COMMENTARY

Anti-VEGF Agents for Neovascular Glaucoma

Shuchi B. Patel, MD

Disclosures

February 24, 2016

Long-Term Outcomes of Neovascular Glaucoma Treated With and Without Intravitreal Bevacizumab

Olmos LC, Sayed MS, Moraczewski AL, et al
Eye (Lond). 2015 Dec 18. [Epub ahead of print]

Neovascular glaucoma (NVG) is a type of glaucoma caused by neovascularization of the angle that eventually leads to peripheral anterior synechiae and consequent angle closure. Numerous ocular conditions in which retinal ischemia is the underlying pathology can lead to NVG. Reduction of the ischemic drive is the primary treatment, traditionally with panretinal photocoagulation (PRP).

During the past decade, intraocular anti-VEGF agents, such as bevacizumab, have been used as off-label therapy. Although the efficacy of bevacizumab in reducing VEGF levels has been established, no studies have directly compared eyes that have been treated with or without bevacizumab for NVG. Thus, no conclusion regarding the exact role of intravitreal bevacizumab injection in eyes with NVG has been established.

Study Summary

Olmos and colleagues performed a retrospective comparative case series of 163 eyes in 151 patients with NVG, including 99 eyes treated without intravitreal bevacizumab (from 1997 to 2005, a time when intravitreal bevacizumab was not available as a treatment for NVG) and 64 eyes treated with intravitreal bevacizumab (from 2005 to 2007). Both groups of patients received standard treatments, including a varying combination of medications to lower intraocular pressure (IOP), PRP, and glaucoma drainage implants as necessitated by the severity of disease and response to treatment.

Visual acuity and IOP were analyzed, as well as the need for and timing of filtering surgery. At the time of diagnosis, both groups of patients had a similar mean IOP (43.1 mm Hg in the non-bevacizumab group vs 40.8 mm Hg in the bevacizumab group). IOP decreased similarly in both groups at 12 months (18.3 mm Hg in the non-bevacizumab group vs 15.3 mm Hg in the bevacizumab group), and the median visual acuity was finger-counting in both treatment groups.

Although bevacizumab delayed the need for glaucoma surgery, PRP was the most important factor that reduced the need for surgery. Visual acuity and IOP in eyes with NVG that were treated with bevacizumab showed no long-term differences compared with eyes that were not treated with bevacizumab. Therefore, this study demonstrated that intravitreal bevacizumab serves as an effective temporizing treatment, but it is not a replacement for definitive treatment of NVG with PRP.

Viewpoint

Anti-VEGF agents are now widely accepted as the standard of care for many ocular conditions.[1,2,3] Given that bevacizumab has been proven to be widely effective in reducing VEGF levels, its use in ischemic conditions that lead to NVG is almost universally accepted.[4,5,6]

Patients often present only after severe neovascularization of the angle has occurred, leading to high IOP and pain. Therefore, a treatment with a rapid onset of action is ideal. Intravitreal anti-VEGF agents are a logical choice to quickly regress the vessels and possibly prevent peripheral anterior synechiae and angle closure.

Most ophthalmologists would agree that this is their first line of treatment. In my own experience, I have noticed significant rapid regression of neovascularization with such treatment. The question that remains is whether further intravitreal injections alone lead to better outcomes or whether the gold standard of PRP in addition to anti-VEGF agents leads to better visual and IOP outcomes.

The results of this study demonstrate that although intravitreal anti-VEGF agents may cause an immediate visible improvement in neovascularization of the angle and delay the need for surgery, long-term PRP is the most important treatment to actually reduce the need for surgery. These valuable data indicate that PRP alone or in addition to intravitreal anti-VEGF agents should be part of the treatment plan for patients with NVG.

It seems that the use of intravitreal anti-VEGF agents should be based on the presentation of each patient. In patients with significant corneal edema that precludes PRP, initial treatment with an anti-VEGF agent can serve as a temporizing measure. Similarly, for patients who need urgent filtering surgery for IOP control, the use of an anti-VEGF agent may decrease the amount of intraoperative bleeding as well as postoperative inflammation. Therefore, although this study demonstrates the importance of PRP in the treatment of NVG, intravitreal anti-VEGF agents, such as bevacizumab, have a role in the treatment algorithm.

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