Glaucoma drainage tube kink after pars plana insertion.

PURPOSE: To describe focal obstruction of drainage tubes by kinking at the scleral entry site after pars plana insertion. METHODS: Case study. RESULTS: Three eyes of three patients underwent uncomplicated placement of a Baerveldt implant into the vitreous cavity at the time of pars plana vitrectomy. Intraocular pressure remained increased after the procedure without evidence of flow. Surgical exploration and modification of the tube placement resulted in immediate intraocular pressure reduction. Compression of the tube at the scleral entry site was confirmed intraoperatively in all eyes by ultrasound biomicroscopy. CONCLUSION: Kinking of the tube at its scleral entry site should be recognized as a possible cause of increased intraocular pressure without bleb formation after pars plana insertion of a glaucoma drainage implant.

Pars plana tube insertion of glaucoma drainage implants and penetrating keratoplasty in patients with coexisting glaucoma and corneal disease.

PURPOSE: To determine the efficacy and associated complications of glaucoma drainage implant (GDI) surgery with pars plana tube insertion and penetrating keratoplasty (PK) in eyes with glaucoma and corneal disease. DESIGN: Retrospective, interventional case series. PARTICIPANTS: All patients who underwent both GDI surgery with pars plana tube insertion and PK before September 1997 were included. METHODS: The medical records of 34 consecutive patients (34 eyes) who had undergone GDI (Baerveldt, Pharmacia & Upjohn, Kalamazoo, MI; Molteno, IOP INC:, Costa Mesa, CA; Krupin, Hood Laboratories, Pembroke, MA; or Ahmed, New World Medical, Rancho Cucamonga, CA) insertion before, concurrent with, or after PK were reviewed retrospectively. All corneal grafts were clear before GDI surgery for patients who underwent glaucoma surgery after PK. Outcomes were evaluated using Kaplan-Meier life-table analysis. MAIN OUTCOME MEASURES: Clinical outcome assessment included corneal graft clarity, intraocular pressure (IOP), visual acuity, and identification of complications. RESULTS: Mean follow-up after completion of both GDI surgery and PK was 12.1 +/- 8.4 months (range, 0-31.8 months). Twelve- and 24-month life-table rates for complete success after both GDI and PK were 63% and 33%, respectively. Twelve- and 24-month life-table success rates for IOP control and corneal graft clarity were 85% and 62%, and 64% and 41%, respectively. Final postoperative visual acuity was the same as or better than (> or =2 Snellen lines) the preoperative level in 29 patients (85%). One or more posterior segment complications occurred in 15 (44%) patients. CONCLUSIONS: Pars plana tube insertion of GDIs is a reasonable option for patients who have undergone PK or in whom PK is anticipated, despite the need for a complete pars plana vitrectomy. Although complications related to limbal tube placement are avoided, the incidence of posterior segment complications may be higher for pars plana insertion. The potential for enhanced corneal graft survival with pars plana versus anterior segment tube placement warrants further investigation.

Trabeculectomy with mitomycin-C in the treatment of pediatric glaucomas.

PURPOSE: To evaluate the effectiveness and safety of trabeculectomy with mitomycin-C (MMC) in the management of childhood glaucomas. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: All patients less than 18 years of age who underwent trabeculectomy with MMC from June 1991 through October 1997 were included. METHODS: The medical records of 29 consecutive patients (29 eyes) were reviewed. Data collected during routine patient follow-up were analyzed. Surgical outcome was evaluated using Kaplan-Meier life-table analysis. MAIN OUTCOME MEASURES: Clinical outcome assessment included intraocular pressure (IOP) control, visual acuity, and identification of complications. Successful IOP control was defined as 5 mmHg < or = final IOP < or = 21 mmHg, with or without antiglaucoma medications and without further glaucoma surgery or loss of light perception. Outcomes for the group of patients with primary infantile glaucoma were compared with those for the group with secondary glaucomas. RESULTS: Mean patient age was 6.4 +/- 4.4 years (range, 0.2-15.3 years). A variety of primary and secondary glaucomas were represented. Mitomycin-C (0.5 mg/ml) on a surgical sponge was applied to the episcleral surface for an average of 3.8 +/- 1.0 minutes (range, 1.5-5.0 minutes). Mean follow-up time for patients categorized as successes was 25.1 +/- 16.0 months (range, 5.5-59.7 months). The 12-, 24-, and 36-month life-table success rates for IOP control were 82%, 59%, and 59% respectively. There was no difference between the primary infantile glaucoma group and the secondary glaucoma group with respect to length of follow-up, rate of successful IOP control, and incidence of complications. Five patients (17%) experienced late bleb-related infection (BRI) at an average of 27.9 +/- 18.1 months (range, 5.4-55.5 months) after surgery. Other complications included hyphema, retinal detachment, late-onset bleb leak, flat anterior chamber, chronic hypotony, decompression retinopathy, suture abscess, and phthisis. CONCLUSIONS: Trabeculectomy with MMC may be useful in the management of childhood glaucomas in which goniotomy, trabeculotomy, or both have failed. However, the high incidence of BRI in this series over an extended follow-up interval dictates caution in using MMC as an adjunct in pediatric trabeculectomy.

