[How to conduct glaucoma therapy when pressure stays high despite topical treatment?].

When glaucoma worsens with elevated ocular pressure despite an initial treatment, an additional reduction of pressure is needed. It is necessary to evaluate the cause of the therapeutic failure which could be the consequence of a low compliance from the patient, a poor efficacy of the topical drug or a short or long term drift of this efficacy. Depending on the aetiology, another monotherapy or a combination of treatments should be initiated. The evaluation of the target pressure and the comparison between this pressure and the current pressure of the eye allows to evaluate the likeliness of reaching the target through medical treatment alone or through surgical approach. When medical treatment is possible, it is usual to combine two drugs, one acting on the aqueous humor inflow and the other one on the uveoscleral outflow pathway. If target pressure is lower than what can be expected to be reached with topical treatment, surgery should be proposed to the patient. Laser Argon trabeculoplasty keeps still some indications, like pigmentary or exfoliative glaucoma. Long term stability of the visual field in glaucoma depends more on the reduction of pressure and on its stability than on the choice of medical or surgical approach.