Anterior ciliary artery ligation with simultaneous intravitreal bevacizumab: an adjuvant treatment for end-stage neovascular glaucoma

Editor,

We read with great interest the article entitled ‘Bevacizumab as adjuvant for neovascular glaucoma’ by Beutel et al., which appeared in the September 2008 issue of Acta Ophthalmologica. In this study patients received an average of 2.75 injections. Additional treatments were laser photocoagulation in 13 (65%) eyes, cyclodestructive procedure in 14 (70%), cryopexy in six (30%), drainage procedures in two (10%), and vitrectomy in five (25%) eyes (Beutel et al. 2008).

We would like to share our experience of an interventional case series including six eyes in six patients with central retinal vein occlusion, complicated with angle-closure neovascular glaucoma (NVG). In our case series, mean intraocular pressure (IOP) was 45 ± 6 mmHg before treatment, with maximal antiglaucoma medication and panretinal photocoagulation. Visual acuity ranged from no light perception to poor light perception.

All patients gave informed consent and the study was performed in adherence to the tenets of the Declaration of Helsinki and in full compliance with the regulations of our institutional review board. All patients were treated with intravitreal bevacizumab (IVB) (1 mg). In all patients, four rectus muscles were tightly ligated at the insertion to the sclera with proline under local anaesthesia and left under the conjunctiva. All cases experienced a regression of the iris neovascularization (INV) in a mean of 6 days (range 2–12 days, median 6 days). In three eyes (50%) IOP decreased, but in three eyes (50%) antiglaucoma surgery (tube-shunt operations) was performed within 3 weeks of the initial surgery in order to control IOP.

At the end of the 6-month follow-up period, all patients were pain-free and IOP was 18 ± 4 mmHg (range 14–22 mmHg). Iris neovascularization recurred in five eyes and stabilized after repeated IVB. No adverse systemic or ocular complications were observed in any of the patients throughout the follow-up period.

Anterior ciliary artery ligation can decrease blood flow to the ciliary body and can reduce aqueous production, which lowers IOP (Kornbleuth et al. 1956). However, it must be reserved for use only in patients with end-stage angle-closure NVG because it carries an increased risk for complications such as visual loss and phthisis (Girard & Beltranena 1960).

Intravitreal bevacizumab effectively stabilizes INV activity and controls IOP in patients with INV alone and in early-stage NVG without angle closure. In advanced NVG, IVB cannot control IOP. In one study, 11 eyes (73%) required early surgical intervention within 1 week of the initial IVB injection and a total of 14 eyes (93%) underwent surgery to stabilize markedly elevated IOP, indicating that IVB may be used adjunctively to improve subsequent surgical results (Wakabayashi et al. 2008).

Intravitreal bevacizumab treatment of INV in proliferative diabetic retinopathy has shown promising short-term results, but further studies are needed to evaluate longterm outcomes (Jiang et al. 2008). To conclude, anterior ciliary artery ligation with simultaneous IVB was effective in causing regression of INV and in decreasing IOP and ocular pain in end-stage NVG.