endocyclophotocoagulation (ECP) has the advantage of being able to place laser treatment precisely where it is needed without damaging adjacent structures, and may cause even less inflammation than transscleral treatment, the cost of the equipment and the fact that this is an intraocular procedure have limited its acceptance.171

When dealing with a blind and painful eye caused by NVG, the goal of IOP reduction is simply to improve patient comfort. There are reports that cyclophotocoagulation may lead to sympathetic ophthalmia, and therefore some physicians feel it should not be used in blind eyes.170 Topical steroids and cycloplegics can provide long-term pain control in some patients. Retrobulbar alcohol or chlorpromazine injection171 is another way to control pain and avoid enucleation or evisceration, although in some badly damaged eyes this is the definitive approach.

In a diabetic eye with a dense cataract, iris angiography to look for NVI can allow the clinician to infer the severity of the diabetic retinopathy.

No single classification system for NVI or NVA has been widely adopted.

Injection of anti-VEGF drugs into the eye can cause rapid, temporary regression of NVI and NVA. Panretinal ablation by laser or cryotherapy is required to cause sustained regression.

If angle structures have been damaged by NVA, various glaucoma treatments can be used to control the intraocular pressure, starting with topical therapy, progressing to surgical therapy, and in eyes with little visual potential sometimes involving ciliary body destruction.

11.12 Summary of Key Points

Whether diabetes predisposes to primary open angle glaucoma is an unresolved issue, a surprising change from a long-held notion linking the two diseases.

Intravitreal triamcinolone injection, commonly used for complications of diabetic retinopathy, is associated with secondary intraocular pressure elevation in a large fraction of cases and must be monitored. Most cases that develop can be successfully treated with topical therapy.

Neovascularization of the iris (NVI) arises in response to retinal hypoxia. Vascular endothelial growth factor (VEGF) produced in the retina diffuses into the vitreous and thence to the aqueous, which bathes the iris and angle. They in turn respond with growth of new vessels.

NVI is usually associated with proliferative diabetic retinopathy. Neovascularization of the angle (NVA) rarely develops without preceding NVI.

NVI will be often missed if the eye is examined after pupillary dilation. If no pupillary margin NVI is present before dilation, it is unnecessary to perform routine gonioscopy to search for NVA.

11.13 Future Directions

The question of diabetes as a risk factor for primary open angle glaucoma will be resolved by large popu- lation-based studies that adequately control for confounding variables. The use of anecortave acetate as a therapy for steroid-induced glaucoma is a promising development in need of further study. Longer duration anti-VEGF drugs and sustained delivery devices may be developed that overcome the short-term effect of intraocular injections of bevacizumab and ranibizumab. Surgical therapy for neovascular glaucoma will continue to be refined.

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