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Neovascular Glaucoma Clinical Presentation

  • Author: Jacqueline Freudenthal, MD; Chief Editor: Hampton Roy, Sr, MD  more...
 
Updated: Dec 10, 2015
 

History

A careful and detailed ocular and systemic history is imperative in diagnosing both neovascular glaucoma (NVG) and the underlying problem causing it.

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Physical

A complete ocular examination of both eyes, particularly of the posterior segment, will almost certainly provide the etiology of neovascularization. Of the 3 most common causes of NVG, ocular ischemic syndrome presents as a diagnostic dilemma and, thus, deserves special mention.

The typical clinical presentation of NVG is the same regardless of the underlying cause. The typical clinical presentation can be divided into the following 2 stages: the early stage and the advanced stage. These stages generally follow each other in progression, and the early stage is subdivided further into rubeosis iridis and secondary open-angle glaucoma.

Early stage (rubeosis iridis)

Findings of rubeosis iridis may include the following:

  • Normal IOP
  • Presence of tiny, neovascular, dilated capillary tufts at pupillary margin
  • High magnification on slit lamp (to view earliest finding in NVG)
  • NVI (irregular, nonradial vessels usually not in the iris stroma)
  • NVA (can occur with or without NVI)
  • Careful gonioscopy in all eyes at high risk for NVG even without pupillary and iris involvement
  • Poorly reactive pupil
  • Ectropion uvea

Early stage (secondary open-angle glaucoma)

Findings of secondary open-angle glaucoma may include the following:

  • Elevated IOP
  • NVI continuous with NVA
  • Proliferation of neovascular tissue over the angle
  • Fibrovascular membranes (develop circumferentially across the angle, blocking the trabecular meshwork)

Advanced stage

In this stage, secondary angle-closure glaucoma is characterized by some or all of the following:

  • Acute severe pain, headache, nausea, and/or vomiting
  • Photophobia
  • Reduced visual acuity (counting fingers to hand motion)
  • Elevated IOP (≥ 60 mm Hg)
  • Conjunctival injection
  • Corneal edema
  • Plus/minus hyphema
  • Aqueous flare
  • Synechial angle closure
  • Severe rubeosis
  • Distorted, fixed, mid-dilated pupil and ectropion uveae
  • Retinal neovascularization and/or hemorrhage
  • Optic nerve cupping (possibly)

Ocular ischemic syndrome

Ocular ischemic syndrome occurs in the presence of more than 90% of patients with carotid artery stenosis, but it can occur as a result of aortic arch disease (eg, syphilis, Takayasu arteritis, dissecting aneurysm), in which case the presentation may be bilateral.

Symptoms include a dull periocular/periorbital pain that can be secondary to the ischemia and/or NVG.

Signs include the following:

  • Vision can vary from 20/20 to no light perception.
  • Midperipheral intraretinal hemorrhage (in contrast to diabetic retinopathy and CRVO where the hemorrhage is mostly situated in the posterior pole)
  • IOP can be elevated secondary to NVG, decreased secondary to ciliary body hypoperfusion, or normal as a result of both processes.
  • Other signs include corneal decompensation, iritis, iris atrophy, cataract, and spontaneous pulsations of the central retinal artery.
  • Intravenous fluorescein angiogram will demonstrate prolonged choroidal filling and increased arteriovenous transit time.
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Causes

Relatively frequent causes of NVG include the following:

Less frequent causes of NVG include the following:

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Contributor Information and Disclosures
Author

Jacqueline Freudenthal, MD Co-Investigator, Ophthalmic Consultants Centre, Toronto

Jacqueline Freudenthal, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, Canadian Ophthalmological Society

Disclosure: Nothing to disclose.

Coauthor(s)

Iqbal Ike K Ahmed, MD, FRCSC Clinical Assistant Professor, Department of Ophthalmology, University of Utah

Iqbal Ike K Ahmed, MD, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Canadian Ophthalmological Society, Ontario Medical Association

Disclosure: Nothing to disclose.

Baseer U Khan, MD 

Baseer U Khan, MD is a member of the following medical societies: Canadian Ophthalmological Society

Disclosure: Nothing to disclose.

Khalid Hasanee, MD Glaucoma and Anterior Segment Fellow, Department of Ophthalmology, University of Toronto

Khalid Hasanee, MD is a member of the following medical societies: Canadian Medical Association, Canadian Ophthalmological Society, Ontario Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Martin B Wax, MD Professor, Department of Ophthalmology, University of Texas Southwestern Medical School; Vice President, Research and Development, Head, Ophthalmology Discovery Research and Preclinical Sciences, Alcon Laboratories, Inc

Martin B Wax, MD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, Society for Neuroscience

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy, Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy, Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

Additional Contributors

Bradford Shingleton, MD Assistant Clinical Professor of Ophthalmology, Harvard Medical School; Consulting Staff, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary

Bradford Shingleton, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Acknowledgements

Yasser A Khan, MD Consulting Staff, Credit Valley Eye Care

Yasser A Khan, MD is a member of the following medical societies: Canadian Medical Association, Canadian Ophthalmological Society, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

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