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Long-term effects of anti-VEGF injection on IOP uncertain
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A literature search found a strong correlation between intravitreal injection and immediate IOP elevation, while the association with long-term IOP rise and glaucoma is less certain.
The study was carried out by the Ophthalmic Technology Assessment Committee Glaucoma Panel to address the question of whether and why anti-VEGF injections may cause IOP elevation and potentially predispose patients to glaucoma.
The literature search was conducted in the PubMed and Cochrane Library databases, leading to the selection of 41 papers meeting the study criteria. Fourteen studies reported on the short-term pressure effects of anti-VEGF injections showing an immediate IOP increase in 100% of patients, with mean post-injection IOP ranging between 28.3 mm Hg and 55.2 mm Hg. A progressive decrease was reported within 1 hour, suggesting that post-injection IOP spikes are transient.
Fourteen studies assessed long-term IOP elevation. While eight of them reported IOP elevation between 9 and 24 months in up to 18.8% of patients, six studies reported no change. A correlation between IOP elevation and the number of injections was not clearly established.
Pretreatment with glaucoma medications, including brimonidine/timolol, oral acetazolamide or anterior chamber tap was reported in five studies and showed some efficacy in reducing IOP spikes. However, the effect on long-term IOP and prevention of glaucoma progression were not assessed.
Only two studies reported on the long-term effects of increased IOP on glaucoma. Thinning of the retinal nerve fiber layer was observed with injections, but the effect of this on glaucoma progression and visual field is unknown, and additional studies are needed, the authors noted.
“Because of the increasing use of anti-VEGF agents, it is important to understand the relationship among anti-VEGF treatments, IOP, and the onset or progression of glaucoma. A timely recognition of IOP elevation related to anti-VEGF injection may postpone the onset or progression of glaucoma and mitigate resulting visual loss,” the authors wrote. – by Michela Cimberle
Disclosure: The authors reported no relevant financial disclosures.
Perspective
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Derek MacDonald, OD, FAAO
When Ontario optometrists began treating glaucoma, I had the pleasure of sitting on a panel that drafted initial collaborative care guidelines. Ironically, the chair was a retinal surgeon, who wryly noted that he didn’t manage glaucoma … he created it.
While iatrogenic “surgical glaucoma” has long been recognized, whether anti-VEGF injections cause or exacerbate glaucoma remains less certain. They certainly cause a short-term IOP elevation that can be quite significant and potentially very damaging to a fragile optic nerve. Fortunately, such optic nerves are relatively few and far between; however, glaucoma is frequently accompanied by comorbidities including AMD, retinal vein occlusion and diabetic macular edema that, untreated, may pose an imminent threat to central vision. Further, other treatments for these conditions (including laser and steroids) may be less effective and pose even greater risks to both short- and long-term IOP stability.
From an anti-VEGF risk-benefit perspective, the latter will trump the former more often than not. Every rule, however, has exceptions (remember, glaucoma is a slowly progressive disease, except when it’s not), and when managing patients with concurrent glaucoma and retinal vascular disease, we must remain vigilant and may consider more aggressive target IOPs or alternative retinal treatments, if possible ... laser, anyone?
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