and group 2(NVG group responded well to the initial non-surgical treatment but eventually required AGVI, 19 eyes). Despite the favorable rate of normalization of post-AGVI IOP (85.7%), 43.8% in Group 1 and 26.3% in Group 2 showed unfavorable visual outcomes. In group 1, delayed surgical timing more than 1 week from the NVG diagnosis showed a significant association with unfavorable visual outcomes (P = 0.041). In group 2, poor patient compliance (follow up loss, refuse surgery) was the main factor of unfavorable visual outcomes. CONCLUSION: When NVG occurs in patients with proliferative diabetic retinopathy after vitrectomy, physicians should be cautious not to delay the surgical intervention, especially in patients with IOP of 30 or more despite non-surgical treatment. Early AGVI within six days might be necessary to preserve useful vision in these patients.

Two-year outcomes of patients presenting to Sydney Eye Hospital with neovascular glaucoma.

BACKGROUND: Neovascular glaucoma (NVG) is a sight-threatening condition that is often refractory to treatment. Current management principles are yet to be standardized due to lack of evidence. We studied the interventions used to treat NVG at Sydney Eye Hospital (SEH) and the two-year surgical outcomes. METHODS: We performed a retrospective audit of 67 eyes of 58 patients with NVG from January 1, 2013, to December 31, 2018. Intraocular pressure (IOP), best-corrected visual acuity (BCVA), number of medications, repeat surgery, recurrent neovascularization, loss of light perception and pain were studied. RESULTS: The average age of the cohort was 59.67 years (SD 14.22). The most common etiologies were proliferative diabetic retinopathy (35 eyes; 52.2%), central retinal vein occlusion (18 eyes; 26.9%) and ocular ischemic syndrome (7 eyes; 10.4%). 70.1% of eyes (47) received vascular endothelial growth factor injections (VEGFI), 41.8% (28 eyes) received pan-retinal photocoagulation (PRP) and 37.3% (25 eyes) received both prior to or within the first week of presentation to SEH. The most common initial surgical interventions were trans-scleral cyclophotocoagulation (TSCPC) (36 eyes; 53.7%) and Baerveldt tube insertion (18 eyes; 26.9%). 62.7% of eyes (42 eyes) failed (IOP > 21 or < 6 mmHg for two consecutive reviews, further IOP-lowering surgery or loss of light perception) during follow-up. Initial TSCPC failed in 75.0% (27/36 eyes) compared with 44.4% (8/18 eyes) after Baerveldt tube insertion. CONCLUSION: Our study reinforces the refractory nature of NVG, often despite intensive treatment and surgery. Improvements in patient outcomes may be achieved with earlier consideration of VEGFI and PRP. This study identifies the limitations of surgical interventions for NVG and highlights the need for a standardized management approach.

RISK FACTORS FOR SURGERY OR BLINDNESS IN NEOVASCULAR GLAUCOMA EYES TREATED WITH ANTI-VEGF INJECTIONS BY A RETINA SPECIALIST.

PURPOSE: To determine baseline patient characteristics that predict the need for glaucoma surgery or blindness in eyes with neovascular glaucoma (NVG) despite intravitreal antivascular endothelial growth factor therapy. METHODS: This is a retrospective cohort study of patients with NVG who had not previously received glaucoma surgery and were treated with intravitreal antivascular endothelial growth factor injections at the time of diagnosis, from September 8, 2011, to May 8, 2020, at a large, retina subspecialty practice. RESULTS: Of 301 newly presenting NVG eyes, 31% required glaucoma surgery and 20% progressed to no light perception vision despite treatment. Patients with intraocular pressure >35 mmHg ( P < 0.001), two or more topical glaucoma medications ( P = 0.003), worse than 20/100 vision ( P = 0.024), proliferative diabetic retinopathy ( P = 0.001), eye pain or discomfort ( P = 0.010), and new patient status ( P = 0.015) at the time of NVG diagnosis were at a higher risk of glaucoma surgery or blindness regardless of antivascular endothelial growth factor therapy. The effect of panretinal photocoagulation was not statistically significant in a subgroup analysis of patients without media opacity ( P = 0.199). CONCLUSION: Several baseline characteristics at the time of presentation to a retina specialist with NVG seem to portend a higher risk of uncontrolled glaucoma despite the use of antivascular endothelial growth factor therapy. Prompt referral of these patients to a glaucoma specialist should be strongly considered.

The mechanism and therapeutic strategies for neovascular glaucoma secondary to diabetic retinopathy.

