Short-term outcomes of the multi-institutional bladder exstrophy consortium: Successes and complications in the first two years of collaboration.

INTRODUCTION/BACKGROUND: Bladder exstrophy is a rare diagnosis that presents major reconstructive challenges. To increase experience and proficiency in the care of bladder exstrophy (BE), the Multi-Institutional BE Consortium (MIBEC) was formed, with a focus on refining technical aspects of complete primary repair of bladder exstrophy (CPRE) and subsequent care. OBJECTIVE: Outcome measures included successful CPRE (absence of dehiscence), complications, and integrated points of technique and care over the short-term. STUDY DESIGN: Boston Children's Hospital, Children's Hospital of Philadelphia and Children's Hospital of Wisconsin alternately served as the host, with observation, commentary and critique by visiting collaborating surgeons. CPRE with bilateral iliac osteotomy was performed at 1-3 months of age. High-definition video capture of the surgery allowed local and distant broadcast to facilitate real-time observation and teaching, and recording of all procedures. RESULTS: From February 2013 to February 2015, MIBEC participating surgeons performed CPRE on 27 consecutive patients (22 classic BE, five epispadias). There were no dehiscences in 27 patients (0%, 95% CI 0-12.5%). Thirteen girls and 14 boys underwent CPRE at a median age of 2.3 months (range 0.1-51.6). One boy had a hypospadiac urethral meatus at CPRE completion. Hydronephrosis of mild or moderate grade was present postoperatively in eight girls and two boys. Additional results, per gender, are presented in the Summary table below. DISCUSSION: Absence of dehiscence in this cohort was comparable or compared favorably with the literature. However, several girls had significant obstructive complications following CPRE. The rate of bladder outlet obstruction (BOO) in girls was increased compared with published reports. A low complication rate was noted in the boys following CPRE, which was comparable to reports in the literature, and early signs of continence and spontaneous voiding were noted in some boys and girls. Limitations included variation in patient age at presentation, thereby introducing a wide age range at CPRE. Outcome data were limited by short follow-up regarding voiding with continence. CONCLUSION: This collaborative effort proved beneficial regarding significantly increased surgeon exposure to CPRE, refinement of CPRE technique, surgeon learning and expertise. Technical refinement of CPRE is ongoing.

Sacral agenesis and neurogenic bladder: Long-term outcomes of bladder and kidney function.

BACKGROUND: Sacral agenesis (SA) is a rare congenital condition that refers to the absence of part or all of two or more lower sacral vertebral bodies. It can be associated with neurogenic bladder dysfunction that does not necessarily correlate with the level of spinal or skeletal defect. Patients with SA should undergo urodynamic studies (UDS) to guide lower urinary tract (LUT) management. OBJECTIVE: This review aimed to update the present institutional experience since 1981 of this rare patient population with detailed, long-term follow-up of bladder and kidney function. STUDY DESIGN: A single institution, retrospective, IRB-approved review was performed on patients born after January 1, 1981 with an isolated diagnosis of sacral agenesis without spina bifida, and followed with urologic involvement at Boston Children's Hospital. Records were reviewed for demographics, radiologic imaging, UDS including cystometrogram (CMG) and electromyography (EMG), surgery, and blood chemistries. Comparisons were made between groups of patients based on age at diagnosis, with specific focus on renal function and stability of neurogenic bladder lesion. RESULTS: Forty-three patients were identified: 23 female and 20 male. Thirty-seven children (86%) had a known age of diagnosis. Nineteen were diagnosed before 2 months old, including five who were diagnosed prenatally, 11 were diagnosed between 2 and 18 months, and seven were diagnosed after 18 months. All 43 had UDS, with 24 (55.8%) studied at the time of diagnosis (Summary Table). Twenty had serial full UDS, with 30% demonstrating neurourologic instability. None developed end-stage renal disease (ESRD) or required spinal cord detethering. DISCUSSION: Many children with SA appeared to be diagnosed prenatally or early in life; SA was mostly identified during evaluation of associated anomalies. Though UDS aid in urologic management, testing was not routinely utilized at the time of diagnosis. CONCLUSIONS: This review of long-term follow-up in SA patients showed stable LUT and renal function, with minimal risk of progression to ESRD.

Test-retest reliability of the Capute scales for neurodevelopmental screening of a high risk sample: Impact of test-retest interval and degree of neonatal risk.

