Study of Disease Pattern of Neovascular Glaucoma

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132 Int J Res Med. 2017; 5(4); 132-136 e ISSN:2320-2742 p ISSN: 2320-2734

Study of Disease Pattern of Neovascular Glaucoma

Komal A Vala1*_{, Mayank P Acharya}2_{, Anwar Sipai}3_{, Radhakrishna Khatri}4_{, Bharg} Kariya5

1,4,5₃rd_{year resident,}2_{Additional professor and HOU,}3_{Assistant professor Department of ophthalmology M. P. Shah medical}

college, Jamnagar

INTRODUCTION

Glaucoma is one of the very long known but poorly understood eye disease that said to be responsible for gradual blindness very frequently yet the most controversial subject in ophthalmology. There is also lack of awareness among people that make this disease one of the headache among ophthalmologists.

It is difficult to define the term glaucoma, which by itself is not a disease but a symptoms complex having raised intraocular pressure that lead to characteristic optic disc changes, visual field loss and signs of retinal ischemia. There are also various procedures and instruments to evaluate their presence and progression. The basis of raised intraocular pressure is in aqueous humour drainage at anterior chamber angle. Gonioscopy is one of the best method to examine anterior chamber angle and classify as open angle and close angle glaucoma. Gonioscopy is also important to evaluate other angle

*Corresponding Author:

Dr. Komal A Vala

C-17 B Quarter,oppo. Kenya Gym M.P.Shah medical college campus Jamnagar-361008

Contact No: 9586585965

Email: drvalakomal@gmail.com

pathology like neovascularization, iris pigments, pseudoexfoliation materials,etc. Neovascular glaucoma is an aggressive

condition which is due to

neovascularization of iris as a result of retinal ischemia. For this reason it is must to rule out other condition that lead to retinal ischemia and neovascularization of iris that also will lead to neovascular glaucoma sooner or later. The established neovascular glaucoma on first consultation of patient should make an ophthalmologist to worry about the fellow eye of the patient as neovascularization of iris is advanced stage of retinal disease which may be bilateral. The gap of time in involvement of other eye gives us chance to do something to diagnose early the predilection of other eye towards the same condition at the time of the least possible damage to that eye.

As early diagnosis is the only way in neovascular glaucoma to prevent further damage to optic nerve head and there by save the patient from gradual blindness, it has great importance to start treatment in terms of medical /surgical/laser technique, and assess patient for its progression. For deciding treatment plan surgeon has to grade the disease as following.

ORIGINAL ARTICLE

ABSTRACT

BACKGROUND: Study of various aspects of neovascular glaucoma,its cause and grading for better understanding

of disease. OBJECTIVE: To know common causes, disease severity, age and sex distribution, grading based on angle involvement for better assessment and treatment of neovascular disease. MATERIALS AND METHODS:

Study of 30 patients has been carried out. Dilated fundus examination of all patients are done to find out underlying causes of ischemia like diabetes, central retinal vein occlusion, trauma, tumors, etc. Tonometry, gonioscopy and other measurement like blood pressure and random blood sugar was done. Incidence of all causes as per age and sex are calculated. RESULT: Neovascular glaucoma is commonest in patients of diabetes and patients having proliferative diabetic retinopathy, followed by ischemic CRVO. Males between 50-60 years of age are more commonly affected.

CONCLUSION: Ischemic changes in retina is most striking feature for the surgeon to suspect neovascular glaucoma,

most common is proliferative diabetic retinopathy. One should grade the disease and plan the treatment according to that for better visual outcome and save the patient from painful blind eye.

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133 Int J Res Med. 2017; 5(4); 132-136 e ISSN:2320-2742 p ISSN: 2320-2734 Grading of Neovascularization of Iris

and Angle

GRADE NEOVASCULARISA TION OF IRIS

NEOVASCULARISATI ON OF ANGLE OF ANTERIOR CHAMBER

1. Fine surface neovascularisation of the pupillary zone of the iris involving less than 2 quadrants

Fine neovascular twigs cross the scleral spur and branch on the trabecular meshwork involving less than 2 quadrants

2. Surface

neovascularisation of the pupillary zone of iris involving more than 2 quadrants

Fine neovascular twings cross scleral spur branching on the trabecular meshwork involving more than 2 quadrants

3 In addition to neovascularization of the pupillary zone,neovascularizatio n of the ciliary zone of the iris or ectropion uveae involving 1 to 3 quadrants

In addision to neovascularization of trabecular meshwork peripheral anterior synechiae(PAS) involving 1 to 3 quadrants

4 Neovascularization of the ciliary zone of the iris or ectropion uveae involving 3+ quadrants

PAS involving 3+ quadrants

METHODS AND MATERIALS

The present study has been conducted on 30 patients (60 eyes) suspected and diagnosed as having neovascular glaucoma.

