Glaucoma 4 The first-generation Molteno and other nonvalved implants sometimes require the ligation of the tube until

the bleb formed is mildly fibrosed and water-tight. [5 ! This is done to reduce postoperative hypotony"sudden drops in postoperative intraocular pressure. #alved implants$ such as the %hmed glaucoma valve$ attempt to control postoperative hypotony by using a mechanical valve. The ongoing scarring over the con&unctival dissipation segment of the shunt may become too thic' for the aqueous humor to filter through. This may require preventive measures using antifibrotic medications$ such as 5-fluorouracil or mitomycin-( )during the procedure*$ or other nonantifibrotic medication methods$ such as collagen matri+ implant$[5,![-.! or biodegradable spacer$ or later on create a necessity for revision surgery with the sole or combinative use of donor patch grafts or collagen matri+ implant. [-/![-0! %nd for glaucomatous painful blind eye and some cases of glaucoma$ cyclocryotherapy for ciliary body ablation could be considered to be performed.[11!

Veterinary implant

T2 3io4urgical has commerciali5ed a new implant specifically for veterinary medicine$ called T2-(larif676. The implant consists of a new biomaterial$ the 4T%2 3ioMaterial$ which consists of silicone with a very precise homogenous pore si5e$ a property which reduces fibrosis and improves tissue integration. The implant contains no valves and is placed completely within the eye without sutures. To date$ it has demonstrated long-term success )longer than a year* in a pilot study in medically refractory dogs with advanced glaucoma. [-1!

Laser-assisted nonpenetrating deep sclerectomy

The most common surgical approach currently used for the treatment of glaucoma is trabeculectomy$ in which the sclera is punctured to alleviate intraocular pressure. 8onpenetrating deep sclerectomy )89:4* surgery is a similar$ but modified$ procedure$ in which instead of puncturing the scleral bed and trabecular meshwor' under a scleral flap$ a second deep scleral flap is created$ e+cised$ with further procedures of deroofing the 4chlemm;s canal$ upon which$ percolation of liquid from the inner eye is achieved and thus alleviating intraocular pressure$ without penetrating the eye. 89:4 is demonstrated to cause significantly fewer side effects than trabeculectomy. <owever$ 89:4 is performed manually and requires higher level of s'ills that may be assisted with instruments.[citation needed! =n order to prevent wound adhesion after deep scleral e+cision and to maintain good filtering results$ 89:4 as with other nonpenetrating procedures is sometimes performed with a variety of biocompatible spacer or devices$ such as the %quaflow collagen wic'$ [-4! ologen (ollagen Matri+$[-5! [--![->! or ?enoplast glaucoma implant.[- ! @aser-assisted 89:4 is performed with the use of a (A 0 laser system. The laserbased system is self-terminating once the required scleral thic'ness and adequate

drainage of the intraocular fluid have been achieved. This self-regulation effect is achieved as the (A0 laser essentially stops ablating as soon as it comes in contact with the intraocular percolated liquid$ which occurs as soon as the laser reaches the optimal residual intact layer thic'ness.

Epidemiology
%s of 0./.$ there were 44.> million people in the world with open angle glaucoma. [>.! The same year$ there were 0. million people in the Bnited 4tates with open angle glaucoma.[>.! 3y 0.0.$ the prevalence is pro&ected to increase to 5 .- million worldwide and 1.4 million the Bnited 4tates. [>.! =nternationally$ glaucoma is the second-leading cause of blindness$ after cataracts. Glaucoma is also the leading cause of blindness in %frican %mericans$ who have higher rates of primary open angle glaucoma. [>/! 3ilateral vision loss can negatively affect mobility and interfere with driving.[>0! % meta-analysis published in 0.., found that patients with primary open angle glaucoma do not have increased mortality rates$ or increased ris' of cardiovascular death.[>1!

Research
The %dvanced Glaucoma =ntervention 4tudy is a large %merican =nstitute-sponsored study designed Cto assess the long-range sequences of interventions involving trabeculectomy and trabeculoplasty in eyes that have failed initial medical treatment for recommends different treatments based on race. 8ational 6ye outcomes of argon laser glaucomaC. =t

The 6arly Manifest Glaucoma Trial is another 86= study which found immediate treatment of people who have early-stage glaucoma can delay progression of the disease. The Acular <ypertension Treatment 4tudy$ also an 86= study$ found topical ocular hypotensive medication was effective in delaying or preventing onset of primary open-angle glaucoma )9A%G* in individuals with elevated intraocular pressure )=A9*. %lthough this does not imply all patients with borderline or elevated =A9 should receive medication$ clinicians should consider initiating treatment for individuals with ocular hypertension who are at moderate or high ris' for developing 9A%G. The 3lue Mountains 6ye 4tudy was the first large$ population-based assessment of visual impairment and common eye diseases of a representative older %ustralian community sample. 2is' factors for glaucoma and other eye disease were determined.

Natural compounds

8atural compounds of research interest in glaucoma prevention or treatment includeD fish oil and omega-1 fatty acids$ alpha lipoic acid$[>4! bilberries$ vitamin 6$ cannabinoids$ carnitine$ coen5yme E/.$ curcurmin$ Salvia miltiorrhiza$ dar'

chocolate$ erythropoietin$ folic acid$ Ginkgo biloba$ ginseng$ @-glutathione$ grape seed e+tract$ green tea$ magnesium$ melatonin$ methylcobalamin$ 8-acetyl-@ cysteine$ pycnogenols$ resveratrol$ quercetin and salt. <owever$ most of these compounds have not demonstrated effectiveness in clinical trials. [4>![4 ![4,! Magnesium$ gin'go$ salt and fludrocortisone$ are already used by some physicians. )8oteD fludrocortisone is not a natural compound$ but a steroid.* (annabis 4tudies in the /,>.s showed mari&uana$ when smo'ed or eaten$ effectively lowers intraocular pressure by about 05F$ as much as standard medications. [>5![>-![>>! =n an effort to determine whether mari&uana$ or drugs derived from it$ might be effective as a glaucoma treatment$ the B4 8ational 6ye =nstitute supported research studies from /,> to /, 4. These studies demonstrated some derivatives of mari&uana lowered intraocular pressure when administered orally$ intravenously$ or by smo'ing$ but not when topically applied to the eye. =n 0..1$ the %merican %cademy of Aphthalmology released a position statement which said$ Cstudies demonstrated that some derivatives of mari&uana did result in lowering of =A9 when administered orally$ intravenously$ or by smo'ing$ but not when topically applied to the eye. The duration of the pressure-lowering effect is reported to be in the range of 1 to 4 hoursC. [>>![> !