The Neovascular Ocular Hypertension Spectrum: A Novel Classification of Neovascular Glaucoma.

Abstract

To propose a novel, anatomically based classification system for eyes traditionally labeled as neovascular glaucoma (NVG) that better reflects disease severity, guides contemporary management, and aligns with modern anti-vascular endothelial growth factor (anti-VEGF) and angle-based surgical treatment paradigms. Perspective and conceptual framework. Not applicable. We synthesized contemporary clinical experience and published literature regarding the diagnosis and management of eyes with anterior segment neovascularization and elevated intraocular pressure (IOP). Emphasis was placed on iridocorneal angle anatomy, extent of peripheral anterior synechiae (PAS), disease activity in response to anti-VEGF therapy, and implications for medical and surgical management. Based on these considerations, we developed a staged classification system prioritizing angle status at the time of presentation. Development of a clinically intuitive, anatomically descriptive nomenclature to categorize disease severity, facilitate communication among clinicians, and support stage-specific treatment protocols. We propose the neovascular ocular hypertension (NVOH) spectrum, consisting of four stages arranged from least to most severe: NVOH suspect, NVOH, partial neovascular angle closure (NVAC), and total NVAC. Disease modifiers of active versus quiescent reflect the presence or regression of anterior segment neovascularization following anti-VEGF therapy. The framework also introduces the term acute neovascular crisis (ANC) to describe symptomatic, acutely elevated IOP associated with active partial or total NVAC. This classification emphasizes the extent of synechial angle closure as a key determinant of management, distinguishing eyes that may be candidates for angle-based microinvasive glaucoma surgery, after achieving quiescence, from those requiring urgent surgical IOP lowering. Limitations include the conceptual nature of the framework and the absence of prospective validation. The NVOH spectrum offers a modernized, anatomically grounded alternative to the ambiguous term "neovascular glaucoma." By prioritizing angle status and disease activity over optic nerve assessment, which is often unreliable in eyes with advanced retinal disease, this classification supports more precise diagnosis, tailored treatment selection, and improved interdisciplinary communication. Prospective studies are needed to validate this nomenclature, refine stage-specific treatment algorithms, and assess its impact on clinical outcomes.