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PubMed This is a summary of 19 peer-reviewed journal articles Updated
Ophthalmology

Fighting a Two-Front War: The Standard of Care for NVG

At a Glance

Treating neovascular glaucoma (NVG) requires a two-step approach: addressing retinal oxygen starvation to stop abnormal blood vessel growth, and lowering intraocular pressure to relieve pain. Standard treatments include anti-VEGF injections, PRP laser therapy, and glaucoma drainage devices.

Treating neovascular glaucoma (NVG) is often described as fighting a “two-front war.” Because the disease is caused by a problem in the back of the eye (oxygen starvation) that creates a problem in the front of the eye (high pressure), doctors must attack both areas at the same time [1][2]. If you only treat the eye pressure, the underlying “SOS” signal (VEGF) will continue to grow new vessels that will eventually overwhelm any treatment [2][3].

Front 1: The Retina (Addressing the Root Cause)

The goal here is to stop the eye from producing the VEGF protein that is fueling the growth of abnormal blood vessels [4].

  • Anti-VEGF Injections: These are often the first step to quickly “turn off” the SOS signal [5]. The medication begins to shrink the abnormal vessels on the iris and in the drainage angle rapidly, often within a few days [6][7]. These injections are not a one-time fix; they are typically repeated every 4 to 6 weeks initially [3][8].
  • Panretinal Photocoagulation (PRP): This is a laser treatment that serves as the “permanent” solution for retinal ischemia [9]. By treating the areas of the retina that aren’t getting enough oxygen, the laser reduces the overall demand for oxygen in the eye, stopping the production of VEGF for the long term [1][10].

Front 2: The Pressure (Clearing the Blockage & Managing Pain)

While the retina is being treated, the high intraocular pressure (IOP) must be brought down. The pain you may be experiencing is directly caused by this pressure spike. The primary way to relieve your eye pain is to lower the pressure inside the eye.

  • Medicated Drops: Doctors usually start with multiple types of eye drops to slow down fluid production or help it drain [11][12]. Note: certain common glaucoma drops, such as prostaglandins or pilocarpine, are typically avoided in NVG because they can worsen inflammation.
  • Glaucoma Drainage Devices (GDD): Also known as a “tube shunt” or Ahmed Valve, this is often the preferred surgery for NVG [11][13]. A tiny silicone tube is inserted into the eye to bypass the blocked drain and shunt fluid out to a small reservoir [11]. This tube and reservoir are hidden under the eyelid and are usually not visible to others. This surgery is typically more successful than traditional options for NVG because it resists blockage from inflammation and scarring [14][13].
  • Trabeculectomy: This is a traditional glaucoma surgery creating a small “trap door” for fluid [15]. It has a higher failure rate in NVG eyes because the active new vessels can quickly scar the new drain shut [16][15].
  • Cyclophotocoagulation (CPC): In cases where the eye pressure is very high but vision potential is very low, doctors may use this laser treatment to target the ciliary body (the part of the eye that produces fluid), effectively “turning down the faucet” [17][18][11].

Understanding Treatment Risks

All medical procedures carry risks that must be weighed against the danger of untreated NVG:

  • Anti-VEGF Injections: Carry a very small risk of serious eye infection (endophthalmitis) or a temporary spike in eye pressure.
  • PRP Laser: Can cause some permanent loss of peripheral vision or night vision, which is a necessary trade-off to save the central vision and the physical structure of the eye.
  • Surgeries (GDD/Trabeculectomy): Carry risks of bleeding, infection, or the pressure going too low initially.

By coordinating these treatments, your care team aims to relieve your pain, stop the growth of new vessels, and manage the pressure to prevent further vision loss [5][19].

Common questions in this guide

Why do I need treatment for both the retina and eye pressure for NVG?
Treating NVG requires addressing both the underlying cause and the symptom. The retina must be treated to stop the production of proteins causing abnormal blood vessels to grow, while the front of the eye is treated simultaneously to lower painful high pressure.
What is the purpose of anti-VEGF injections for neovascular glaucoma?
Anti-VEGF injections act quickly to shrink abnormal blood vessels in the eye by blocking the signals that cause them to grow. They are usually the first step in treatment to turn off this signal and may need to be repeated every few weeks initially.
Why is a glaucoma drainage device preferred over a trabeculectomy?
A glaucoma drainage device, like an Ahmed valve, is often preferred for NVG because it resists blockage from inflammation and scarring. Traditional trabeculectomy surgeries have a higher failure rate because active new blood vessels can quickly scar the new drain shut.
What are the risks of panretinal photocoagulation (PRP) laser treatment?
PRP laser treatment can cause some permanent loss of peripheral or night vision. However, this is considered a necessary trade-off to stop abnormal vessel growth, lower the eye's oxygen demand, and save your central vision.
When is cyclophotocoagulation (CPC) used for NVG?
CPC is a laser treatment used when eye pressure remains dangerously high but the potential for vision recovery is very low. It works by targeting the part of the eye that produces fluid to effectively turn down the production of fluid and relieve eye pain.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.How are you and the retina specialist coordinating my care to ensure both the pressure and the ischemia are treated?
  2. 2.Is my drainage angle still open enough for laser treatment (PRP) to work, or has it begun to scar?
  3. 3.If we need surgery, why do you recommend a drainage device (like an Ahmed valve) over a trabeculectomy for my specific case?
  4. 4.What is the goal of the anti-VEGF injection I'm receiving, and how long will its effects last?
  5. 5.At what point would we consider cyclophotocoagulation (CPC), and what are the risks for my remaining vision?

Questions For You

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References

References (19)
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    [Current views on pathogenesis and treatment of neovascular glaucoma].

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This page explains standard treatment options for neovascular glaucoma for educational purposes only. Always consult your ophthalmologist or glaucoma specialist to determine the best care plan for your specific condition.

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