AIM: Reliable and valid screening and assessment tools are necessary to identify children at risk for neurodevelopmental disabilities who may require additional services. This study evaluated the test-retest reliability of the Capute Scales in a high-risk sample, hypothesizing adequate reliability across 6- and 12-month intervals. METHODS: Capute Scales scores (N = 66) were collected via retrospective chart review from a NICU follow-up clinic within a large urban medical center spanning three age-ranges: 12-18, 19-24, and 25-36 months. On average, participants were classified as very low birth weight and premature. Reliability of the Capute Scales was evaluated with intraclass correlation coefficients across length of test-retest interval, age at testing, and degree of neonatal complications. RESULTS: The Capute Scales demonstrated high reliability, regardless of length of test-retest interval (ranging from 6 to 14 months) or age of participant, for all index scores, including overall Developmental Quotient (DQ), language-based skill index (CLAMS) and nonverbal reasoning index (CAT). Linear regressions revealed that greater neonatal risk was related to poorer test-retest reliability; however, reliability coefficients remained strong. CONCLUSIONS: The Capute Scales afford clinicians a reliable and valid means of screening and assessing for neurodevelopmental delay within high-risk infant populations.

Clinical experience with the double-plate Ahmed glaucoma valve.

PURPOSE: To evaluate the clinical efficacy and safety of the double-plate Ahmed Glaucoma Valve. DESIGN: Multicenter, retrospective observational case series. METHODS: We reviewed 50 eyes in 50 patients treated with the double-plate Ahmed Glaucoma Valve with mean follow-up of 11.7+/-7.9 months. RESULTS: Average intraocular pressure was reduced from 36.0+/-12.4 mm Hg before surgery to 15.8+/-7.7 mm Hg at the most recent follow-up after surgery (P<.001). The number of glaucoma medications was decreased from 3.3+/-0.8 before surgery to 1.4+/-1.4 after surgery (P<.001). The percent of success was 76% of eyes at the latest follow-up. Choroidal effusion occurred in four eyes (8%) and did not require surgical treatment in any eye. CONCLUSIONS: Despite a poor prognosis group of patients in this study, the double-plate Ahmed Glaucoma Valve was effective in lowering intraocular pressure with a low incidence of complications associated with hypotony.

Orbital complications after aqueous drainage device procedures.

A retrospective case series of 2 patients with orbital complications after tube shunt placement for glaucoma is reported. The first patient presented with limited motility and conjunctival injection in the setting of intraocular gas leakage in the superior orbit after previous vitreoretinal surgery. The second patient presented with multiple signs of orbital cellulitis. Both patients improved with intravenous antibiotics. Although rare, orbital complications may occur after glaucoma tube shunt surgery.

Comparison of double-plate Molteno and Ahmed glaucoma valve in patients with advanced uncontrolled glaucoma.

BACKGROUND AND OBJECTIVE: To compare double-plate Molteno (DPM) with the Ahmed glaucoma valve (AGV) in the treatment of eyes with complicated glaucoma. PATIENTS AND METHODS: This matched, retrospective, case-control study was based on diagnosis, number of previous operations, and age. There were 30 patients in each group and only patients with a minimum of 6 months follow up were included. Double-plate Molteno or Ahmed glaucoma valve insertion was performed on each patient to control intractable glaucoma. Success was defined as IOP <22 mm Hg and >4 mm Hg on the last two visits, a decrease of no more than 2 lines in the visual acuity, and no additional surgical intervention to control IOP. RESULTS: The Kaplan-Meier estimated probability of success at 12 and 24 months was 73% and 56% with DPM and 60% and 50% for AGV (P = 0.72). Mean IOP measured 13.36 +/- 5.2 mm Hg following DPM and 16.7 +/- 5.6 mm Hg following AGV at 12 months (P = 0.026) and 13.3 +/- 5.1 mm Hg with DPM and 19 +/- 5.8 mm Hg with AGV at 24 months (P = 0.009). Of the patients involved in the study, 83.5% exhibited hypertensive phase (HP) of AGV vs 43.5% of DPM (P = 0.04). AGV had a tendency to fail earlier (5 months +/- 7 following AGV vs 13 months +/- 13 following DPM, P = 0.07, t-test). Patients with either a second valve insertion or valve removal were 7/30 of AGV vs 1/30 in DPM (P = 0.05). Stent removal was needed by 10/30 DPM and 8/30 AGV had needling/5-FU. CONCLUSIONS: The percentage of patients free from failure was similar between the two groups at 36 months. DPM is associated with lower mean IOP in the long term compared to AGV.

