Neovascular Glaucoma

Posterior segment ischaemia drives iris and angle neovascularisation leaving to fibrovascularisation

• Despite an open angle, PAS form and membrane contracture leads to synechial angle closure
• Can progress over a matter of days
• VEGF is the primary angiogenic factor
• Angle closure is by an anterior pulling mechanism

Causes

• Ischaemic CRVO
• Diabetes
• More rare:
  • Ocular ischaemic syndrome/carotid occlusive disease
  • CRAO
  • BRVO
  • Chronic RD
  • Sickle cell retinopathy
  • Posterior segment tumours

Clinical features

• Pain
• Features of the underlying condition as above
• Iris rubeosis: non-radial vessels at the pupil-sphincter margin
• AC flare/cells or hyphaema
• Ectropion uvea
• Red eye/conjunctival injection
• Corneal oedema
• Abnormal vessels in the angle and fibrovascular tissue overlying the TM on gonioscopy

Tests

• Dilated fundoscopy
• FFA
• Carotid doppler
• B-scan US
• Haematology/biochemistry eg to detect anaemia, diabetes etc.

Management

• anti-VEGF: can be delivered into the AC too which can cause regression of NVI but this can sometimes cause further contracture and more angle closure
• Aqueous suppression and even hyperosmotic therapy can be used to control IOP before surgery
• PRP for retinal ischaemia
• Treatment of RD
• Carotid endarterectomy
• Cycloplegia (pilocarpine is contraindicated)
• Topical steroid
• Glaucoma surgery
• Laser cyclophotocoagulation