Neovascular glaucoma (NVG) is a devastating secondary glaucoma characterized by the appearance of neovascular over the iris and the proliferation of fibrovascular tissue in the anterior chamber angle. Proliferative diabetic retinopathy (PDR) is one of the leading causes of NVG. Currently increasing diabetes population drive the prevalence rate of NVG into a fast-rising lane. The pathogenesis underlying NVG makes it refractory to routine management for other types of glaucoma in clinical practice. The combination of panretinal photocoagulation (PRP), anti-vascular endothelial growth factor (VEGF) injections, anti-glaucoma drugs, surgical intervention as well as blood glucose control is needed. Early diagnosis and aggressive treatment in time are crucial in halting the neovascularization process and preserving vision. This review provides an overview of NVG secondary to diabetic retinopathy (DR), including the epidemiology, pathogenesis and management, so as to provide a better understanding as well as potential therapeutic strategies for future treatment.

Fibrilación auricular no valvular y obstrucción venosa retiniana: la Cohorte Valdecilla / Nonvalvular atrial fibrillation and retinal vein occlusion: The Valdecilla Cohort

Introduction and objectives Retinal vein occlusion (RVO) and nonvalvular atrial fibrillation (NVAF) are associated with vascular risk factors (VRF) and aging. The aim of this study is to analyze differences in the prevalence of VRF, vascular events, glaucoma, and anticoagulant treatment in patients with NVAF and RVO compared to a control group of the general population from the same geographic area. Methods This is a prospective, single-center, case-control study. All patients diagnosed with RVO from December 2008 to March 2020 as well as a control group were included. Clinical, laboratory, electrocardiographic, and carotid ultrasound variables were analyzed. Results A total of 386 patients with RVO and 343 controls were studied. Patients with RVO and NVAF were older and more of them had hypertension, a history of vascular events, and carotid atheromatosis than subjects with RVO without NVAF. In patients with NVAF who were on anticoagulants, those who had RVO differed from the controls with NVAF in that they had a higher prevalence of glaucoma (32 vs. 5.3%; p<0.034), with no significant differences regarding age, VRF, vascular events, or type of anticoagulant therapy (acenocumarol or direct-acting oral anticoagulants). Conclusions Patients with RVO and NVAF were older and had a higher prevalence of hypertension and carotid atheromatosis than subjects with RVO without NVAF. Patients with NVAF and RVO had higher prevalence of glaucoma than subjects with NVAF without RVO. In patients with NVAF, it is recommended to optimized VRF treatment and glaucoma control to prevent the development of RVO (AU)

Introducción y objetivos La obstrucción venosa retiniana (OVR) y la fibrilación auricular no valvular (FANV) se relacionan con los factores de riesgo vascular (FRV) y con el envejecimiento. Este trabajo tiene por objetivo analizar las diferencias en la prevalencia de los FRV, de los eventos vasculares, del glaucoma y del tratamiento anticoagulante en los pacientes con FANV y OVR comparada con un grupo control de la población general de la misma área geográfica. Métodos Estudio prospectivo unicéntrico de casos y controles. Se incluyeron todos los pacientes diagnosticados de OVR desde diciembre de 2008 hasta marzo de 2020, y un grupo control. Se analizaron variables clínicas, de laboratorio, electrocardiográficas y de ultrasonidos de carótida. Resultados Se estudiaron 386 pacientes con OVR y 343 controles. Los pacientes con FANV y OVR eran de mayor edad, tenían más hipertensión, antecedente de eventos vasculares y ateromatosis carotídea que los sujetos con OVR sin FANV. En los pacientes con FANV anticoagulados, aquellos que tenían OVR, diferían de los controles con FANV en una mayor prevalencia de glaucoma (32 vs. 5,3%; p<0,034), sin hallarse diferencias significativas respecto a la edad, los FRV, los eventos vasculares o la terapia anticoagulante pautada (acenocumarol o anticoagulantes de acción directa). Conclusiones Los pacientes con OVR y FANV tienen mayor edad y mayor prevalencia de hipertensión arterial, y ateromatosis carotídea que los que no tienen FANV. Aquellos con FANV y OVR difieren de los que no tienen OVR en la mayor incidencia de glaucoma. En los pacientes con FANV sugerimos optimizar el tratamiento de los FRV y el control del glaucoma para prevenir el desarrollo de la OVR (AU)

Neovascular Glaucoma: An Update.

