Neovascular Glaucoma Secondary to CRAO September 1, 2011 Jenny Luu, ODa,b – Optometry Resident a. VA Southern Nevada Healthcare System, b. Southern California College of Optometry, Fullerton An eighty year old African-American male with Neo-Vascular Glaucoma secondary to Central Retinal Artery Occlusion presents with chronic eye pain and severe visual impairment in his left eye. A. Case History § Demographics: 80 year old African-American male presents to clinic July 15, 2011 § Chief complaint: throbbing eye pain/irritation OS x 6 days. § Pain so severe that patient is unable to sleep § Currently taking Advil for pain relieve § Symptom has happened before in 2/2011. § Denies injury, light sensitivity, and discharge § Ocular History – Last eye exam 2/15/2011. § CRAO OS x11/17/09, NVG secondary to CRAO § Christmas Tree Cataract OS x2009 § Carotid Doppler 11/24/09 (40-59%) stenosis of left ICA § s/p Avastin injection OS x12/23/09, 4/9/10, 8/27/10, 2/11/11 § PRP OS x1/8/10, 7/23/10 § s/p Ahmed valve x8/31/10 § NVI x4/8/2010 § Medical History – Diabetes Type 2 x7 years, COPD, Arrhythmia, HTN, Allergies to Ranitidine § Medications: § Ocular: Travatan qhs OS, Cosopt BID OS, Alphagan TID OS § Systemic: Advil, Simvastatin 80 mg, Insulin Novolog, Nifedipine 60 mg, Vardenafil Hcl 20 mg, Omeprazole 20 mg, Aspirin B. Pertinent findings § Clinical § Visual Acuity: Aided § OD: 20/25 § OS: Light Perception (LP) § Pupils § OD: Round, Reactive to Light § OS: Fixed/dilated OS, (+)APD OS by RSFLT § EOM’s: full without restriction, (-) pain OU § Confrontations § OD: FTFC § OS: unable to test, LP § IOP: § OD: Refused to have pressure taken § OS: 58, 60, and 58 mmHg @ 2:50 pm GAT § Physical § Slit Lamp Examination: § OD: Unremarkable for all except • Lids/Lashes: 1+ flakes • Conjunctiva: trace injection • Lens: NSC, CC § OS: Unremarkable for all except • Lids/Lashes: 1+ flakes • Conjunctiva: 1+ injection, uncomplicated ahmed tube shunt with buried sutures at 1 o’clock position • Cornea: 1+ central band SPK • Anterior Chamber: 1.8 mm inferior hyphema • Iris: neovascularization from pupillary margins extending to angle • Lens: Christmas tree cataract C. Differential diagnosis § Eye Pain § IOP spike from NVG OS § Dry eye § Infection of ahmed tube shunt § Reduced Vision § IOP spike from NVG OS § Dry eye § Hyphema § Christmas tree cataract § Hyphema § NVI D. Diagnosis and Discussion § Neovascular Glaucoma OS with NVI and hyphema: § Secondary angle closure glaucoma, caused by fibro-vascular tissue growth over the angle of the anterior chamber. These are typically resulted from neovascularization of the iris and rarely neovascularization of angle § Neovascularization typically arise from CRVO, Diabetic Retinopathy, Carotid Obstructive Disease, and less often CRAO, intraocular tumors, and retinal detachment § The areas of hypoxic retina from these disease and complications cause the release of VEG-F. The VEG-F allows for new vessels growth to re-supply the ischemic retina. § Christmas Tree Cataract OS: Metabolic cataract § Opacities behind the anterior capsule that varies in numerous colors. § Typically associated with myotonic dystrophy E. Treatment, management § Neovascular Glaucoma: § Continue Travatan qhs OS, Cosopt BID OS, and Alphagan TID OS. § Start Diamox 500 mg BID PO x 1 week § Start Pred Forte 6x/day, Atropine BID OS § Tube Shunt once active bleeding of hyphema subsides § Avastin Injection OS § Goal is to reduced pressure for patient comfort § Patient’s IOP was reduced to 46 mmHg and pain reduced. § Patient’s hyphema reduced to 0.8 mm § Christmas Tree Cataract: Cataract extraction § Not indicated at this time since patient is LP OS, and cataract extraction will not improve vision and cause NVG to worsens § Bibliography/Sources § Ehlers, Justis P and Chirag Shah. (2008). The Wills Eye Manual; Fifth Edition. Baltimore: Lippincott Williams & Wilkins. pp. ???? § Kanski, J. (2006). Clinical ophthalmology: A systemic approach, Sixth edition. New York: Butterworth Heinemann Elsevier. pp. 402-404 F. Conclusion § Less likely conditions such as CRAO can cause neovascularization and needs to be monitor closely with dilation and gonioscopy § Prognosis for visual function is usually poor. The goal is to relieve pain for patient’s comfort. § Removal of cataract of this patient can actually cause the condition to worsens and not improve visual function .