The association between intravitreal injections and glaucoma: an update

Intravitreal antivascular endothelial growth factor (VEGF) injections are the cornerstone of retinal disease management but raise concern for intraocular pressure (IOP)-related complications. This review summarizes recent evidence on transient and sustained IOP elevation, structural and vascular effects, and management strategies.

Acute IOP spikes occur in nearly all eyes, typically resolving within an hour, but recovery is delayed in glaucoma and ocular hypertension (OHT), increasing optic nerve risk. Spike magnitude depends on patient factors (age, diabetes, vitreous volume, lens status) and technical factors (needle gauge, reflux, injection volume). Sustained IOP elevation is less predictable, with higher rates for bevacizumab and ranibizumab than aflibercept, and cumulative injection burden correlating with reduced outflow facility, retinal nerve fiber layer (RNFL) thinning, and greater need for glaucoma surgery. Acute spikes cause immediate RNFL thinning, while long-term loss is uncommon in nonglaucomatous patients. Prophylactic IOP-lowering therapy, paracentesis in high-risk eyes, and agent or delivery selection may mitigate risk.

Uniform protocols inadequately address patient-specific factors, warranting individualized management strategies. Prophylactic measures, careful agent selection, and multidisciplinary management can mitigate IOP-related complications in susceptible patients.