Open-angle glaucoma secondary to blood clot in the Schlemm's canal following scleral buckle surgery and its treatment with tPA.

Obstruction of the episceral venous system can present with glaucoma. We present two patients who were referred to us for management of acute glaucoma with presumed episceral venous compression. The first patient had open-angle glaucoma with probable elevated episcleral venous pressure and blood in the Schlemm's canal, following a 360 degrees scleral buckle surgery. The second patient had open-angle glaucoma from delayed peribulbar hemorrhage following uncomplicated cataract surgery with blood in the Schlemm's canal. Both patients were successfully treated with intracameral injection with tissue plasminogen activator (tPA).

Surgical repair of leaking filtering blebs.

PURPOSE: To report the surgical management of leaking filtering blebs occurring after blebitis or persistent hypotony. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Twenty-two eyes of 20 patients with late bleb leak, blebitis or endophthalmitis, hypotony maculopathy, or bleb dysesthesia on presentation to the glaucoma service who required surgical bleb revision from 1990 through 1999. INTERVENTION: Pedicle flap, partial excision, and advancement or free conjunctival autologous graft techniques for surgical bleb revision. Type of bleb revision was dependent on the dimensions of the bleb and quality of surrounding conjunctiva. MAIN OUTCOME MEASURES: Preoperative and postoperative intraocular pressure (IOP), status of bleb leak, reoperation for glaucoma, or requirement for postrevision glaucoma medical therapy, with success defined as the need for two or fewer glaucoma medications after revision. RESULTS: Eighty-six percent (19/22) of eyes that underwent surgical bleb revision had resolution of leak and IOP control using two or fewer medications after one or more bleb revisions. The preoperative IOP (mean +/- standard deviation) was 3.7 +/- 2.6 mmHg (range, 0-8 mmHg). After an average follow-up of 21 months (range, 8-108 months), the IOP was 11.0 +/- 4.4 mmHg for patients taking 0.6 +/- 1.0 glaucoma medications. Eighteen percent (4/22) of eyes required two or more bleb revisions. In one eye, an IOP spike of 36 mmHg developed after revision, which required laser suture lysis on two occasions before the IOP was significantly lowered. The three failures were: one eye that required three or more medications for IOP control, a patient whose eye had a persistent leak after revision and who was not mentally competent to undergo repeat revision, and one eye that required combined glaucoma and cataract surgery after revision. CONCLUSIONS: Surgical bleb revision has a high success rate of closing late bleb leaks, maintaining glaucoma control, and preserving vision, with few postoperative complications. The appropriate surgical procedure for revision must be based on the individual clinical situation and can result in successful bleb revision.

Molecular basis of iduronate-2-sulphatase gene mutations in patients with mucopolysaccharidosis type II (Hunter syndrome).

Mucopolysaccharidosis type II (Hunter syndrome) is an X linked lysosomal storage disorder resulting from heterogeneous mutations in the iduronate-2-sulphatase (IDS) gene. To detect IDS gene mutations, direct sequencing of IDS cDNA fragments coupled with assays on IDS genomic amplicons was applied to 18 unrelated patients with MPS II. Seventeen mutations were detected from the 18 patients including seven missense mutations (S71R, A82E, A85T, R88C, R468W, R468Q, and E521V), five deletions (alphaR95, 383delAT, 596delAACA, 1148delC, and 1216delCT), two insertions (208insC and 1063insA), two splicing mutations (1006+5g-->c in intron 7, 1122C-->T in exon 8), and an intragenic deletion of IDS exons 4, 5, 6, and 7. Nine of the small mutations were novel mutations. Mutation 596del-AACA was detected in two unrelated patients. The mutation in intron 7 was found to cause aberrant splicing and resulted in a 22 bp insertion into its mRNA transcript. The intragenic deleted IDS gene expressed two aberrant mRNA transcripts consisting of exons 1-2-8-9 and 3-8-9. Analysis of mutations A85T, R88C, R468Q, R468W, and 438C/T found no polymorphism for the four missense mutations but about 36% heterozygosity for the 438C/T silent mutation. These results provide further evidence of mutational heterogeneity for MPS II. Also, underlying sequence directed mutagenesis mechanisms for some recurrent mutations in the IDS gene were proposed.

