Somebody posed this interesting question:
Just wanted to know if anyone is using avastin in Neovascular glaucoma- intravitreal/intracameral. any advantage of intracameral over intravitreal ( ofcourse coupled with PRP)?
any specific precaution to be taken while giving intracameral in this situation?
The responses were varied and interesting from leading practicing eye doctors in India:
My favorite combination is intravitreal avastin + prp followed in few days by ahmed glaucoma implant. Works wonderful. Many times with surprisingly good regression and visual results. The Agv refreshes internal environment and drains out vegf.
Have used intravitreal avastin in NVG with good results in terms of reducing
NVI , NVA and IOP.
Its safe to give intravitreal only without doing paracentisis to avoid hyphema ( which may occur if you give intracamerally). Also its better to address the source of VEGF production which lies in retina only as NVI, NVA will occur only if the level of VEGF crosses app 700 to 800 p gm in ant segment.
Intracameral or intravitreal avastin can be given for NVI. IOP needs to be brought down by mannitol before giving avastin. Trab can be done 3-5 days later and if media permits a PRP.
I give it intravitreally the source of the VEGF. We can give the complete dose if given intravitreal than intracameral. Risk of hyphema with intracameral is higher.
Will be nice to hear the experiences of other members as well.
Just to add that intracameral Avastin is fraught with risk of hyphema, Source of VEGF being retina. Intravitreal is more rational. Also intracameral does not stay as long in AC as much as in vitreous gel.
NVG Management as I do it –
If clear cornea Try Transpupillary Laser and Adjuvant Cryo (ARC). Side by side IOP control / If required Trab with MMC, sos AGV.
If there is corneal haze Reduce IOP and try laser/cryo ablation. If not possible give intravitreal Avastin. Usually the NVI regresses rapidly and Laser is possible after Avastin. Antiglaucoma surgery may be done if medical methods to reduce IOP fail.
The exact sequence of doing Laser or Avastin may vary from case to case.
Using Avastin first in all cases is not a bad idea though. It helps you buy time for more specific management later.
If there is associated cataract and/or Vitreous hemorrhage then I give Avastin first, followed by lens and vitreous surgery with thorough endo ablation. Residual high IOP may be managed side by side appropriately.
If visual potential poor Avastin and cyclodestructive (Cryo)
We do a gonioscopic exam and segregate such patients into those with and without significant (>180 degrees) angle closure. In those without the same, Avastin works quite well with reduction of neovascular activity even on day 1, reduction of IOP and corneal clearing allowing laser ablation.
In those with angle closure, we have not found any effect on the IOP and the cornea. Though NV decreases, there is no short or long term benefit. Here, it is preferable to go for surgery- shunt or trab with mmc. Luckily, we have not encountered significant intraop bleeding even without Avastin.
Iv had a very bad experience with avastin in nvd/nvd. .. .had a pale disc following injection..pre operatively pressures were managed and intra op paracentesis was done..its a tricky situation..
Its the disease process which is the cause. Not avastin
While considering intracameral anti VEGF injections in eyes with neovascular glaucoma, the first step would be to medically reduce the IOP to facilitate the injection in a safe manner. Gonioscopy would be ideal but not always possible considering the associated media haze (corneal oedema and reaction in anterior chamber) and patients discomfort.Intracameral injections have been found to be a useful adjunct even when Glaucoma filtration surgery(GFS) is planned and hence gonioscopy can be considered post injection once things have quietened down. Depending upon the findings on gonioscopy a decision regarding medical management / GFS can be considered.
Our friend Mango aka Aam in Australia
Gold Coast, Australia