Neovascular glaucoma (NVG) is a severe type of secondary glaucoma with devastating complications and generally poor visual prognosis. NVG is defined by the development of pathological neovessels over the iris and the iridocorneal angle that can block the outflow of aqueous humor, causing elevation of intraocular pressure (IOP). The pathogenesis of NVG is, in most cases, associated with ischemia of the posterior segment, which is most frequently associated with proliferative diabetic retinopathy or central retinal vein occlusion. The advanced stages of NVG are by iris and angle neovascularization, angle, and extremely high IOP, accompanied by ocular pain and poor vision. The therapeutic approach of NVG is based on the reduction of retinal ischemia by panretinal photocoagulation. Intravitreal anti-VEGF administration can contribute to the regression of neovascularization, and topical and systemic medications may be necessary for IOP control. However, if medical treatment with these agents is not enough, surgical procedures may be required to lower IOP and prevent glaucomatous optic neuropathy. Early and prompt diagnosis, with identification of the underlying etiology, can improve IOP control and final visual outcome. The aim of this study is to review current knowledge of the pathogenesis and management of NVG.

A Review of Neovascular Glaucoma: Etiology, Pathogenesis, Diagnosis, and Treatment.

Neovascular glaucoma (NVG) is a rare, aggressive, blinding secondary glaucoma, which is characterized by neovascularization of the anterior segment of the eye and leading to elevation of the intraocular pressure (IOP). The main etiological factor is retinal ischemia leading to an impaired homeostatic balance between the angiogenic and antiangiogenic factors. High concentrations of vasogenic substances such as vascular endothelial growth factor (VEGF) induce neovascularization of the iris (NVI) and neovascularization of the angle (NVA) that limits the outflow of aqueous humor from the anterior chamber and increases the IOP. NVG clinical, if untreated, progresses from secondary open-angle glaucoma to angle-closure glaucoma, leading to irreversible blindness. It is an urgent ophthalmic condition; early diagnosis and treatment are necessary to preserve vision and prevent eye loss. The management of NVG requires the cooperation of retinal and glaucoma specialists. The treatment of NVG includes both control of the underlying disease and management of IOP. The main goal is the prevention of angle-closure glaucoma by combining panretinal photocoagulation (PRP) and antiangiogenic therapy. The aim of this review is to summarize the current available knowledge about the etiology, pathogenesis, and symptoms of NVG and determine the most effective treatment methods.

23G Minimally Invasive Vitrectomy Combined with Glaucoma Drainage Valve Implantation and Phacoemulsification Cataract Extraction for Neovascular Glaucoma Secondary to Proliferative Diabetic Retinopathy with Vitreous Hemorrhage.

Objective: To evaluate the clinical efficacy of the combined application of 23G minimally invasive vitrectomy, glaucoma drainage valve implantation, and phacoemulsification cataract extraction in the treatment of neovascular glaucoma (NVG) secondary to proliferative diabetic retinopathy (PDR) combined with vitreous hemorrhage (VH). Methods: Eighty-three patients (91 eyes) with PDR diagnosed as NVG phase III complicated with VH from June 2018 to May 2020 were selected as the study subjects. The subjects were randomly divided into 3 groups: group A was treated with 23G minimally invasive vitrectomy combined with glaucoma drainage valve implantation; group B was given 23G minimally invasive vitrectomy combined with phacoemulsification cataract extraction; and group C was treated with 23G minimally invasive vitrectomy combined with glaucoma drainage valve implantation and phacoemulsification cataract extraction. The uncorrected visual acuity (UCVA), intraocular pressure (IOP), and iris neovascularization (INV) scores were recorded and compared among the 3 groups before and after operation, and then the postoperative pain relief and complications were observed. Results: Through observation, there was no significant difference in the UCVA, IOP, and INV scores in the 3 groups before operation. After the operation, the UCVA, IOP, and INV scores of the 3 groups were significantly lower than those before operation. After operation, the UCVA of the 3 groups increased first and then decreased, and it improved most significantly in the 3rd month after operation and decreased in the 4th month after operation. There were significant differences in UCVA among the 3 groups at each time point after operation. From the 1st day to the 6th month after operation, the IOP of the 3 groups showed an upward trend, and there was no significant difference among the 3 groups in IOP at each time point after operation. At the 1st, 3rd, and 6th months after operation, the INV score of group A and group B was higher than that of group C. There was no significant difference in the INV score between group A and group B. The incidence of complications was not significantly different among the 3 groups. Conclusion: 23G minimally invasive vitrectomy, glaucoma drainage valve implantation, and phacoemulsification cataract extraction can effectively improve the UCVA, IOP, and INV scores of NVG secondary to PDR with VH, and the combined application of the 3 methods has better security.

Comparisons of the short-term effectiveness and safety of surgical treatment for neovascular glaucoma: a systematic review and network meta-analysis.

