Surgical options may benefit those with severe neovascular glaucoma

PITTSBURGH — Patients with advanced neovascular glaucoma may benefit from a variety of surgical options, said a surgeon speaking at a symposium on angiogenesis here.

Eyes in advanced stages of neovascular glaucoma tend to be severely inflamed, said Robert J. Noecker, MD, speaking at a symposium on “Angiogenesis and its inhibition” at the University of Pittsburgh Medical Center. The patient’s corneas have begun to decompensate and IOPs are high, with 50 mm Hg to 60 mm Hg not uncommon, Dr. Noecker said.

To treat neovascular glaucoma, physicians must determine the underlying cause, usually a retinal vascular problem, he said.

“We need to decide what stage the patient is in to base our treatment paradigm,” Dr. Noecker said. “We want to decide if prophylaxis can cause further problems, whether we are catching the problems early, or if we’re just doing palliative therapy in end-stage disease.”

If patients have useful vision, Dr. Noecker recommends surgical intervention. Trabeculectomy has a high failure rate in patients with advanced neovascular glaucoma, he said. But with adjunctive use of antimetabolites, particularly mitomycin C, trabeculectomy may be beneficial in these patients. Molteno, Ahmed and Baerveldt drainage implants are also becoming more commonly used in this type of glaucoma, he noted.

Cyclodestruction using cryotherapy or cyclophotocoagulation can be beneficial, but these destructive procedures can lead to sequelae such as cataract formation and continued vision loss.

Endocyclophotocoagulation, a relatively new approach to cyclodestruction, may prove beneficial for patients with neovascular glaucoma, Dr. Noecker said. The therapy is done with direct visualization, allowing more complete destruction of the ciliary epithelium compared to transscleral procedures, he said.

“This tends to be a kinder and gentler approach to ablating the ciliary body to decrease the IOP,” he said.

Dr. Noecker said some studies suggest a beneficial effect from applying photodynamic therapy to the neovascularization or using triamcinolone acetonide to address the underlying retinal pathology.