Trabeculectomy with intraoperative 5-fluorouracil.

BACKGROUND AND OBJECTIVE: To investigate the outcome and complication rates of trabeculectomy following the combined use of intraoperative, topical 5-fluorouracil (5-FU) and low-dose, postoperative subconjunctival 5-FU injections. PATIENTS AND METHODS: Forty-one eyes of 41 patients with advanced, medically uncontrolled glaucoma underwent trabeculectomy with intraoperative episcleral application of 5-FU (50 mg/ml for 5 minutes). A variable number of subconjunctival 5-FU injections were administered postoperatively at the discretion of the operating surgeon. RESULTS: Six-, 12-, and 15-month life-table success rates (5 mm Hg < or = intraocular pressure [IOP < or = 21 mm Hg) were 100%, 97%, and 83%, respectively. Mean postoperative IOP was 12.1 +/- 4.3 mm Hg. An average of 2.2 +/- 1.6 (range 0 to 7) supplemental subconjunctival 5-FU injections were administered postoperatively. Corneal epithelial erosions developed in 7 (17%) of the eyes. Five of 7 patients who underwent subsequent surgical procedures maintained successful control of IOP at an average of 11.0 +/- 4.8 (range 5 to 16) months after the secondary surgery. CONCLUSION: Trabeculectomy with intraoperative 5-FU is effective in controlling IOP while possibly minimizing the need for frequent postoperative injections and the occurrence of corneal epitheliopathy.

Pericardial patch grafts in glaucoma implant surgery.

PURPOSE: The authors determine the safety and effectiveness of pericardial patch grafts in glaucoma implant surgery. METHODS: A retrospective chart review was conducted on all patients who underwent a glaucoma implant procedure with the use of a pericardial patch graft to cover the subconjunctival portion of the tube at The New York Eye and Ear Infirmary between September 1, 1995 and June 30, 1996. Charts were assessed for evidence of delle formation, graft rejection, graft-related infection, graft thinning, or tube erosion. RESULTS: Forty-four eyes of 44 patients were enrolled. Mean follow-up was 10.2 +/- 4.0 months (range, 2.3 to 18.6 months). Infection, tube erosion, graft rejection, and graft-related inflammation did not occur. Five eyes were noted to have asymptomatic thinning of the patch without evidence of tube erosion. CONCLUSIONS: Preserved human cadaveric pericardial patch grafts appear to be well-tolerated for use with glaucoma drainage devices. As with other grafting material, potential for graft thinning is possible and further long-term experience is needed.

Bleb-related ocular infection in children after trabeculectomy with mitomycin C.

