Neovascular Glaucoma Following Central Retinal Artery Occlusion and Carotid Stenting: A Case Report on Surgical Timing and Dual Antiplatelet Therapy Considerations

INTRODUCTION AND IMPORTANCE Neovascular glaucoma (NVG) following central retinal artery occlusion (CRAO) in patients requiring dual antiplatelet therapy (DAPT) after carotid stenting presents a complex clinical challenge. The timing of glaucoma surgery must balance hemorrhagic risks from antiplatelet therapy against the urgent need for intraocular pressure control. This case highlights critical decision-making considerations in managing NVG when surgical intervention is complicated by recent vascular procedures requiring ongoing anticoagulation. CASE PRESENTATION A 33-year-old male with proliferative diabetic retinopathy developed CRAO secondary to 80–90% right internal carotid artery stenosis. Following emergent carotid stenting and initiation of DAPT (aspirin and ticagrelor), he developed refractory NVG in the affected eye. Despite maximal medical therapy including topical glaucoma medications and intravitreal anti-VEGF injections, intraocular pressure remained elevated (24–42 mmHg) over six months. Progressive visual deterioration occurred from counting fingers at 6 feet to hand motions, with cup-to-disc ratio progression from 0.6 to 0.9, ultimately resulting in ciliary body shutdown. CLINICAL DISCUSSION This case demonstrates the limitations of conservative management in NVG when surgical intervention is contraindicated due to bleeding risks. The Law et al. study showing 31.8% hemorrhagic complication rates in patients continuing anticoagulation during glaucoma surgery informed the decision to delay intervention. However, the progressive optic nerve damage highlights the need for earlier multidisciplinary consultation to explore antiplatelet bridging strategies or modified surgical approaches with lower bleeding risks. CONCLUSION NVG in patients on DAPT following carotid stenting requires individualized multidisciplinary management. While conservative therapy may be initially appropriate given bleeding risks, the refractory nature of NVG to medical management alone necessitates early surgical planning. Future cases may benefit from coordinated antiplatelet modification protocols and consideration of cyclophotocoagulation as a lower-risk surgical option.