Intravitreal ranibizumab as adjuvant treatment for neovascular glaucoma

The purpose of this study was to describe a prospective case series of 5 eyes treated with intravitreal ranibizumab injection for neovascular glaucoma (NVG). Five patients with clinically uncontrolled NVG secondary to proliferative diabetic retinopathy (4 patients) and central retinal vein occlusion (1 patient), non-responsive to maximal tolerable medication and panretinal photocoagulation, received intravitreal ranibizumab injection (0.5 mg). Patients were seen at 1st, 3rd and 7th day after the ranibizumab injection and when it was necessary. Success was defined as intraocular pressure (IOP) <d” 21mmHg, with or without medication. Those with persistent IOP > 21, despite maximal tolerable medication, underwent trabeculectomy with 0.5mg/ml mitomycin C (MMC) for 1 minute. Failure was defined as IOP > 21 mmHg, phthisis bulbi, loss of light perception or additional glaucoma surgery. The primary outcome was 6-month IOP control. Mean IOP before the ranibizumab injection was 37 mmHg (7 mmHg SD). Two out of five eyes underwent only ranibizumab injection, having an IOP control after the procedure. Three patients were submitted to trabeculectomy with MMC on the 7th day after the injection. At 6-month follow-up, the mean IOP was 12mmHg (3 mmHg SD). All eyes showed regression of rubeosis iridis and IOP control. Visual acuity improved in 2 eyes worsened in 1 eye, and remained stable in 2 eyes. These data suggest that intravitreal ranibizumab injection may be a useful tool in the treatment of NVG.

Descritores: Glaucoma neovascular/quimioterapia; Quimioterapia adjuvante; Pressão intraocular; Injeções intravítreas; Anticorpos monoclonais/uso terapêutico; Relatos de casos INTRODUCTION N eovascular glaucoma (NVG) is a severe form of glaucoma characterized by rubeosis iridis and intraocular pressure (IOP) elevation.Hypoxic disease of the retina such as diabetic retinopathy and occlusion of major retinal vessels account for more than one half of this glaucoma.Once retinal hypoxia is established the natural history of neovascular glaucoma can be divided in four stages: prerubeosis stage, preglaucoma stage, open-angle glaucoma stage, and angleclosure glaucoma stage. (1)anretinal photocoagulation has been shown to significantly reduce or eliminate anterior neovascularization and may reverse IOP elevation in the open-angle glaucoma stage.When the IOP begins to rise, medical therapy is required to control the pressure during the open-angle glaucoma stage.The mainstays of the therapy at this stage are drugs that reduce aqueous production such as carbonic anhydrase inhibitors, topical beta-blockers and alpha agonists.Although surgical intervention is often necessary, trabeculectomy alone and other shunt-tube drainage procedures for NVG are challenging because new vessels tend to recur, bleed easily, are always associated with postoperative inflammation and have higher rate of failure to control IOP. (2)4) Intravitreal ranibizumab is the standard of care for the treatment of exudative macular degeneration.This pharmacologic agent, which selectively inhibits vascular endothelial growth factor (VEGF), might be an important adjunctive therapy in the management of NVG by causing rapid and consistent regression of neovascularization in the anterior segment.
The purpose of this study is to describe a prospective case series of five eyes treated with intravitreal ranibizumab injection for NVG.

Cases report
A total of 5 patients with clinically uncontrolled NVG, secondary to proliferative diabetic retinopathy (PDR) (4 patients) and central retinal vein occlusion (CRVO) (1 patient), non-responsive to maximal tolerable medication and panretinal photocoagulation, received intravitreal ranibizumab (0.5 mg) injection via the pars plana and if necessary were scheduled for trabeculectomy, at University of Campinas -Brazil.Ethics committee approval was obtained and all participants gave informed consent.
We excluded patients with cloudy media, previous surgery on the superior conjunctiva, history of uveitis, infectious retinopathy, retinal detachment, hemoglobinopathy, trauma or previous vitreoretinal surgery.
After discussing treatment options and obtaining informed consent, a single injection of intravitreal ranibizumab (0.5 mg) was administered (Figure 1).Patients were seen on 1st, 3rd and 7th day after the ranibizumab injection and when it was necessary.Success was defined as IOP ≥ 21mmHg with or without medication.Those with persistent IOP > 21, despite maximal tolerable medication, underwent trabeculectomy with 0.5mg/ml mitomycin C (MMC) for one minute.Failure was defined as IOP > 21 mmHg, phthisis bulbi, loss of light perception or additional glaucoma surgery.The primary outcome was 6-month IOP control.
All patients were on the open-angle glaucoma stage.Mean IOP before the injection was 37 mmHg (7 mmHg SD).Two of them underwent only intravitreal ranibizumab injection, having an IOP control after the procedure with 2 anti-glaucoma medications.Three patients were submitted to trabeculectomy with MMC on the 7th day after the injection.At 6-month followup, the mean IOP was 12mmHg (

Figure 1 :Figure 2 :
Figure 1: (A) Right eye of a 56-year-old male with neovascular glaucoma secondary to proliferative diabetic retinopathy; (B) Three-day follow-up of the same eye after intravitreal ranibizumab injection; note the rubeosis iridis regression

Table 1 Clinical data of cases of intravitreal ranibizumab injection as adjuvant treatment for neovascular glaucoma
3 mmHg SD).Other outcome