Download Inning Chen - American Academy of Optometry

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.