Author: Daisy Bassey-Duke (United Kingdom)
Co-authors: Julia Cunningham, Ramesh Sivaraj
A transient spike in intraocular pressure is an accepted risk of Anti-Vascular Endothelial Growth Factor (Anti-VEGF) treatment and studies have demonstrated a link between anti-VEGF treatment and glaucoma progression in patients known to have glaucoma. It has also been suggested that Anti-VEGF treatment may be linked to an increased risk of glaucoma or ocular hypertension (OHT) in patients not previously known to have either. With high demand for Anti-VEGF treatment and the recent COVID-19 epidemic there has been a move towards providing care via diagnostic hubs and virtual clinics as well as an increase in the use of treat and extend protocols in order to extend capacity; this reduces patient-doctor interactions. In turn, this may increase the risk of patients who may develop OHT or glaucoma being missed. The purpose of this case series is to determine if there is any value in routinely measuring intraocular pressures (IOP) in all patients (including non-glaucomatous patients) undergoing anti-VEGF treatment, in order to pick up those who may go on to develop OHT or glaucomatous change.
Anti VEGF injection service, Out-patient departments at a tertiary care Ophthalmology Unit in the West Midlands, United Kingdom.
Intraocular pressures (IOP) were measured in 200 eyes of 178 patients receiving anti-VEGF injections using rebound tonometry. Raised intraocular pressure was defined as an average pressure over 3 consecutive readings of >21mmHg or >5mmHg above baseline. Exclusion criteria were known diagnosis of glaucoma, known diagnosis of ocular hypertension or patients already on intraocular pressure lowering medication.
There were 70 men and 108 women included in the analysis, with age ranging from 33 to 94 years and an average age of 72 years. Cases were undergoing treatment for neovascular age related macular degeneration and macular oedema secondary to diabetic maculopathy or retinal vein occlusions. The number of injections per eye ranged from 1 to 86, averaging at 18.5 injections. The average change in IOP from baseline being -2.4 mm Hg in the right eye and -1.9mmHg in the left eye Of the 178 cases tested 4 had IOPs measured at >21mmHg. 8 of 178 had an IOP rise of >5mmHg compared to baseline. 1 case of >5mmHg IOP change was in an untreated eye and 2 cases had a bilateral increase in pressure despite receiving Anti-VEGF treatment in only one eye. The remaining 5 patients had pressure increases in their treated eye though the number of injections in these patients ranged from 14 to 45 with no obvious correlation between the increase in intraocular pressure and the number of injections.
No significant link was found between number of Anti-VEGF injections and rise in intraocular pressure. However, the advanced age of majority of the patients undergoing Anti-VEGF treatment remains a risk factor for glaucoma as evidenced by the cases that developed a rise in IOP in untreated eyes. Routine assessment of intraocular pressures as part of the diagnostic workup in this cohort of patients would highlight patients at risk of developing glaucoma.