Inclusion Criteria:

 Patients with complaints of headache, colour halos, difficulty in dark adaptation, dimness of peripheral vision with high intra ocular pressure were selected.

 Patients with suspected glaucomatous optic nerve head changes who came for some other ocular complaints.

 Patients of diabetes and hypertension are included.

 Patients with history of AGS done were included.

 Patients with past history of glaucoma were included.

 Patients having past history of ocular injury.

Exclusion Criteria: Patients who

presented with acute attack of angle closure glaucoma were excluded.

 All patients were examined thoroughly.  Details history including past history and

family history noted.

 Thorough Slit lamp examination of anterior chamber was done.

 Fundus examination of both eyes after fully dilatation of pupil was made with

I. Direct ophthalmoscopy II. Indirect ophthalmoscopy

III. Slit lamp biomicroscopy using +90 D. Fundus examination was aimed to note the findings like optic nerve head changes, vascular changes, cup/disc ratio, diabetic retinopathy, ischemic central retinal vein occlusion, etc.

 Intraocular pressure measured by goldmann aplanation tonometer.

 Angle structure examination done by Goldmann’s four mirror goniolens and graded according to Shaffer’s grading as Grade 0, I , II, III, or IV.

 Grading of neovascular glaucoma done as per standard classification.

RESULTS

In this study we had studied 30 patients of neovascular glaucoma. Total examined eyes were 60,among them 43 eyes having neovascular glaucoma. So incidence of neovascular glaucoma was 71.6%.

Incidence of Neovascular Glaucoma(NVG): Among the patients of

Diabetes, 22 eyes were of proliferative diabetic retinopathy and 8 eyes were of Nonproliferative diabetic retinopathy. But neovascular glaucoma was found in 21 eyes of proliferative diabetic retinopathy

and not in any eyes having

nonproliferative diabetic retinopathy. So incidence of neovascular glaucoma in proliferative diabetic retinopathy was 99.8% and in nonproliferative diabetic retinopathy was 0%.

Table 1: Incidence of NVG Among Diabetes Pt

Figure 1: Incidence of Nvg In Diabetes

Among the patients of CRVO, 17 eyes were of ischemic CRVO and 5 eyes were of Non ischemic CRVO. But neovascular glaucoma was found in all eyes of

INCIDENCE OF NVG AMONG DIABETES PT PDR NPDR

TOTAL NO OF EYES 22 8 EYES WITH NVG 21 0

0 20 40

PDR NPDR

N

O

F E

YE

S

INCIDENCE OF NVG IN DIABETES

TOTAL NO OF EYES

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ischemic CRVO and none of the non ischemic CRVO had neovascular glaucoma. So incidence of neovascular glaucoma in ischemic CRVO was 100% and in non ischemic CRVO was 0%.

Table 2: Incidence of NVG Among Pt of CRVO

Figure 2: Incidence of NVG in CRVO Age and Sex Distribution of All NVG Patients

Our study of 30 patients included 17 male and 13 female (M:F – 1.3:1). Majority of patients were between 50-60 years of age group (63.3%).

Table 3: Age Distribution

AGE OF PATIENTS (YEARS)

NO OF PATIENTS

PERCENTAGE

40 – 49 5 16.60% 50 – 59 19 63.30% 60 – 69 6 20%

Table 4: Sex Distribution

Sex Distribution Among Nvg Patients Male 17

Female 13

Figure 4: Age and Sex Distribution of PDR and CRVO Patients.

In the group of proliferative diabetic retinopathy, male-female distribution was almost similar with males (53%) at slight higher risk than and females (47%). Mean age at presentation were 54.34 years. Males were maximally presenting between the age group of 60-70 years of age whereas most of the females presenting between 50-60 years. In these 15 patients 3

patients were having grade 1, 7 patients were of grade 2 and 5 patients were having grade 3 disease .So almost 50% patients were of grade 2 neovascular glaucoma. Mean age at presentation for ischemic CRVO were 64.5 year, as 63.63% patients were age group between 60-70 years. A male predominance with male: female ratio 1.7:1 was found in ischemic CRVO. Both males and females were commonly presenting between 60-70 years age group. In 10 patients of ischemic CRVO, 3 patients were having grade 1, 2 patients were of grade 2 and 6 patients were having grade 3 disease .So 54.54% of patients of CRVO were presented with grade 3 neovascular glaucoma, which was higher than proliferative diabetic patients.