Bleb infections: clinically different courses of "blebitis" and endophthalmitis.

BACKGROUND AND OBJECTIVES: To assess the differences in history, clinical course, and response between five cases of blebitis and three cases of endophthalmitis following mitomycin trabeculectomy. PATIENTS AND METHODS: The authors conducted a retrospective review of eight consecutive cases of bleb-related infection following successful mitomycin trabeculectomy. RESULTS: All patients with blebitis responded to treatment with return of visual acuity and intraocular pressure to preinfection levels. In the three cases of endophthalmitis, one patient underwent enucleation, one had a final visual acuity of counting fingers, and the third had a visual acuity of 20/60. CONCLUSIONS: Blebitis, a limited form of bleb-related infection with thin, cystic, leaky blebs, responds to intensive topical antibiotic treatment, returning visual acuity and IOP to preinfection levels. Bleb-related endophthalmitis causes a more virulent form of bleb-related infection that involves thin- or thick-walled blebs, with or without leakage, and poor visual prognosis despite immediate intensive topical, systemic, and intravitreal antibiotic administration combined with core vitrectomy.

Bleb infections: clinically different courses of "blebitis" and endophthalmitis.

1. Researchers have recently introduced the term "blebitis" to describe a limited form of bleb-related infection (with infection and inflammation limited to the bleb and the peri-bleb area, with or without anterior chamber involvement) in contrast to the more classic form of endophthalmitis. 2. Bleb-related endophthalmitis is the virulent form of bleb-related infection in which patients present with rapidly worsening visual acuity, redness, and pain with diffuse conjunctival congestion, opalescent blebs (with or without epithelial defects) with intense fibrin and/or hypopyon in the anterior chamber, and florid vitritis. 3. Blebitis and bleb-related endophthalmitis are two distinct bleb-related infections, each with different presentations, prognoses, and outcomes. It is important that clinicians recognize this and treat patients accordingly.

Ciliary body neurilemoma. Unusual clinical findings intimating the diagnosis.

BACKGROUND: Neurilemomas (schwannomas) rarely occur intraocularly. When present, they pose a diagnostic dilemma for the physician and often are mistaken as a malignant lesion, resulting in enucleation. METHODS: The authors report the clinical findings of a 46-year-old man with a slowly progressive growing mass of the anterior chamber, associated with glaucoma and the development of cataract. To further delineate the tumor's features, ancillary techniques, including ultrasonography, computed tomography, and magnetic resonance imaging, were conducted. A definitive anterior chamber biopsy of the tumor was performed with histologic examination and electron microscopy. RESULTS: Ultrasonography, high-resolution computed tomography and magnetic resonance imaging showed a well-delineated mass of the inferior ciliary body involving nearly 5 clock hours of the angle. Two clinical features that suggested a longstanding tumor were brilliant transillumination of the mass (leading to the impression of a "cystic mass," not corroborated by ultrasonography) and retrodisplacement of the involved iris root. The histology, and particularly the electron microscopic features, confirmed the diagnosis of a neurilemoma, a benign tumor of the anterior segment. CONCLUSION: Intraocular neurilemomas are extremely rare tumors. Few are well documented with modern ancillary techniques. Clinical findings in conjunction with radiographic and ultrasonic features may support the diagnosis of a benign tumor. For this patient, confirmation via biopsy permitted combined cataract and glaucoma surgery to rehabilitate the eye, which retains 20/20 visual acuity 3 years after the procedure.

Iris retraction syndrome after intraocular surgery.

BACKGROUND: The authors report the postoperative development of iris retraction syndrome in two individuals. This is a rare syndrome that can present with pupillary block after an unrepaired rhegmatogenous retinal detachment. PATIENTS: The authors report two patients who had the iris retraction syndrome shortly after intraocular surgery. One patient had pupillary block that developed 6 months after cataract extraction and posterior chamber intraocular lens implantation. A second patient had uveitis, hypotony, and pupillary seclusion 4 weeks after pars plana vitrectomy. RESULTS: Both patients were treated successfully with a scleral buckling procedure and peripheral iridectomy. CONCLUSION: Postoperative uveitis that occurs with iris retraction and pupillary seclusion should alert the physician of an occult retinal detachment and warrant a thorough dilated funduscopic examination. Features unique to this report include the development of iris retraction syndrome in the presence of a pseudophakos, the rapidity of onset of this disorder after retinal detachment, and its masquerade as a persistent postoperative uveitis.

