A 66-year-old White man with a history of hyperlipidemia, hypertension, and coronary artery disease with angioplasty and stenting presented to the ophthalmology clinic for a routine eye exam. The right eye (OD) had a history of pars plana vitrectomy for epiretinal membrane 3 years prior and subsequent uncomplicated cataract surgery 6 months afterward. He used no ocular medications at baseline. He reported no visual complaints, pain, discomfort, photophobia, redness, or headache. His visual acuity (VA) was 20/50 OD and 20/20 OS with -6.5 diopter glasses. The IOP was 47 mmHg OD and 15 mmHg OS. The anterior segment exam OD revealed a clear cornea without microcystic edema, a deep and quiet anterior chamber without hyphema, NVI at the pupil margin in multiple locations, NVA throughout an otherwise open angle with no peripheral anterior synechiae (PAS), and a 1 piece PCIOL in the capsular bag with mild posterior capsule opacity (PCO). The anterior segment exam OS was unremarkable with a clear cornea, deep and quiet anterior chamber, no NVI or NVA, and 2+ nuclear sclerosis. The fundus exam of both eyes revealed tilted myopic nerves with a symmetric cup-to-disc ratio of 0.5 in both eyes and a full neuroretinal rim for 360 degrees in both eyes with no focal rim changes that would suggest glaucomatous optic neuropathy in either eye. There was no macular edema, no exudates, no flame-shaped hemorrhages, attenuated but nontortuous retinal vasculature without visible neovascularization at the disc (NVD) or elsewhere (NVE), and mid-peripheral dot blot hemorrhages (DBH) in both eyes (). The fundus exam was not consistent with PDR or RVO, and OIS was suspected. The glaucoma service was consulted, and the patient received 3 rounds of timolol, dorzolamide, and brimonidine in the right eye and 500 mg oral acetazolamide; the IOP improved to 16 mmHg 2 hours later. The retina service was consulted, and fluorescein angiography demonstrated profound peripheral retinal non-perfusion in both eyes with no NVD or NVE (). The patient was diagnosed with open-angle NVG secondary to OIS in the right eye and underwent prompt intravitreal injection with 1.25 mg (0.05 ml) bevacizumab (IVB) that day. The antineovascular branch of the treatment plan with the retina service (DS) was to administer at least 6 monthly IVB injections, with multiple sessions of PRP (PASCAL argon laser, Retina 200 lens, parameters described in ) scheduled in between the IVB injections, until the PRP was deemed to be complete. At that point, the IVB injections would be stopped, and the glaucoma service would monitor him for any recurrent anterior segment neovascularization or elevated IOP. The IOP-control branch of the treatment plan with the glaucoma service (MQ) was to initiate 3 topical IOP-lowering medications (dorzolamide-timolol and brimonidine) and subsequently escalate medical therapy if needed. If the IOP were to become uncontrolled despite maximum tolerated medical therapy and the anterior segment neovascularization was fully regressed at that time, then an angle-based procedure such as gonioscopy-assisted transluminal trabeculotomy would be offered in an attempt to surgically salvage the conventional outflow pathway (consistent with SCOPING Protocol goals) and avoid or delay an aqueous shunt or cyclophotocoagulation, if possible. A systemic work-up to identify the source of the OIS was performed by the vascular neurology service. A computed tomography angiography demonstrated atherosclerotic calcifications along the bilateral petrous, cavernous, and supraclinoid internal carotid artery (ICA) segments, with multifocal mild and moderate stenoses most pronounced along the bilateral supraclinoid ICA segments. However, the patient was not recommended to pursue neurovascular intervention. Between Week 0 and Week 22 inclusive, the patient underwent the SCOPING protocol with 6 serial monthly IVB injections interspersed with 4 PRP sessions (). One day after IVB#1, the visual acuity was still 20/50, the IOP was down from 42 mmHg to 19 mmHg on two IOP-lowering medications, and gonioscopy revealed regressing NVA and no PAS. Throughout the treatment course, the IOP remained physiologic in the teens, even without any IOP-lowering medications after Week 5. He underwent laser capsulotomy at Week 10 for visually significant PCO. At Week 24, two weeks after the SCOPING treatment series, the visual acuity had improved to 20/20, the IOP was 19 mmHg, and gonioscopy revealed fully regressed NVA and no PAS. At this point, his conventional outflow pathway was considered to be “medically salvaged,” and no further antineovascular treatment was recommended by the retina service. He was counseled to continue follow-up with the glaucoma service in 6 weeks. When the patient presented for follow-up at Week 30, the IOP had risen to 22 mmHg, and gonioscopy revealed recurrent trace NVA in all quadrants and no PAS. He was diagnosed with recurrent anterior segment neovascularization in the setting of stopping serial anti-VEGF injections and underwent a second course of treatment consisting of 4 monthly IVBs and 4 PRP sessions. Only 4 IVBs were planned for this second course rather than 6 because the retina service considered this recurrence to be less severe than the initial presentation. At Week 34, the visual acuity was stable at 20/20, and the IOP was 16 mmHg on no IOP-lowering medications. At Week 38, the IOP was down to 10 mmHg. On Week 48, two weeks after his second course of treatment, the visual acuity was 20/20, the IOP was 20 mmHg, and there was only trace regressing NVA in 2 quadrants on gonioscopy. His conventional outflow pathway was still considered to be “medically salvaged,” in line with the goals of the SCOPING protocol. When the patient followed up four weeks later at Week 52, the IOP was elevated at 27 mmHg with new NVI and NVA. Considering the repeated recurrent anterior segment neovascularization with elevated IOP, despite a total of 10 IVB injections and more than 4000 total spots of PRP over the span of 52 weeks, the retina service recommended a third “course” of treatment, this time with serial monthly IVB injections in perpetuity (). Two weeks after IVB#1 of this third series, his IOP was 14 mmHg on one IOP-lowering medication, and the NVI and NVA had regressed yet again. The patient's timolol was stopped, and he was recommended to follow-up with retina monthly in perpetuity for serial monthly IVB injections. At the next retina follow-up visit at Week 56, which is his most recent follow-up to date, the VA OD was still 20/20, and the IOP OD was 13 on 0 IOP-lowering medications. The patient underwent the next IVB injection as planned, and his conventional outflow pathway is still considered to be “medically salvaged.”