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Combination bevacizumab and panretinal photocoagulation for neovascular glaucoma Inning Chen, OD & Alyon J Wasik, OD, FAAO Abstract: Bevacizumab, a potent inhibitor of vascular endothelial growth factor, was used off-label in conjunction with panretinal photocoagulation to treat iris and angle neovascularization secondary to proliferative diabetic retinopathy. I. Case History Demographic: 71 year old Caucasian male CC: Sudden painless vision loss and increased wavy floaters OD noticed that morning. PoHx: Proliferative diabetic retinopathy OU S/p panretinal photocoagulation OD Pseudophakia s/p PC IOL OU Mild macular pucker OU MedHx: Diabetes Mellitus type I x 44 years, hypertension. Meds: Insulin humalog, glargine, atenolol, hydrochlorothiazide, II. Pertinent Findings BCVA: OD 20/60 OS 20/50 SLE: OD Clear OS Neovascularization of the iris from 10-30-12:30 IOP: OD 15 OS 36 Gonio: DFE: Vit: C/D: Mac: Ves Perip: Lab tests: BP: IVFA: OD Unremarkable OS 360’ angle neovascularization; fibrovascular membrane and traction @11:00 to 1:30, and @ 7:30 OD Mild diffuse hemorrhage OS clear OD 0.30 OS 0.30 OD Mild pucker, no CSME OS 2 dot hemorrhages inferior to fovea, mild pucker, no CSME OD NVD from 7-1:00 OS NVE/fibrosis inferior and superior to macula along arcades OD Extensive PRP scars OS Scattered dot hemorrhages Hba1c 7.7 142/71 OD Early hyperfluorescence confirms NVD OS Very mild leakage from NVE III. Differential Diagnosis Primary/leading: Inflammatory glaucoma Primary open angle glaucoma Ghost cell glaucoma Others: Pseudoexoliative glaucoma Pigmentary glaucoma Angle recession glaucoma Phacolytic glaucoma Acute angle closure IV. Diagnosis and discussion The vitreous hemorrhage was the cause for the sudden vision loss OD. In addition to this finding, upon examination the patient had also developed neovascularization of the iris and angle with raised intraocular pressures OS. He was diagnosed with vitreous hemorrhage OD most likely secondary to PDR and NVG OS. Vascular diseases such as diabetes, vein occlusions, and ocular ischemic syndrome may induce neovascular glaucoma. Neovascularization in the iris and angle secondary to proliferative diabetic retinopathy can lead to the formation of fibrovascular tissue and peripheral angle synechiae which will cause elevated IOP, pain, and loss of vision if the condition is not treated in a timely manner. V. Treatment, management The patient was treated the same day with heavy PRP OS by a retinal specialist in the community. The next day, he had an intravitreal bevacizumab injection. The patient was started on brimonidine 0.2% TID OS The vitreous hemorrhage OD was closely monitored once every 2-3 weeks until resolution. His IOP was still elevated when he returned to the VA eye clinic the next day so combination dorzolamide 2% and timolol 0.5% BID was added to the medical regiment. When he returned 5 days later, the iris and angle neovascularization regressed and the IOP was in the low teens. During the next several months, the IOP remained low so the medications were discontinued. At the 1 year follow-up, the regressed anterior segment neovascularization was stable without sign of recurrence, the IOP was WNL, and the vision was stable. The traditional treatment for NVG is PRP, but is only effective in 70-73%. Patients may also need glaucoma surgery to control IOP. If these treatments are unsuccessful, optic nerve damage, intractable pain, and/or permanent loss of vision can result from NVG. VEGF promotes the formation of new vessels and increases the permeability of the existing vasculature. Bevacizumab, an anti-VEGF antibody, has been shown to lead to rapid resolution of iris and angle neovascularization in conjunction with PRP for the treatment of NVG. References o Wakabayashi T, et al. Intravitreal bevacizumab to treat iris neovascularization and neovascular glaucoma secondary to ischemic retinal diseases in 41 consecutive cases. American Academy of Ophthalmology 2008. Article in Press o Ehlers J et al. Combination intravitreal becacizumab/panretinal photocoagulation vs panretinal photocoagulation alone in treatment of neovascular glaucoma. Opht Comm Society 28(5), May 2008, 696-702 o Pavan P, et al. Diabetic rubeosis and panretinal photocoagulation. Arch ophthalmol vol 101, June 1983 o Vatavuk Z, et al. Intravitreal bevacizumab for neovascular glaucoma following central retinal arterial occlusion. European Journal of Ophthalmology 2007 17:2; 269-271 o Oshima Y, et al. Regression of iris neovascularization after intravitreal injection of bevacizumab in patients with proliferative diabetic retinopathy. Am J Ophthal 2006; 124: 155-157 Conclusion: Our case presents a patient who neovascularization and IOP have been successfully controlled without the need for anti-glaucoma medications or other surgical intervention for up to 12 months after the combined procedures.