iOpeners with Nicole Bajic, MD: Mary Qiu, MD, on tailored NVG pathways

With January being Glaucoma Awareness Month, it seems fitting to discuss neovascular glaucoma (NVG), a challenging and vision-threatening condition that requires thoughtful, individualized management. In this episode of iOpeners from Ophthalmology Times, host Nicole Bajic, MD, comprehensive ophthalmologist at the Cole Eye Institute, Cleveland Clinic, speaks with her colleague, Mary Qiu, MD, a glaucoma specialist with a strong research and clinical focus on NVG, about how she approaches these complex cases.

Stratifying NVG management by angle anatomy

Qiu describes how her management philosophy evolved from residency—where NVG patients often went straight to urgent Ahmed tube shunt surgery—to a more tailored approach she learned during fellowship at Cleveland Clinic and has applied over the past 5 years at the University of Chicago. Central to this strategy is careful gonioscopy at presentation.

As she explains, “this angle anatomy at the time of presentation is really critical to helping us decide what to do next.”

Open-angle vs closed-angle NVG: Divergent treatment pathways

For patients who present with NVG but retain an open angle, Qiu notes that anti-VEGF therapy, an anterior chamber tap if needed, and maximal glaucoma medications can often successfully lower intraocular pressure. In these cases, pressure may normalize without emergent tube surgery. This allows time for close follow-up and, if necessary later, consideration of angle-based procedures such as goniotomy. She notes that these cases require close coordination with retina specialists to ensure that neovascularization remains suppressed and the angle remains functional.

In contrast, eyes presenting with total synechial angle closure represent, in Qiu’s words, “a completely different workflow.” For these patients, she favors urgent primary cyclophotocoagulation to immediately reduce aqueous production and lower pressure without the added bleeding risk of incisional surgery. Anti-VEGF therapy is administered concurrently so the eye is stabilized while waiting for neovascular regression.

Collaborative glaucoma and retina care in NV

Once the eye is quieter and pressure control stabilizes, tube surgery can be performed later in a more controlled, elective setting. Qiu explains that this staged approach allows surgeons to avoid emergent valve placement and instead consider non-valved tubes with better long-term outcomes. Reviewing outcomes at the University of Chicago, she notes that many eyes with open angles were able to avoid tube surgery entirely. She refers to these cases as “salvaging their angle,” reducing exposure to long-term tube-related complications.

Qiu also discusses a selective role for trabeculectomy in quiescent NVG, particularly in settings where tube shunts are not available, again underscoring that sustained collaboration with retina colleagues is essential. She notes, NVG is “a really complex, multidisciplinary illness,” and success depends on individualized, anatomy-driven decision-making and long-term retinal disease control.

Readers may direct their NVG-related questions to Qiu at [email protected].