Three weeks after a central retinal vein occlusion, a 66-year-old diabetic man presents with pain, redness, vision of counting fingers, corneal oedema and fine vessels crossing the pupil margin and angle structures on gonioscopy. IOP is 48 mmHg. The immediate priority before definitive filtration surgery is:

• A Immediate laser peripheral iridotomy
• B Intravitreal anti-VEGF injection combined with panretinal photocoagulation to regress the neovessels ✓
• C Long-term topical pilocarpine four times daily
• D Oral corticosteroids alone with observation

Explanation

This is neovascular glaucoma driven by retinal ischaemia and VEGF release. Rubeosis iridis starting at the pupillary margin precedes angle neovascularisation and synechial closure. Intravitreal anti-VEGF rapidly regresses the neovessels, and panretinal photocoagulation addresses the underlying ischaemia, allowing subsequent tube shunt surgery to succeed. Laser iridotomy does not help because closure is synechial, not pupillary block, and miotics aggravate inflammation and may pull neovessels into the angle.

Reference: Shields' Textbook of Glaucoma, 6th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.