Late-stage neovascular glaucoma typically requires surgery, individualized management
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Late-stage neovascular glaucoma can require surgical management, typically with a glaucoma drainage implant, but treatment should be individualized depending on patient factors, according to a speaker.
“In neovascular glaucoma, we treat the underlying cause of the disease. In the late stages of the disease, the angle may be closed and usually patients need some sort of glaucoma surgery, often with glaucoma drainage implants,” Peter Andreas Netland, MD, PhD, said at Glaucoma Subspecialty Day at the virtual American Academy of Ophthalmology meeting.
Initial treatment can depend on the underlying cause and etiology of the neovascular glaucoma. Mostly this involves treatment of retinal ischemia with anti-VEGF antibodies and laser, which may reduce the need for glaucoma surgery. However, these treatments can also improve outcomes in patients who do eventually require surgery.
Surgical treatment can also depend on the stage of the disease. Stage 2 patients with open-angle neovascular glaucoma and elevated IOP may not necessarily need surgery, while stage 3 patients with closed-angle neovascular glaucoma and markedly elevated IOP are often treated surgically, Netland said.
Additionally, patients with controlled neovascularization and inflammation may be appropriate candidates to undergo trabeculectomy with mitomycin C. The success rates of the procedure decrease over time, and most do not report success rates after 12 months, he said.
“An alternative to trabeculectomy may be transscleral filtration with a Xen implant (Allergan). There are case reports of this that have appeared and success has been achieved, but angle surgery with MIGS has not be helpful to date, and we wouldn’t anticipate this approach would be useful clinically,” he said.
Glaucoma drainage implants may be necessary for later-stage neovascular glaucoma. IOP is typically well controlled with the implants, but loss of light perception vision can be observed despite the IOP control. Treatment to reduce or prevent retinal or optic nerve damage may help improve success rates further, he said.
The visual potential of a patient can also influence surgical management decisions. Patients with some visual potential may be appropriate candidates for glaucoma drainage implants. However, if visual potential is limited, surgeons can shift to less invasive options, such as cyclodestructive procedures, Netland said.
“When there is really no visual potential, we can perform cyclodestruction, but we often can start thinking of other treatments such as neurolytic treatments to reduce pain and even evisceration and enucleation,” he said.
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Netland PA. Surgical considerations in neovascular glaucoma: The glaucoma perspective. Presented at: American Academy of Ophthalmology annual meeting; Nov. 13-15, 2020 (virtual meeting).
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