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Editors Selection IGR 18-1

Surgical treatment: Anti-VEGF vs. Valve for neovascular glaucoma

Comment by Sarwat Salim on:

69037 Intravitreal ranibizumab injection combined trabeculectomy versus Ahmed valve surgery in the treatment of neovascular glaucoma: assessment of efficacy and complications, Liu L; Xu Y; Huang Z et al., BMC Ophthalmology, 2016; 16: 65

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Neovascular glaucoma (NVG) is a potentially devastating glaucoma caused by diseases that lead to retinal ischemia and release of vascular endothelial growth factors (VEGF). Recently, anti- VEGF therapy has become a mainstay in treating NVG. Several studies have reported regression of neovascularization, reduced ocular pain, and reduced intraocular pressure (IOP) when using anti-VEFG agents in conjunction with glaucoma surgery.^1-4

Liu et al. prospectively assessed the efficacy and safety of intravitreal ranibizumab (0.5 mg) combined with trabeculectomy (18 eyes) and compared it to FP7 Ahmed valve surgery (19 eyes) at six months for treating neovascular glaucoma. Mitomycin C was used during trabeculectomy (0.4 mg/ml for 1-2 min duration). Panretinal photocoagulation was performed in approximately 90% of the cases in both groups prior to surgery. There was no difference in baseline characteristics, including preoperative IOP. Surgical success was defined as IOP ≥ 6 mm Hg and ≤ 21 mm Hg without any glaucoma medications, additional surgery, or loss of light perception vision. IOP was significantly reduced in both groups with no difference between the two groups at month 6 (P = 0.324). Complete surgical success was 61.1% and 57.9% in the trabeculectomy and Ahmed groups, respectively. Postoperative complications were more commonly encountered in the Ahmed group (42.1% vs. 16.7%). The authors concluded that, compared to Ahmed surgery, intravitreal ranibizumab combined with trabeculectomy had fewer complications and a higher success ratio.

This study affirms the use of anti-VEGF therapy in optimizing surgical outcomes and minimizing complications during trabeculectomy

Current literature is limited in comparing different surgical techniques for NVG. The authors are commended for studying the outcomes of two commonly performed procedures for neovascular glaucoma in a prospective interventional series. This study affirms the use of anti-VEGF therapy in optimizing surgical outcomes and minimizing complications during trabeculectomy. Although this is an important clinical study when analyzing outcomes of two procedures separately, one needs to be cautious when interpreting results, comparing two techniques, and drawing conclusions. The study compared two totally different surgeries with lack of controls. While neovascularization and inflammation were controlled in the trabeculectomy group with prior anti-VEGF injection, Ahmed valve surgery was performed in inflamed eyes with active neovascularization. Because ranibizumab was not used in the Ahmed group, this could have accounted for more complications. The study would have more merit if outcomes were compared of trabeculectomy with and without ranibizumab or Ahmed valve implantation with and without ranibizumab. The study is also limited by a small sample size and short follow-up. It is well known that long-term treatment outcomes are limited in NVG due to progression of underlying disease, irrespective of type of surgical intervention. Therefore, additional research is needed, particularly prospective multicenter trials, with a longer follow-up to understand the efficacy and safety of different surgeries in NVG when augmented with anti-VEGF therapy and pan-retinal photocoagulation.

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