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Home , Diabetic retinopathy, Retinopathy

Topic: Anterior Segment 08/28/2015

Primary Author: Mirjeta Abazaga; Secondary Author: Joanna Komar Affiliation: NY Health Harbor VA: SUNY College of Optometry, Ocular Disease Residency. Title: Neovascular associated with proliferative diabetic ; Diagnosis and management.

81 year old male with history of proliferative develops neovascular glaucoma OS. Patient has history of PRP OU with progression of into anterior segment/angle of eye OS. Treatment with glaucoma regiment and possible surgical intervention.

I. Case History:

• Patient demographics- 81 Year old African American male • Chief complaint: Pain of the eye OS- with long-standing Hx of Diabetic retinopathy • Medical history: (+) Type II- dependent for- 35 years (+)Colon Cancer (+)Prostate Cancer • Ocular history: (+)proliferative diabetic retinopathy with neovascular glaucoma (+)panretinal photocoagulation OU (+)cyclocryablation inferior 180 OS (+) extraction sulcus IOL OS • Medication: -Ocular Medication- Simbrinza BID OS and Ketotifen BID OU -Medical- Ampicillin, Insulin-Glarigine, Ipratropium, Metformin, Tamsulosin.

Topic: Anterior Segment 08/28/2015

Primary Author: Mirjeta Abazaga; Secondary Author: Joanna Komar Affiliation: Harbor Health VA medical Center: SUNY College of Optometry, Ocular Disease Residency

II. Pertinent findings:

• Preliminary Testing: -BCVA: OD: 20/70+2 pinhole: 20/60- OS: Count finger at 60 cm -: PERRL (+)APD OS -EOM: full and smooth OU -IOP: OD:11mmHg OS: 28mmHg w/ GAT at 10:30am

• Biomicroscopy: -Lids: MGD OU; OS -: 3+ injection OU -: SPK inferior OU -Ant.chamber: deep and quiet OU -/:OD:(-)NVI OD, OS: 1 vessel loop from 2 to 3 o’clock periphery OS and 1 loop at 11 o'clock, uveae present OS; iridocorneal adhesion temporally/nasally

• Dilated Exam:

-Vitreous: syneresis OU -: OD: 0.3 h/v (shallow cup) OS: 0.99 h/v OS -Macula: OD: flat with scattered exudates OS: exudates and fibrotic membrane -Vessels: attenuation and scattered dot hemes OU -Periphery: PRP 360 OD/OS, OD: fibrotic membrane from disc going superiorly scattered exudates OU • Imaging: -HVF 24-2: OS shows arcuate defect with possible nasal step -Fundus Photos OU: PRP laser scars scattered in posterior pole OU

Topic: Anterior Segment 08/28/2015

Primary Author: Mirjeta Abazaga; Secondary Author: Joanna Komar Affiliation: Harbor Health VA medical Center: SUNY College of Optometry, Ocular Disease Residency

III. Differential Diagnosis:

• Primary: Neovascular glaucoma • Alternative Differentials: acute angle-closure, dry eye, corneal abrasion, injury to the eye, , .

IV. Diagnosis and discussion:

• Neovascular glaucoma secondary to diabetic retinopathy with retinal . • Fibrovascular membrane growth over the anterior chamber and into the angle. • Contraction of the membrane will cause peripheral anterior synechiae- and leading to angle closure (painful eye) •

V. Treatment and Management:

• Reduce IOP: Topical: beta-blockers, alpha- agonist, systemic or topical CAI. • Current treatment for Pt. Simbrinza BID OS only with systemic condition (diabetes) under control • Panretinal photocoagulation OU and cyclocryablation inferior 180 OS

Literature Review:

• Atropine can be used to reduce IOP through uveoscleral outflow • A response to treatment of IOP with Ganfort(bimatoprost/timolol) in a group of 50 patients 72.5% of patients shows a 3X decrease in IOP compared to standard treatment involving patients with secondary neovascular glaucoma and diabetes mellitus. • Management of painful eye in patient with angle closure/ “absolute glaucoma” include retrobulbar alcohol injection and cyclodestructive procedures. • Alternative treatment considering Anti-VEGF treatment comparing Topic: Anterior Segment 08/28/2015

Primary Author: Mirjeta Abazaga; Secondary Author: Joanna Komar Affiliation: Harbor Health VA medical Center: SUNY College of Optometry, Ocular Disease Residency

off-label use of and showing to affective at preventing or even regressing iris and iridocorneal angle neovascularization.

VI. Conclusion:

• Proliferative diabetic retinopathy is almost always ischemic in nature. Under hypoxic conditions, development of vascular endothelial growth factor leads to growth of new unstable/immature vessels in the posterior and anterior segment of the eye. Most common ischemic diseases include diabetic retinopathy, central retinal vein occlusion and carotid disease.

• In the current case, patient developed neovascular glaucoma OS leading to surgical intervention including PRP and cyclocryablation OS. Currently maintaining intraocular pressure controlled with Simbrinza BID OS only and with systemic condition (diabetes) under control. Intraocular pressure OU are stable.

• Neovascular glaucoma is difficult to manage and as current research shows alternative treatments include: glaucoma medication, off-label Anti-VEGF injections and surgical interventions. Research is still on going.

Topic: Anterior Segment 08/28/2015

Primary Author: Mirjeta Abazaga; Secondary Author: Joanna Komar Affiliation: Harbor Health VA medical Center: SUNY College of Optometry, Ocular Disease Residency

References:

1. Lipatov, DV, TA Chistyakov, AG Kuzmin, and AA Tolkacheva. "The Fixed Combination Efficacy Assessment in Patients with Secondary Neovascular Glaucoma and Diabetes Mellitus." Current Diabetes Review 11.4 (2015): 281-84. PubMed. Web. 27 Aug. 2015. .

2. Park, SC, D. Su, and C. Tello. "Anti-VEGF Therapy for the Treatment of Glaucoma: A Focus on Ranibizumab and Bevacizumab." Expert Opinion On Biological Therapy 12.12 (2012): 1641-647. PubMed. Web. 18 Aug. 2015. .

3. Akhtar, N., A. Tayyab, A. Kausar, and S. Jaffar. "Pain Management with Retrobulbar Alcohol Injection in Absolute Glaucoma." The Journal of Pakistan Medical Association 65.6 (2015): 678-80. PubMed. 19 Aug. 2015.

4. Gerstenblith, Adam T., and Michael P. Rabinowitz. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of . Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2012. Print.