الفهرس 
Anatomical ConsiderationsOnly 14 pages are availabe for public view
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Abstract
The term refractory glaucoma is being used for any kind of glaucoma which has not responded to medical or surgical treatment and need subsequent surgical re- intervention. Management of refractory Glaucoma remains an uphill and most challenging task for any Glaucoma surgeon. The peculiarities involved with deranged anatomical configuration, physiology and dynamics of aqueous circulation is far different from the other glaucoma patients.
Refractory glaucomas can be classified into:
Congenital, neovascular, aphakic, pseudophakic, uveitic, glaucoma in dark races, malignant glaucoma, post keratoplasty glaucoma and Silicone oil induced glaucoma.
The wound healing response is the most important determinant of the final IOP after trabeculectomy, with excessive postoperative scarring significantly reducing success, so modulation of wound healing is required, so that the chance of subconjunctival fibrosis is minimized to achieve a successful outcome.
Currently the most reliable approach is to use the antiproliferative agents MMC and 5-FU. However, these agents are far from perfect and so there are new agents to control the wound healing more safely.
The application of 3D collagen-glycosaminoglycan copolymers and transplantation of single layer of AM in trabeculectomy resulting in a reduction of scar formation.
Intracameral bevacizumab may be used as an adjunctive therapy during trabeculectomy in eyes with neovascular glaucoma.It can be also used Post-operativly by needle bleb revisions.
CAT-152, a human monoclonal antibody that neutralises transforming growth factor b2(TGFβ2), seems a promising future alternative to antimetabolites now in use to prevent bleb failure.
Glaucoma drainage devices (Aqueous shunts) shunting aqueous humor to the sub-Tenon. The tube is placed into the anterior chamber or through the pars plana. It may be valved and the non-valved shunts. A newer non-valved device is the Optonol Ex-PRESS shunt is usually placed under a trabeculectomy-style scleral flap. SOLX Gold Shunt, promote the flow of fluid along the surface of the implant, is placed supraciliary space, shunt aqueous from the anterior chamber into the suprachoroidal space.
Laser trabeculoplasty lowers pressure by improving the flow of fluid out through the normal drainage pathways of the eye. selective laser trabeculoplasty (SLT) and micropulse laser (MLT) trabeculoplasty are newer techniques that much less traumatic to the eye than Argon Laser Trabeculoplasty (ALT), which has been the standard laser procedure. ALT can cause tissue destruction and scarring of healthy cells in the trabecular meshwork structure. SLT and MLT reduces intra-ocular pressure without this risk,so they may be safely repeated several times.
Cyclodestruction is one of the surgical modalities of management of refractory glaucomas. For cases in which surgical procedures to increase aqueous outflow have a small liklehood of success, many surgeons consider cyclodestructive procedures, aimed at lowering intraocular pressure by reducing aqueous production.The use of laser as an energy source for cyclodestructive surgery offers a more precise means of damaging the ciliary body, and with less injury to adjacent structures, either by transscleral cyclophoto-coagulation or endoscopic cyclophotocoagulation
Endoscopic cyclophotocoagulation is an efficacious procedure so that the ciliary body can be visualised and treated more selectively this stands out as a more attractive option compared to the other blind techniques.