Table 5: Age Ischemic PDR and CRVO

AGE PDR ISCHEMIC CRVO

MALE FEMALE TOTAL MALE FEMALE TOTAL 40 -49 2 1 3 1 0 1

50-59 3 4 7 2 1 3

60-69 3 2 5 4 3 7

TOTAL 8 7 15 7 4 11 Figure 5: Age and Sex Wise Distribution

Table 6: Age Distribution of Percentage of Patients

AGE DISTRIBUTION OF NVG IN PERCENTAGE AGE OF

PATIENTS

NVG PDR ISCHEMIC CRVO

40 – 49 16.60% 20% 9.09% 50 – 59 63.30% 46.60% 27.27% 60 – 69 20% 33.30% 63.63%

Figure 6: Age Distribution of Percentage of Patients

0.00% 20.00% 40.00% 60.00% 80.00% 100.00%

NVG PDR ISCHEMIC

CRVO

16.60% 20% _9.09%

63.30% _46.60%

27.27%

20% _33.30%

63.63%

40 - 49 50 - 59

INCIDENCE OF NVG AMONG PT OF CRVO ISCHEMIC

CRVO

NONISCHEMIC CRVO

TOTAL NO OF EYES 17 5 EYES WITH NVG 17 0

0 5 10 15 20

ISCHEMIC NON ISCHEMIC

NO

O

F

EYE

S

INCIDENCE OF NVG IN CRVO

TOTAL NO OF EYES EYES WITH NVG 17% 63% 20% AGE DISTRIBUTION

40 - 49

50 - 59

60 - 69

0 10 20 M A LE FE M A LE TO TA L M A LE FE M A LE TO TA L

PDR ISCHEMIC CRVO

N O O F PA TIN TS Axis Title

AGE AND SEX WISE DISTRIBUTION

40 -49

50-59

60-69

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Table 7: Grading of NVG in Different Groups

GRADING OF NVG AMONG DIABETIC PATIENTS GRADE 1 GRADE 2 GRADE 3 NO. OF PATIENTS 3 7 5 PERCENTAGE 20% 46% 34%

Figure 7:No. of Diabetic Patients

Table 8: Grading of NVG Among Patients of Ischemic CRVO

GRADING OF NVG AMONG PATIENTS OF ISCHEMIC CRVO

GRADE 1 GRADE 2 GRADE 3 NO. OF PATIENTS 3 2 6 PERCENTAGE 27% 18% 55%

Figure 8: No. of CRVO Patients

CONCLUSION

Neovascular glaucoma is rapidly blinding disease. So it is very important to know its nature and underlying cause to manage these patients satisfactorily. In our study we had examined 30 patients (total 60 eyes), we came up with the following conclusions:

 Neovascular glaucoma was more common in age group between 50-60 years (63.30%).

 Males were common than females with male: female ratio being 1.3:1.

 According to cause, neovascular glaucoma was more common in diabetic retinopathy (50%), second most common cause is central retinal vein occlusion (37%), trauma (6.6%), long standing retinal detachment (3.3%), ocular ischemic syndrome (3%).

 Among Diabetic retinopathy, neovascular glaucoma was seen in proliferative diabetic retinopathy (99.8%). Non proliferative diabetic

retinopathy did not progress to neo vascular glaucoma.

 Neovascular glaucoma in proliferative diabetic retinopathy patients was more common age group between 50-60 years (46.60%) and equally common between male and female.

 Among Central retinal vein occlusion (CRVO) patients, neovascular glaucoma was manifested only in Ischemic CRVO (100%). No any Non ischemic CRVO patients presented with neovscular changes.

 Neovascular glaucoma in Ischemic CRVO was more common in patients of age group between 60-70 years (63.63%) with males were more commonly affected than females (M:F - 1.7:1).  Ischemic CRVO patient were found with

more severe disease (Grade 3- 54%) than proliferative diabetic retinopathy (Grade 3- 40%).

Hence, we feel that all the patients with ischemic CRVO and proliferative diabetic retinopathy should be treated aggressively before they came to us with painful blind eye.

REFFERENCE

1. Gartner s. Henkind P:

neovascularisation of iris (Rubiosis iris),Surv Ophthalmol 22:291,1978. 2. Madsen PH: Rubeosis of the iris and

hemorrhagic glaucoma in patients with proliferative diabetic retinopathy, Br J Ophthalmol 55:368, 1971.

3. Gartner s. Henkind P:

neovascularisation of iris (Rubiosis iris),Surv Ophthalmol 22:291,1978. 4. Madsen PH: Rubeosis of the iris and

hemorrhagic glaucoma in patients with proliferative diabetic retinopathy, Br J Ophthalmol 55:368, 1971.

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treatment of neovascular

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retinal vein occlusion.

Ophthalmologica. 2003;217:167–188 7. Avery RL, Pearlman J, Pieramici DJ,

Rabena MD, Castellarin AA, Nasir 20%

47% 33%

NO. OF DIABETIC PATIENTS

GRADE 1

GRADE 2

GRADE 3

27%

18% 55%

NO. OF CRVO PATIENTS

GRADE 1

GRADE 2

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