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The paper presents current problems associated with advanced glaucoma treatment and new trends in therapeutic management. Evaluation of the disease progression with only visual field testing may not be sufficient in such cases. Sensitive indicator of the deterioration is visual acuity reduction, which may also be a parameter used in surgery results estimation. Treatment of advanced glaucoma should concentrate on surgical methods because of more effective IOP control and its fluctuations. After surgery there is a risk of sudden visual loss without visible pathology explaining this deterioration called wipe-out or snuff-out phenomenon. However advanced glaucoma doesn’t aggravate safety of antiglaucoma surgery. Wipe-out phenomenon occurs extremely rare and refers to very advanced glaucoma or cases accompanied with ischemia. Patients after surgery have much more chance of preserving remaining visual field, if central vision isn’t lost during operation, whereas progression in visual field analysis is rare provided that surgery ensures good IOP control.
Drainage devices (aqueous shunts – AS) in glaucoma surgery have been improved within last 40 years. They are used in refractory glaucoma, caused by: conjunctival scarring after previous filtrating surgery, abnormalities of the irido-corneal angle, neovascular and inflammatory glaucoma, presence of corneal grafts or keratoprosthesis, previous vitreoretinal surgery. AS consist of a silicon tube (implanted into the anterior chamber) and a plate, made of silicone or polypropylene (explant, sutured between rectus muscles). Fibrous bleb, surrounding explant after some weeks is a filtration reservoir. The results of AS surgery are comparable to trabeculectomy with mitomycin C; there are no differences between results of different AS models.
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Aqueous humor is produced by the ciliary body by active secretion and filtration of plasma. Most of the aqueous humor flows from the posterior chamber, through the pupil, to the anterior chamber, and exit at the iridocorneal angle into the intrascleral venous plexus. The balance between formation and drainage maintains intraocular pressure. In glaucoma the pressure in the eye increased. Prolonged or recurrent elevation of intraocular pressure lead to degeneration of the retina and optic nerve. The presence of a “red eye”, corneal edema, mydriasis, blepharospasm, blidness, and buphtalmos can be seen. Pupillary light reflex may be slow or absent. Glaucoma is divided into primary (including congenital) and secondary categories. The iridocorneal angle may be open, narrow or closed in either type. The primary glaucoma in cats is a heredietary condition. Secondary glaucoma is more commonly encountered than primary. Secondary glaucoma is most frequently due to severe anterior uveitis or iris melanoma. The elevation of intraocular pressure results from other disease processes within the eye. Feline aqueous humor misdirection syndrome is a unique form of glaucoma seen in cats. Aqueous humor is misdirected posteriorly into the vitreous instead of anteriorly in the anterior chamber. The objectives of therapy are to maintain vision and eliminate pain by increasing aqueous outflow, decreasing aqueous production and preventing or delaying glaucoma in the other eye. Aggressive medical (topical beta-blockers and carbonic anhydraze inhibitor) and possibly surgical therapy ( YAG laser, partial vitrectomy or lens removing) is indicated if the eye still has vision. If the eye is reversibly blind enucleation procedures should be performed.
Aqueous humor is produced by the ciliary body by active secretion and filtration of plasma. Most of the aqueous humor flows from the posterior chamber, through the pupil, to the anterior chamber, and goes out at the iridocorneal angle into the intrascleral venous plexus. The balance between formation and drainage maintains intraocular pressure. In glaucoma the pressure in the eye increased. Prolonged or recurrent elevation of intraocular pressure lead to degeneration of the retina and optic nerve. The presence of a “red eye”, corneal edema, mydriasis, blepharospasm, blidness, and buphtalmos can be seen. Pupillary light reflex may be slow or absent. Glaucoma is divided into primary (including congenital) and secondary categories. The iridocorneal angle may be open, narrow or closed in either type. Secondary glaucoma is most frequently due to severe anterior uveitis or iris melanoma. Aggressive medical and possibly surgical therapy is indicated for patients with glaucoma that continues to progress despite use of medications therapy. In some cases, trabeculectomy surgery may be recommended. This procedure we applied in the case of our patient.
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