38 EyeWorld Asia Pacific | June 2024 About the Physicians Emily Schehlein, MD | Brighton Vision Center, Brighton, Michigan | emschehlein@gmail.com Christina Y. Weng, MD, MBA | Professor of Ophthalmology, Fellowship Program Director, Vitreoretinal Diseases & Surgery, Baylor College of Medicine, Houston, Texas | christina.weng@bcm.edu Relevant Disclosures Schehlein: Perceptron Health, Glaukos, Allergan Weng: AGTC, Allergan/Abbvie, Alcon, Alimera Sciences, Apellis Pharmaceuticals, Iveric Bio, Novartis, REGENXBIO, Regeneron, DORC, DRCR Retina Network, Genentech, EyePoint, Springer Publishers References 1. Shah SM, al. Risk, prevalence, and progression of glaucoma in eyes with age-related macular degeneration treated with intravitreal anti-vascular endothelial growth factor injections. Am J Ophthalmol. 2022;243:98–108. 2. Islam YFK, et al. Glaucoma drainage device erosions in patients receiving anti-vascular endothelial growth factor therapy for diabetic retinopathy. Clin Ophthalmol. 2022;16:3681–3687. 3. de Vries VA, et al. The effects of intravitreal injections on intraocular pressure and retinal nerve fiber layer: a systematic review and meta-analysis. Sci Rep. 2020;10:13248. 4. Good TJ, et al. Sustained elevation of intraocular pressure after intravitreal injections of anti-VEGF agents. Br J Ophthalmol. 2011;95:1111–1114. 5. Bakri SJ, et al. Intraocular pressure in eyes receiving monthly ranibizumab in 2 pivotalage-related macular degeneration clinical trials. Ophthalmology. 2014;121:1102–1108. 6. Eadie BD, et al. Association of repeated intravitreous bevacizumab injections with risk for glaucoma surgery. JAMA Ophthalmol. 2017;135:363–368. 7. Chang EK, et al. Effects of postoperative intravitreal injections on outcomes of traditional glaucoma surgery in patients with preoperative intravitreal injections. Ophthalmol Glaucoma. 2022;5:219–228. 8. Lam LA, et al. Intravitreal injection therapy: current techniques and supplemental services. J Vitreoretin Dis. 2021;5:438–447. 9. Liu KC, et al. Recurrent tube erosions with anti-vascular endothelial growth factor therapy in patients with age-related macular degeneration. Ophthalmol Glaucoma. 2020;3:295–300. 10. Pirinen I, et al. Glaucoma progression in patients receiving intravitreal anti-VEGF treatment for neovascular age-related macular degeneration. Acta Ophthalmol. 2023;101:261–265. 11. Du J, et al. Effects of intravitreal anti-VEGF therapy on glaucoma-like progression in susceptible eyes. J Glaucoma. 2019;28:1035–1040. 12. Hoang QV, et al. Effect on intraocular pressure in patients receiving unilateral intravitreal anti-vascular endothelial growth factor injections. Ophthalmology. 2012;119:321– 326. 13. Wen JC, et al. Intravitreal anti-VEGF injections reduce aqueous outflow facility in patients with neovascular age-related macular degeneration. Invest Ophthalmol Vis Sci. 2017;58:1893–1898. 14. Bilgic A, et al. Sustained intraocular pressure rise after the treat and extend regimen at 3 years: aflibercept versus ranibizumab. J Ophthalmol. 2020;2020:7462098. 15. Cui QN, et al. Repeated intravitreal injections of antivascular endothelial growth factors and risk of intraocular pressure medication use. Graefe’s Arch Clin Exp Ophthalmol. 2019;257:1931–1939. 16. Matlach J, et al. Investigation of intraocular pressure fluctuation as a risk factor of glaucoma progression. Clin Ophthalmol. 2018;13:9–16. 17. El Chehab H, et al. Effect of topical pressure-lowering medication on prevention of intraocular pressure spikes after intravitreal injection. Eur J Ophthalmol. 2013;23:277– 283. 18. Hård Af Segerstad P. Risk model for intraoperative complication during cataract surgery based on data from 900,000 eyes: previous intravitreal injection is a risk factor. Br J Ophthalmol. 2022;106:1373–1379. 19. Khanani AM, et al. Efficacy and safety of avacincaptad pegol in patients with geographic atrophy (GATHER2): 12-month results from a randomised, double-masked, phase 3 trial. Lancet. 2023;402:1449–1458. 20. Jaffe GJ, et al. C5 inhibitor avacincaptad pegol for geographic atrophy due to age-related macular degeneration: a randomized pivotal phase 2/3 trial. Ophthalmology. 2021;128:576–586. This article originally appeared in the March 2024 issue of EyeWorld. It has been slightly modified and appears here with permission from the ASCRS Ophthalmic Services Corp. which is typically transient and resolves. However, patients can undergo a more chronic form of IOP elevation over time with multiple injections. “Newer treatment options for dry AMD/ GA, which inhibit the complement system, are administered very similarly to current anti-VEGF IVIs and will be familiar to ophthalmologists who perform these injections,” she said. “Therefore, it is very likely that a subset of patients will undergo a transient IOP spike following injection, as shown in clinical trials.” She added that there is little data on the long-term effects of these medications, so it is important to monitor these patients by checking the intraocular pressure at each injection and clinic visits.17,20 “With these newer medications, the current guidelines are to inject them monthly or bi-monthly, and for many patients, the duration is indefinite,” Dr. Schehlein said. “As there is some data that increased number of injections can increase the risk of glaucoma surgery and the long-term effect of this new medication on intraocular pressure is unknown, clinicians should consistently monitor their patients’ intraocular pressure and proceed with caution in patients with advanced glaucoma. It is worth considering if glaucoma patients starting on these new medications should have glaucoma testing more frequently or if patients with a strong family history of glaucoma, glaucoma suspect, or ocular hypertension should undergo periodic baseline testing while receiving these newer types of injections.” Based on early data and experience, Dr. Schehlein’s practice is to monitor intraocular pressure closely, especially in moderate to advanced glaucoma patients, with a low threshold to repeat testing sooner and add treatment, laser, or surgery if the pressure is rising. She added that a side effect of these new IVIs for GA and dry AMD is anterior chamber inflammation, which glaucoma specialists should be on the lookout for during regular exams. GLAUCOMA
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