Long-term efficacy of argon laser trabeculoplasty. A 10-year follow-up study.

PURPOSE: Argon laser trabeculoplasty (ALT) is commonly used in the treatment of open-angle glaucoma. Varying success rates in lowering intraocular pressure (IOP) and controlling glaucoma are reported in studies with follow-up periods from 1 to 5 years, and few reports are available with follow-up to 10 years. The authors retrospectively reviewed the efficacy of ALT in patients followed up to 10 years. METHODS: Ninety-three patients with open-angle glaucoma underwent 360 degrees ALT. Mean follow-up was 52 +/- 43 months (mean +/- standard deviation; range, 1-132 months). Successful treatment at the time of final follow-up was defined as a decrease in IOP of 3 mmHg or greater from pretreatment level, IOP of 19 mmHg or less, stable visual field, stable optic nerve, and no further laser or surgical intervention. RESULTS: The decrease in IOP was 8.9 +/- 5.4 mmHg at 1 year, 10.0 +/- 4.2 mmHg at 5 years, and 8.9 +/- 5.2 mmHg at 10 years. The probability of success at 1 year was 77%, at 5 years 49%, and at 10 years 32%. Failure was most common in the first year after treatment (23%), and thereafter failure occurred at a rate of 5% to 9% per year. The mean decrease in IOP for all 93 eyes at time of maximum follow-up was 6.1 +/- 7.1 mmHg. CONCLUSION: Argon laser trabeculoplasty is an effective means for reducing IOP in many patients followed for an extended time. However, up to one half of eyes within 5 years of ALT and two thirds of eyes within 10 years may require additional laser or surgical intervention for glaucoma control.

Holmium laser sclerectomy. Success and complications.

PURPOSE: To investigate the safety and efficacy of holmium YAG laser sclerectomy, a new laser filtration procedure. METHODS: The authors performed holmium YAG laser sclerectomy on 49 eyes of 46 patients (mean follow-up, 12.3 +/- 1.1 months). RESULTS: Mean preoperative intraocular pressure (IOP) was 26.9 +/- 1.3 mmHg; postoperative mean IOP on last follow-up visit was 19.7 +/- 1.6 mmHg. Thirty (61%) of 49 eyes achieved a final IOP of 5 to 22 mmHg, 29 (59%) of 49 had a final IOP of 5 to 19 mmHg, and 21 (43%) of 49 had a final IOP of 5 to 15 mmHg. Sixteen (73%) of 22 eyes treated postoperatively with 5-fluorouracil (5-FU) had a final IOP of 21 mmHg or less. Twenty-seven percent of eyes lost one or more lines of vision, and 36% of eyes gained one or more lines of vision; there was no median change in visual acuity. Complications included suprachoroidal hemorrhage in 7 (14%) of 49 eyes and intraoperative vitreous hemorrhage in 2. Seventeen (35%) of 49 eyes required a second IOP-lowering procedure. CONCLUSION: Holmium YAG laser sclerectomy is an effective means to perform glaucoma filtration surgery. This is a full-thickness filtering procedure, with all of the risks attendant.

Contact transscleral Nd:YAG laser cyclophotocoagulation. Midterm results.

BACKGROUND: Early reports of both contact and noncontact transscleral Nd:YAG laser cyclophotocoagulation have been encouraging; however, recent evidence indicates a significant incidence of hypotony, visual loss, and phthisis with the noncontact technique with more than 6 months of follow-up. The authors sought to determine the intermediate term effects of contact transscleral Nd:YAG laser cyclophotocoagulation (CYC). METHODS: The authors followed 116 eyes of 114 patients for a minimum of 1 year after treatment of advanced glaucoma with CYC. RESULTS: The mean preoperative intraocular pressure (IOP) of 35.0 +/- 1.0 mmHg decreased to 18.6 +/- 1.1 mmHg (P less than 0.0001) during the average follow-up of 19.0 +/- 0.6 months (range, 12 to 36 months). Intraocular pressure control of 3 to 25 mmHg was achieved in 72%, 3 to 22 mmHg in 65%, and 3 to 19 mmHg in 56% of eyes. Retreatment was required in 31 of the 116 eyes (27%). Intraocular pressure decreased to less than 3 mmHg in 9 eyes and to 0 mmHg in 6 of these 9 eyes. Nineteen eyes, all with initial visual acuity of counting fingers or worse, progressed to no light perception; 17 of 36 eyes (47%) with visual acuity of 20/200 or better lost 2 or more Snellen lines. CONCLUSION: Midterm results of CYC continue to be encouraging but are tempered by a nearly 10% incidence of hypotony or phthisis and the progression of visual loss.

