Ki-Cheol Chang, MD Department of Ophthalmology, Dankook University Hospital, South Korea Financial disclosure : Author has no commercial associations

Retinal Ischemia (Diabetic retinopathy, CRVO, OIS, etc ) Ocular Neovascularization Iris Neovascularization (INV), PAS, Angle closure Neovascular Glaucoma (NVG) For Retinal ischemia  Panretinal photocoagulation (PRP) Anti-VEGF ? For IOP control  Ocular anti-hypertensive medications Glaucoma drainage surgeries Cyclodestructive procedures For Retinal ischemia  Panretinal photocoagulation (PRP) Anti-VEGF ? For IOP control  Ocular anti-hypertensive medications Glaucoma drainage surgeries Cyclodestructive procedures VEGF, BFGF, IGF-I, EGF

 To evaluate the usefulness of Intravitreal Bevacizumab* (IVB) for treatment of NVG caused by ischemic retinal disease * Bevacizumab (Avastin ®, Genentech Inc, South San Francisco, CA) 1. Full-sized recombinant antibody that binds all isoforms of VEGF 2. Half-life : up to 20 days 3. Approved by FDA as antiangiogenic agent for the treatment of metastatic colon cancer 4. Off-lebel ophthalmic uses of IVB - PDR, CME, ARMD with CNVM, INV and NVG, etc.

 Ophthalmic evaluations : History, V/A, IOP, Slit-lamp biomicroscopy, Gonioscopy, Fundus exam (including FAG if possible)  2.5 mg/0.1 mL Intravitreal bevacizumab (Avastin ® ) with paracentesis  For reduction of retinal ischemia, 1 week later, PRP if possible (even if PRP had been done)  Despite of IVB and maximal tolerable medical treatment(MTMT), IOP > 25mmHg  surgical management was considered if possible  During follow-up, If INV recur  additional PRP with or without IVB

 Participants : 12 patients were included with NVG d/t ischemic retinal disorders ( – )  All Pre-IVB IOPs couldn’t be controlled despites of MTMT  All patients showed complete or significant INV regression at 1 week after IVB  Open-angle stage (PAS<90) NVG  IOP could be controlled without surgical management  Angle closure stage (PAS>270) NVG  For IOP control, additional glaucoma surgery were needed.  No eye taken subsequent Ahmed implantation showed intra - and post - operative bleeding  Only one eye showed hyphema during paracentesis directly after IVB

Patients characteristics

Figure 1. Case 2 (43/M, PDR) (upper row) pre-IVB (IOP=42, PAS < 90) A. Iris neovascularization (INV) was detected at papillary margin. B,C. NV and focal PAS were detected at anterior chamber angle. (lower row) 1 week after IVB (IOP=12) D,E,F. NV at pupillary margin and anterior chamber angle resolved completely.

Figure 2. Case 4 (70/F, CRVO) A.Pre-IVB (IOP=31, 3 60º PAS), Severe IN V was detected. B.1week after IVB, INV decreased signifi cantly, however, IOP was 37 mmHg C. 4 week after IVB, only ghost INV was detected. D.4 months after IVB, INV recurred and then additional PRP was done.

Figure 3. Case 3 (72/M, CRVO). Due to mature cataract and corneal opaci ty, PRP was not available. 1 week after IVB, Ahmed valve implantation was done without intraoperative bleeding. A,B. pre-IVB(IOP=34). C. 5 months after IVB, there was no recurrence of INV.

 Our study showed that IVB might be a safe and effective adjunct in NVG as previous reports showed.  Advantages of IVB in NVG A. Rapid resolution of anterior segment neovascularization 1. More effective IOP control 2. Improving postoperative results by reducing inflammation and bleeding B. Can be a (temporary ?) substitute of PRP when PRP is impossible d/t media opacity such as mature cataract, vitreous hemorrhage and corneal opacity

 However, Adequate PRP is essential A. INV and NVG occurred despite of previous PRP B. The effect of IVB is transient (3 months or more ?) C. Inadequate PRP or persistent retinal ischemia  Recurrence of ocular neovascularization  Complete regression of INV A. main indicator of adequate PRP B. However, it can also be induced by IVB with inadequate PRP  Be careful not to ignore the importance of adequate PRP

 NVG with closed angle usually needed subsequent glaucoma surgeries despite complete INV regression after IVB and PRP  Intra-cameral vs. Intra-vitreal Intravitreal IVB 1. may be more effective for combined retinal neovascularization or macular edema 2. lower risk of hyphema during injection 3. higher risk of posterior segment complication including endophthalmitis