OBJECTIVE: The purpose of the study is to report the clinical course of bleb-related ocular infection in children after trabeculectomy with adjunctive mitomycin C. DESIGN: The study design was a retrospective review of all patients with a diagnosis of bleb-related ocular infection after trabeculectomy with adjunctive mitomycin C. PARTICIPANTS: Three children were identified in whom late postoperative bleb-related ocular infection developed. INTERVENTION: Treatment consisted of vitreous biopsy with intravitreous antibiotic and corticosteroid injection and/or bleb culture with topical and intravenous antibiotic administration. MAIN OUTCOME MEASURES: Visual acuity and intraocular pressure were measured. RESULTS: Bleb-related ocular infection developed an average of 16.7 +/- 10.9 months after trabeculectomy (range, 4-23 months). The mean age at presentation was 7.0 +/- 2.6 years (range, 4-10 years). Vitreous cultures were positive for staphylococci in two cases. A bleb culture from the third case also grew staphylococcus. All of the children recovered their initial vision after treatment of infection. However, one lost six lines of vision after a subsequent retinal detachment. Additional glaucoma surgery was required in one patient. CONCLUSIONS: Late bleb-related ocular infection may occur in children after trabeculectomy with mitomycin C and is characterized by abrupt onset, bleb infiltration, and rapid progression. Despite early preservation of vision after treatment of infection, significant late visual loss can occur.

Ultrasound biomicroscopy in anterior ocular trauma.

BACKGROUND AND OBJECTIVE: The authors investigated the role of ultrasound biomicroscopy after ocular trauma. PATIENTS AND METHODS: Ultrasound biomicroscopy was performed in six eyes of six patients at the New York Eye and Ear Infirmary after a variety of traumatic ocular injuries. RESULTS: Eyes with angle recession, iridodialysis, cyclodialysis, hyphema, an intraocular foreign body, scleral laceration, and subluxed crystalline lens were imaged without complication. Ultrasound biomicroscopy aided in the diagnosis when visualization was limited by media opacities or distorted anterior segment anatomy. CONCLUSION: Ultrasound biomicroscopy is a safe and effective adjunctive tool for the clinical assessment and management of ocular trauma, especially when visualization is limited and multiple traumatic injuries are involved.

Suprachoroidal hemorrhage after Molteno implantation.

PURPOSE: The objective of this study is to identify the rate and the associated risk factors for suprachoroidal hemorrhage (SCH) after Molteno drain implantation. METHODS: Data from the Molteno pilot study and single versus double-plate Molteno study were reviewed retrospectively for the occurrence of SCH. Follow-up intervals, demographic variables, ocular data, and medical history were collected. RESULTS: SCH occurred in 6% of the patients enrolled in the Molteno studies; all cases were delayed and none were intraoperative. Significantly associated factors in a multiple logistic regression for SCH were the extent of intraocular pressure (IOP) drop after surgery, the post-operative IOP, a diagnosis of angleclosure glaucoma, and possibly the number of prior surgeries as well. Eyes with SCH did significantly less well in terms of visual acuity outcomes and were more likely to have inadequately controlled IOP. CONCLUSIONS: This study suggests that SCH occurs at the same frequency after Molteno implantation as after filtering surgery with antimetabolite use and that eyes with SCH do less well.

Laser suture lysis after mitomycin C trabeculectomy.

PURPOSE: To evaluate the timing, efficacy, and complications of laser suture lysis (LSL) after mitomycin C trabeculectomy in patients with glaucoma at high risk for failure of filtering surgery. METHODS: The authors retrospectively reviewed the charts of 62 consecutive patients who underwent a total of 66 sessions of LSL after trabeculectomy with mitomycin C. RESULTS: The interval from surgery to LSL ranged from 2 to 65 days (mean +/- standard deviation, 17.9 +/- 14.9 days). The average intraocular pressure (IOP) reduction after LSL was 11.9 +/- 8.9 mmHg (range, 3-40 mmHg). A longer interval to LSL was correlated with a lesser degree of pressure reduction (P=0.0004, Wilcoxon rank-sum test). After LSL, hypotony developed in 13 (21%) patients (IOP < 6 mmHg on 2 consecutive measurements at least 24 hours apart). This resolved spontaneously after 7 to 304 days (104.1 +/- 109.1 days) in 12 (92%) of the 13 patients. Life-table success rates (success defined as 6 mmHg

Echographic evaluation of primary cysts of the iris pigment epithelium.