Argon laser gonioplasty in the treatment of angle-closure glaucoma.

We used argon laser gonioplasty to treat angle-closure glaucoma unrelieved by patent iridectomy. Laser energy (mean; 30 spots, 723 mW, and 0.2 second) was applied to the peripheral iris stroma to open the anterior chamber angle. Twenty of 32 eyes were successfully treated. After a median follow-up period of 18 months, 17 of these 20 successfully treated eyes (85%) had an intraocular pressure less than or equal to 19 mm Hg, and 19 of these 20 successfully treated eyes (95%) had an intraocular pressure less than or equal to 21 mm Hg. The 20 successfully treated eyes had a median duration of angle closure of 12 days. Twelve unsuccessfully treated eyes had a median duration of angle closure of 90 days. All successfully treated eyes had more than 50% of the treated angle opened by argon laser gonioplasty and all but three successfully treated eyes had more than three clock hours opened by argon laser gonioplasty. Argon laser gonioplasty may be successful in treating angle-closure glaucoma unrelieved by iridectomy, especially in cases that are recognized and treated soon after onset.

Probe placement and power levels in contact transscleral neodymium:YAG cyclophotocoagulation.

Transscleral cyclophotocoagulation using a free-running, thermal-mode neodymium:YAG laser with a 2.2-mm-diameter sapphire-tipped contact probe was performed on 27 enucleated human eyes to investigate the effect of probe placement and power levels. We concluded from gross, light, and scanning electron microscopic examinations that a tissue destructive effect on ciliary body and epithelium was produced by positioning the anterior edge of the probe tip 0.5 to 1.0 mm from the visible limbus using a 5- to 9-W power setting for 0.7 second. An 11-W power setting resulted in extensive loss of anatomic integrity of the ciliary body. Limbal probe placement produced significant iris and lens damage while positioning the probe 1.5 mm posterior to the limbus affected primarily pars plana. Damage to the sclera was not observed using this method of cyclophotocoagulation.

Surgical goniosynechialysis for angle-closure glaucoma.

Fifteen patients with synechial angle-closure glaucoma uncontrolled by medical and laser therapy were treated with surgical goniosynechialysis. Five patients were treated with goniosynechialysis alone, and ten were treated with goniosynechialysis in combination with other surgical procedures. The procedure was successful, in terms of reducing synechiae, in 14 eyes (93%). The extent of angle closure was reduced from 340 degrees +/- 45 degrees (mean +/- standard deviation) preoperatively to 80 degrees +/- 70 degrees postoperatively; the mean reduction was 260 degrees +/- 95 degrees (P less than 0.0001) for the group overall and 280 degrees +/- 80 degrees (P less than 0.0007) for the subgroup treated with goniosynechialysis alone. The mean preoperative intraocular pressure (IOP) was 40 +/- 4 mmHg. The mean postoperative IOP was 14 +/- 4 mmHg. The mean reduction in IOP was 26 +/- 15 mmHg (P less than 0.0001) for the group overall and 27 +/- 18 mmHg (P less than 0.015) for the subgroup treated with goniosynechialysis alone. Glaucoma medications were reduced from a mean of 2.6 +/- 1.0 preoperatively to 1.1 +/- 1.2 postoperatively for the group overall and to 1.4 +/- 1.5 for the subgroup treated with goniosynechialysis alone. Complications consisted of two eyes with intraoperative bleeding. One of these required intraoperative conversion to surgical trabeculectomy. The other was associated with a transient postoperative IOP elevation to 40 mmHg. Surgical goniosynechialysis may be an effective means of reducing synechiae and lowering IOP, either alone or in conjunction with other surgical procedures, in patients with angle closures of less than 6 months' duration.