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Neovascular Glaucoma NVG

Neovascular Glaucoma (NVG) . . . . . Neovascular Glaucoma is one of the mostChallenging forms of secondary glaucomas. It occurs when the fibrovascular tissue proliferates onto the chamber angle, obstructs the trabecular meshwork, and produces peripheral anterior synechiae and progressive angle closure. The elevated intraocular pressure is often difficult to control and frequently results in loss of vision..

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Neovascular Glaucoma NVG

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    1. Neovascular Glaucoma (NVG) Saleh A. Al-Obeidan, MD Department of Ophthalmology College of Medicine King Saud University

    2. Neovascular Glaucoma (NVG)

    3. NVG

    4. NVG Pathogenesis Leading causes: Retinal Ischemia Responsible for 97% - Diabetic Retinopathy - Central Retinal Vein Occlusion Brown GC et al. Ophthalmology 1984

    6. NVG Pathogenesis X-Factor VEGF - Vascular Endothelial Growth Factor 1 of 9 non polypeptide growth factors Specific for endothelial cells (EC) Causes EC migration and mitosis Increases EC permeability

    7. NVG Pathogenesis VEGF (source in the eye) Expressed and produced by: Corneal endothelium, Iris pigment epithelium, RPE, Ganglion cells, Astrocytes, Muller cells, Uveal melanocyte, and Choroidal fibroblasts.

    8. NVG Pathogenesis VEGF Markedly elevated in aqueous humor of patients with NVG.

    9. NVG Pathogenesis VEGF (210 Vitrectomy samples) - Vitreous (VEGF) PDR 36x NPDR - Vitreous (VEGF) > Aqueous (VEGF) - (VEGF) ?75% post PRP VEGF plays a major part in mediating active intraocular neovascularization in patients with ischemic retinal diseases. N Engl J Med 1994;331:1480-7

    10. NVG Pathogenesis Anti Angiogenic Therapy: Intravitreal injection of crystalline cortisone causes regression of iris neovascularization Jonas et al. J Glaucoma 2001

    11. NVG Pathogenesis Anti-Angiogenic Therapy: Anti VEGF (Ranibizumab, Lucentis) ? Intravitreal injection prevented formation of CNV in monkeys and decreased leakage of already formed CNV with no significant toxic effects

    12. NVG Pathogenesis Anti Angiogenic Therapy: ? Anti VEGF [SU 5416 (Semaxinib)] Durable and rapid recovery of visual functions in a patient with von Hippel-Lindau syndrome

    13. NVG Pathogenesis Anti Angiogenic Therapy: ? Anti VEGF [Aptamer (Macugen)] ? Remarkable reduction in the size of CNV ? Remarkable visual improvement “26.7% gained 3 lines or more”

    14. NVG Pathogenesis Anti Angiogenic Therapy: Bevacizumab [Avastatin]

    15. NVG Pathogenesis Panretinal Photocoagulation and Ocular Neovascularization ? PRP upregulate expression of transforming growth factor-? (TGF- ?) ? TGF- ? is a powerful vascular endothelial cell proliferation inhibitor.

    16. NVG Pathogenesis Panretinal Photocoagulation and Ocular Neovascularization ? Photo coagulated cultured human RPE & rat retinas upregulate expression of high level of Pigment Epithelium Derived Factor (PEDF) ? PEDF has been shown to be a potent inhibitor of ocular angiogenesis

    17. NVG Pathogenesis Panretinal Photocoagulation and Ocular Neovascularization Major benefit of PRP may be destruction of VEGF source.

    18. Reduced vision Injected eye A/C reaction Elevated IOP < 40 mmHg Middilated, non reactive pupil Rubeosis irides (NVI) Neovascularization of the angle (NVA)

    19. NVG Enucleation is only practical treatment No means are known to prevent NVG The treatment of NVG is disheartening

    20. NVG Outcomes have improved dramatically. New medical and surgical approaches. Better understanding and control of angiogenesis.

    21. NVG

    22. Recognition of patients at HIGH RISK Recognition of NVI before angle closure is critical Treatment

    23. Recognition high risk patients Correction of the underlying pathology Close observation (NVI & NVA) Efficient & sufficient PRP

    24. Visual potential Clarity of the media

    25. Control inflammation & pain Cycloplegia Steroids

    26. Control IOP Aqueous suppressants Avoid miotics & prostaglandines

    27. Panretinal photocoagulation (PRP) 1st line of therapy (if possible) Reduces & can eliminate ant. seg. neovascularization. Panretinal cryoablation

    28. Filteration surgery Tube surgery Cyclodystructive procedures Others

    29. NVG Treatment Cyclophotocoagulation Visual loss up to 46.6% Shields & Shields 1994 Cyclocryotherapy Visual loss of up to 70% Caprioli et al. Ophthalmology 1985 Phthisis Bulbi 34% Krupin T et al. Am J Ophthalmol 1978;86:24-6

    30. NVG Treatment Tube shunts: Variable success rates Probably more suitable for previously operated eyes (e.g. failed filter proced. Aphakia) High rate of visual loss (19-48%) and phthisis bulbi (11-25%)

    31. Filteration surgery

    32. Full PRP Improves the Outcome of Trabeculectomy in NVG

    33. Full PRP Improves the Outcome of Trabeculectomy in NVG

    34. Full PRP Improves the Outcome of Trabeculectomy in NVG

    35. Treatment

    36. NVG Points to Remember It is a preventable condition.

    37. NVG Points to Remember It is a treatable condition.

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