OOMC News

Authored by: Danielle Strauss, MD

CC: 52 year-old woman was referred to us for suspected glaucoma due to IOP elevation, and possible diabetic retinopathy. Pt reports blurry vision OU for a few months, reports mild ache over her right brow.

PMHX: Type 2 diabetes – a1c unknown, not well controlled. HTN

Past ocular history: No family history of glaucoma, denies any treatment for retinal issues, no surgical history

BCVA: 20/150 OU

IOP: 72 OD, 32 OS

SLE:

Conjunctiva/sclera 1+ injection od, white and quiet os

Cornea: 1+ stromal edema od, clear os

Iris- ++rubeosis ou

1+ NS cataracts ou

Gonioscopy  +neovascularization of the angle OU

DFE: see imaging below

Imaging:

Widefield color fundus photo of the right eye showed diffuse microaneurysms, dot and blot hemorrhages, lipid deposition in the macula, and neovascularization elsewhere (NVE) and neovascularization of the disc (NVD).

Here is a closer look at the posterior pole of the right eye with NVD and NVE.

Widefield color photo of the left eye showed similar changes.

Due to the concerning retinal changes on the exam, we decided to proceed with additional imaging including fluorescein angiography (FA) and OCT.

FA of the left eye showed similar changes.

Assessment:

51 year-old woman with ischemic proliferative diabetic retinopathy (PDR), significant retinal ischemia, and secondary neovascular glaucoma (NVG) with uncontrolled intraocular pressure OU. Ischemic macular changes OU.

Plan:

• Start maximal IOP lowering therapy including Vyzulta, combigan and azopt OU. Start Diamox 500mg bid.
• Glaucoma consultation tomorrow
• Immediate treatment with intravitreal injection of Avastin right eye today with an anterior chamber paracentesis to lower the intraocular pressure (starting 72mm hg).
• Plan full treatment for diabetic retinopathy with bilateral anti-vegf injections and full laser pan retinal photocoagulation in both eyes.
• Endocrinology consultation for uncontrolled diabetes

Follow up:

The patient returned the following day and the IOPs were 31 OD and 23 OS. Rhopressa was added to the drop regimen. An intravitreal injection of Avastin was given to the left eye.

Within the next week, thanks to the immediate injections of Avastin we performed,  there was regression of the rubeotic vessels as well as neovascular vessels in the angle. The iops were 21 ou. Diamox is being tapered off slowly.  In cases of NVG due to ischemic PDR, the use of anti-vegf agents is critical in helping to control the iop and reduce the VEGF burden in the eye.

Anti-vegf agents, including Avastin, Lucentis and Eylea are used in conjunction with laser to stop the progression of PDR and prevent further complications of uncontrolled diabetic retinopathy such as vitreous hemorrhages or tractional retinal detachments.

Currently, the patient is being followed closely by both the glaucoma and retina teams and has had further intravitreal injections of avastin in each eye as well as laser treatment.

SD-OCTs show improvement of the macular edema and vision has improved to 20/70 OD, and 20/50 OS.