OBJECTIVE: To compare the effectiveness and safety of the six interventions for neovascular glaucoma. DESIGN: A systematic review and network meta-analysis. METHODS: Randomised controlled trials and cohort studies which compared the six interventions in neovascular glaucoma were identified using the following databases searched up to 1 September 2020: PubMed, Cochrane Library, Embase and Web of Science. The quality assessment was conducted by using the Cochrane risk of bias tool and the Newcastle-Ottawa scale. The primary outcome measure was the weighted mean differences for intraocular pressure reduction. Secondary one was ORs for success rate. Outcome measures were reported with a 95% CI and p<0.05 was considered statistically significant. Network meta-analysis was performed using Stata V.15.0. RESULTS: Twenty-three studies involving a total of 1303 patients were included. The types of surgical treatments included Ahmed glaucoma valve (AGV) implant surgery, AGV combined with intravitreal anti-vascular endothelial growth factor (AGV +IVAV), cyclophotocoagulation (CPC), cyclocryotherapy (CCT), trabeculectomy with mitomycin (Trab(MMC)) and Trab(MMC) combined with IVAV (Trab(MMC)+IVAV). Network meta-analysis showed that in comparison with AGV, AGV +IVAV (MD=4.74, 95% CI 1.04 to 8.45) and Trab(MMC)+IVAV (MD=6.19, 95% CI 0.99 to 11.40) showed a favourable effect in intraocular pressure reduction (IOPR) 6 months after surgery. Compared with CCT, AGV (OR=-0.17, 95% CI -0.53 to -0.05), AGV +IVAV (OR=-0.10, 95% CI -3.48 to -1.19), CPC (OR=-0.12, 95% CI -0.53 to -0.05), Trab(MMC) (OR=3.54, 95% CI 1.15 to 10.91) and Trab(MMC)+IVAV (OR=5.78, 95% CI 2.29 to 14.61) showed a superior impact in success rate. The order of efficacy as best intervention ranked as follows: Trab(MMC)+IVAV (IOPR 6 months after surgery, surface under the cumulative ranking (SUCRA)=88.1), CPC (IOPR 12 months after surgery, SUCRA=81.9), AGV +IVAV (IOPR 12 months after surgery, SUCRA=79.9) and AGV +IVAV (success rate, SUCRA=92.7). Adverse events were also summarised in detail. CONCLUSION: In the treatment of neovascular glaucoma, AGV+IVAV and CPC were more effective in IOPR and success rate than the other four interventions. Additionally, AGV+IVAV is superior to CPC concerning the success rate in the long-term treatment. However, considering the limitations of this review, more high-quality trials, especially those surgical interventions not mentioned in this review, should be carried out in the future to further confirm the current findings.

Comparing Surgical Outcomes in Neovascular Glaucoma between Tube and Trabeculectomy: A Multicenter Study.

OBJECTIVE: To compare the surgical outcomes between Baerveldt glaucoma implant (BGI) surgery and trabeculectomy with mitomycin C for patients with neovascular glaucoma (NVG). DESIGN: Retrospective clinical cohort study at 5 clinical centers in Japan. PARTICIPANTS: Patients treated with trabeculectomy or BGI for NVG between April 1, 2012, and December 31, 2019, at 5 clinical centers were recruited. METHODS: The inclusion criteria were age ≥ 20 years and having NVG. The exclusion criteria were eyes with no light perception vision and with previous tube-shunt surgery. If both eyes in the same patient satisfied the inclusion criteria, the eye that was treated first was investigated. We included 100 eyes undergoing BGI surgery and 204 eyes undergoing trabeculectomy. MAIN OUTCOME MEASURES: The primary outcome was surgical success or failure, with failure being defined according to 3 criteria: < 20% reduction of the preoperative intraocular pressure (IOP) or criterion A (IOP > 21 mmHg), criterion B (IOP > 17 mmHg), or criterion C (IOP > 14 mmHg). Cases of reoperation, a loss of light perception vision, or hypotony were also considered failures. RESULTS: The probability of success was significantly higher in patients undergoing BGI surgery than in those receiving trabeculectomy for criteria A (P < 0.01) and B (P = 0.01). Trabeculectomy was significantly associated with surgical failure in the multivariable analysis for criterion A (hazard ratio, 1.70) and criterion B (hazard ratio, 1.50). The overall incidence of postoperative complications was similar between the 2 groups. Reoperations for glaucoma were required significantly more frequently in the trabeculectomy group than in the BGI surgery group (20.1 % vs. 5.0%; P < 0.01). CONCLUSIONS: Baerveldt glaucoma implant surgery had a higher success rate compared with trabeculectomy in patients with NVG for a target IOP < 21 mmHg or < 17 mmHg. The rates of postoperative complications were similar between both surgical procedures. Additional glaucoma surgery was required more frequently after trabeculectomy than after BGI surgery.