Neovascular glaucoma: from ischemic pathophysiology to drainage tubes and modern pharmacotherapy

ABSTRACT

This narrative review summarizes the pathophysiology, diagnosis, and management of neovascular glaucoma and provides a comprehensive guide for clinical ophthalmologists. An iterative snowballing approach, together with targeted searches of PubMed/MEDLINE, Embase, and the Cochrane Library, identified 81 studies addressing key aspects of neovascular glaucoma, including molecular mechanisms, advanced diagnostic modalities, and surgical strategies. Neovascular glaucoma is an aggressive form of secondary glaucoma driven by ischemia-induced upregulation of vascular endothelial growth factor and angiopoietin-2 through the hypoxia-inducible factor-1α pathway. Diagnosis is primarily based on clinical findings and is increasingly supported by advanced imaging techniques. Management requires a multimodal approach combining panretinal photocoagulation and anti-vascular endothelial growth factor therapy with intraocular pressure-lowering interventions, including glaucoma drainage devices, micropulse transscleral cyclophotocoagulation, and slow-coagulation transscleral cyclophotocoagulation. Glaucoma drainage devices achieve the greatest intraocular pressure reduction, whereas micropulse transscleral cyclophotocoagulation offers the most favorable safety profile. Slow-coagulation transscleral cyclophotocoagulation represents an intermediate option, with a reported success rate of 71.7% and favorable safety outcomes. Emerging therapies aim to provide sustained angiogenic control while targeting fibrosis and neuroprotection.

Keywords: Glaucoma, neovascular/diagnosis; Glaucoma, neovascular/physiopathology; Glaucoma neovascular/drug therapy; Glaucoma drainage implants; Angiogenesis inhibitors/therapeutic use; Vascular endothelial growth factor A; Light coagulation; Neuroprotection; Revie

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