• Anatomy
• Retinal vein blockage/occlusion
• Rubeotic glaucoma
• Treatment: laser & drops
• Controversies in treatment
• See animation

This type of glaucoma follows a severe retinal vein blockage or severe diabetic eye disease. The animation here explains the condition if you are online, but this text is helpful if you need to print out a leaflet.

• What is glaucoma?
  • Text
  • Animation of glaucoma
  • Professionals: notes
  • SLT laser
• Angle closure glaucoma & narrow angle glaucoma / laser iridotomies
  • Animation of laser iridotomy
  • Chronic narrow angle glaucoma
  • Text
  • Professionals: notes
• Internat. Glaucoma Association
• Intraocular hypertension
• Low tension glaucoma
• Pre-perimetric glaucoma
• Visual field testing
• Drops & tablets for glaucoma
• Animations etc
  • Glaucoma
  • Laser iridotomy
  • Trabeculectomy
  • Rubeotic glaucoma
  • Progression model
  • SLT laser
• Rubeotic glaucoma
  • Text
  • Rubeotic glaucoma animation
  • Professionals: notes
• Students: Cases
  • Case 1
  • Case 2
  • Case 3
  • Case 4
  • Case 5
  • Case 6
  • Case 5
  • Case 8
  • Case 9
  • Case 10
  • Case 11
• Pseudoexfoliation..link
• Pigmentary glaucoma ..link
• Trabeculectomy
  • Text
  • Animation
  • Audit
    • 2006 with photos
    • 2008
• More technical
  • Corneal thickness & IOP
  • Hypotony
  • Arcuate scotomas ..glaucoma?
• Glaucoma letters
• Glaucoma photos (professionals)

The healthy eye sees as light enters the eye and hits the retina. The 'retina' is the 'film' of the eye, just like the film of a camera.

Blood travels through the optic nerve in arteries to reach the retina, and is normally drained away out of the eye in veins.
See animation

The front chamber of the eye is filled with a clear watery fluid, the aqueous or (aqueous humour).

The aqueous is made in the middle chamber of the eye, and flows through to the front chamber. It then flows through a drainage system, the 'trabecular meshwork', out of the eye into the blood stream.

(It has nothing to do with tears.)

High blood pressure, smoking, glaucoma or an unhealthy diet may damage the retinal veins.
One day the vein can block, and then blood my leak out. The retina then 'floods' like a river overflowing, and it becomes thick like a sponge. Unfortunately the retinal damage makes your sight very poor in the affected eye.

There is no treatment that will restore your sight after a retinal vein occlusion. Treatment, such as lowering blood pressure, is aimed at protecting the other eye or preventing other problems such as a stroke.

About ½ the patients who develop a severe retinal vein occlusion will develop this rubeotic glaucoma condition.

This diagram shows the retinal haemorrhages, in a photo here.

If there is a lot of damage to your eye from diabetes you may also get this condition....the process is very similar. It may also follow other conditions, such as a 'total' retinal detachment.

This damaged or 'sick' retina produces growth chemicals, call growth factors.
We call this damaged retina 'ischaemic'.

The growth chemicals spread to the front of the eye. Here they reach the drainage system (the trabecular meshwork).
The main growth factor is VEGF, that is vascular endothelial growth factor.

See animation

Here the VEGF makes tiny blood vessels grow, which we call 'new blood vessels'.

At about the same time the blood vessels grow in the drainage system, they grow on the surface of the iris, where your doctor can see them.

These tiny blood vessels then block the drainage meshwork, so the aqueous fluid cannot leave the eye. As the fluid cannot escape, the pressure goes up, like a tyre being pumped up too much.

The eye cannot burst, but it becomes much harder.

In a way this is a 'faulty healing process'.

Without laser treatment this condition can lead to a painful blind eye in about ½ the people affected. Luckier people have the condition but there is no pain.
When the eye is painful and blind treatment is very difficult, and often not very successful. So doctors concentrate on preventing the eye becoming painful.

With laser treatment, when the 'sick' ischaemic retina is lasered, it stops producing the VEGF growth chemical. Without the VEGF, the tiny blood vessels growing in the trabecular meshwork stop growing.
If the laser is very successful, the blood vessels stop growing, and then the trabecular meshwork drain opens up, and the pressure goes down.
If it is partly successful, the blood vessels stop growing, but the drain remains blocked by scar tissue.

Several thousand retinal laser burns are needed, in 3-5 sessions. If the drainage angle is scarred, Cyclodiode laser may be needed.

Drops may help in this condition at the beginning. These include steroid eye drops such as Dexamethasone, and drops to dilate the pupil, such as atropine. Generally, these are only used for a few months, as they have many side effects if used for longer. Atropine makes your mouth dry and must be kept away from children. See animation.

A new treatment, injection of anti-growth factors, is likely to be very helpful. Avastin is cheap and very helpful, although a series of injections may be needed. The drug is injected in to the vitreous cavity of the eye (identical to this treatment for ARMD) .

Avastin is not yet licensed for this use...it has proved very helpful, but it is too early to say for certain. It is standard treatment in the US and is available in many private clinics in the UK. If you want Avastin you will have to ask your ophthalmologist. There are other drugs, Macugen and Lucentis, which are likely to be very effective also, but these are more expensive (£~600/injection), and there is very little published for these drugs in RG.  See papers.

Traditionally RG has been a very serious condition and they eye often does not recover its sight, but with these new treatments sight is more liely to improve. The injection will be needed early, as soon as possible after the condition is daigosed. Almost certainly laser will still be needed AS WELL.

If you want Avastin in the UK on the NHS your ophthalmologist will have to get funding from your Primary Care Trust (PCT). About half of PCTs will fund Avastin for this use, half will not. The drug is not particularly expensive, but the injection procedure in a clean room has risks and costs the NHS £3-700. As Avastin is not licenced, it is not being studied by NICE, and unless this changes will never be made widely available on the NHS.

There is no prospect of it being widely available for RG without this changing..we urgently need scientific studies to confirm that it works (or does not work), but there is no funding for the studies. If the studies showed that it was effective it would obtain a licence, and then NICE would consider it.

Other doctors, and the Royal College of Ophthalmologists, recommend waiting till rubeotic glaucoma (or at least the blood vessel growth on the iris and trabecular meshwork) develops, and then carry out the laser. But unfortunately treatment at this stage is not always successful. The author of this page prefers early laser, but knows many experts who prefer waiting for the rubeosis.
Basically, everyone who sees 6/60 (20/200) or worse has a high risk of developing rubeotic glaucoma. There is a higher risk if you are diabetic.

If you see 6/24 (20/80) or better you have a small risk and may often be fine without laser. If you see 6/36 (20/120) there is an intermediate risk.

For professionals see and here with photos. Basic explanation here, medline, search.