Neovascular glaucoma: pathophysiology, diagnosis, and contemporary management

Neovascular glaucoma (NVG) is a vision-threatening secondary glaucoma driven by pathologic neovascularization of the iris and anterior chamber angle and is most commonly secondary to ischemic retinal diseases. Despite advances in retinal imaging and anti-vascular endothelial growth factor (anti-VEGF) therapy, NVG remains difficult to manage and is associated with high rates of vision loss, ocular morbidity, and surgical failure.

This narrative review synthesizes the contemporary understanding of NVG pathophysiology, summarizes diagnostic approaches with emphasis on anterior-segment and retinal imaging, evaluates current medical and surgical management strategies, and highlights emerging directions for research and clinical innovation.

NVG originates from retinal ischemia, which elevates intraocular VEGF and other proangiogenic and inflammatory mediators, inducing rubeosis iridis and fibrovascular membrane formation at the angle. Clinical staging ranges from early iris neovascularization with normal intraocular pressure (IOP) to advanced angle closure with refractory IOP elevation and painful blind eyes. Diagnosis requires careful slit-lamp examination and gonioscopy, supplemented by multimodal imaging: ultrawidefield fluorescein angiography quantifies retinal nonperfusion; and anterior-segment OCT and ultrasound biomicroscopy delineate membrane extent and angle architecture; anterior-segment OCTA is investigational for vascular mapping. Management relies on two parallel goals-rapid suppression of anterior segment neovascularization and definitive treatment of the underlying retinal ischemia. Intravitreal anti-VEGF injections rapidly regress neovascularization and improve surgical conditions, but are temporizing unless combined with panretinal photocoagulation (PRP) or other ischemia-directed therapies.

Long-term success in NVG patients requires integrated, individualized care that couples antiangiogenic bridging, durable management of retinal ischemia, and optimized surgical strategies.