[What strategy after three trabeculectomy failures?]

Three trabeculectomy failures raises the delicate problem of refractory glaucoma with unresponsive ocular hypertony. The therapeutic strategy requires first a careful assessment of the reasons for the previous failures (internal or external obstacles to filtration which might have responded to preventive treatment), then, depending on the patient's age, type of glaucoma, anatomic status of the ocular structures and the visual potential of the eye, a choice has to be made between different surgical techniques aimed at favoring aqueous humor evacuation (trabeculectomy associated with antimetabolites or drainage implant) or destruction of the ciliary body to reduce intraocular pressure by limiting the production of aqueous humor. Choosing between these two possibilities is not an easy task as success rates are highly variable on such eyes and complications are frequent, leading to lower visual acuity in 30 % of the cases. These salvage procedures recall that first line trabeculectomy must be optimized in all cases.