PURPOSE: Primary cysts of the iris pigment epithelium frequently appear to be focal elevations of the peripheral iris. To differentiate them from other anterior segment tumors requires the ability to assess the distribution, tissue characteristics, and progression of such lesions, which we accomplished by using anterior segment echography. METHODS: We reviewed the medical records of 49 consecutive patients referred to the Doheny Eye Institute for echographic evaluation of focal bulging of the peripheral iris. Echography of the anterior segment was performed on each patient by using an immersion technique. Clinical examination was also performed on 20 (41%) patients at the time of initial examination. RESULTS: We identified 52 iris pigment epithelial cysts in 52 eyes of the 49 patients studied. All lesions were single, localized to the posterior iris surface, and demonstrated a well-circumscribed, echolucent structure on B-scan echography. Average maximal sagittal thickness was 1.6 +/- 0.4 mm. Cysts were most frequently located in the inferotemporal quadrant (31%). Minimal increase in size or regression of lesions was noted in the nine patients (ten eyes) for whom follow-up echographic examinations were available. CONCLUSIONS: Primary iris pigment epithelial cysts possess characteristic features with regard to location, size, and internal structure, which can be accurately documented with echography. Clinically evident lesions tend to be between 1 and 4 mm in maximum sagittal thickness, conform to the contour of posterior chamber structures without distortion, produce anterior bulging of the peripheral iris, are preferentially located in the inferotemporal quadrant, and demonstrate limited potential for growth.

Experience with the Baerveldt glaucoma implant in treating neovascular glaucoma.

PURPOSE: The authors present a retrospective study designed to assess the effectiveness of the Baerveldt glaucoma implant in controlling intraocular pressure (IOP) and maintaining visual function in eyes with neovascular glaucoma. METHODS: The medical records of all 36 patients (36 eyes) who underwent Baerveldt glaucoma implantation for medically uncontrolled neovascular glaucoma between February 1991 and December 1992 were reviewed. RESULTS: Eighteen patients received Model 350 implants, 16 received Model 500 implants, and 2 received Model 200 implants. The 12- and 18-month life-table success rates (success defined as 6 mmHg < or = final IOP < or = 21 mmHg without additional glaucoma surgery or devastating complication) were 79% and 56%, respectively. Visual acuity remained stable or improved in 10 (31%) patients. Postoperative complications included flat anterior chamber, serous choroidal detachment, and obstruction of the proximal tube tip with fibrovascular tissue, each of which occurred in four (11%) patients. Eleven (31%) patients lost light perception. There were no significant differences between the groups receiving the Model 350 and Model 500 implants with respect to life-table success rates, percentage of postoperative IOP reduction, or complication rates. Patients in the Model 500 implant group required significantly fewer antiglaucoma medications post-operatively, but also demonstrated a significantly greater mean visual acuity reduction. Better preoperative visual acuity and increased patient age were positively correlated with a successful outcome. CONCLUSIONS: Baerveldt implantation is effective in controlling IOP elevation associated with neovascular glaucoma. Postoperative visual loss, despite adequate IOP control, is common. Young patient age and poorer preoperative visual acuity are significant predictors of surgical failure.

Delayed-onset pneumococcal endophthalmitis after mitomycin-C trabeculectomy: association with cryptic nasolacrimal obstruction.

PURPOSE: Delayed-onset endophthalmitis is a well-recognized complication of glaucoma filtering surgery, but, to our knowledge, no previous reports have associated this entity with occult nasolacrimal duct obstruction. METHODS: A 16-month-old girl developed endophthalmitis 1 month after a mitomycin-C trabeculectomy for congenital glaucoma. A diagnostic pars plana vitrectomy, anterior chamber paracentesis, and injection of intravitreal antibiotics were performed. RESULTS: Streptococcus pneumoniae was cultured from the aqueous and vitreous samples. Gradual clearing of the infection was achieved with systemic, intravitreal, and topical antibiotic therapy. Examination following resolution of the infection revealed complete obstruction of the ipsilateral nasolacrimal duct. CONCLUSIONS: The high incidence of Streptococcus pneumoniae as the causative organism in delayed-onset endophthalmitis following glaucoma filtering surgery may be related, in part, to preexisting lacrimal outflow obstruction. Careful preoperative evaluation with attention to lacrimal outflow disorders is imperative prior to glaucoma filtering surgery, especially in children.

Experience with the baerveldt implant in young patients with complicated glaucomas.

PURPOSE: Previous studies have suggested that glaucoma shunt implantation may be useful in the management of glaucoma in young patients in whom goniotomy and/or trabeculotomy have failed or are inappropriate. Herein, we describe our initial experience with Baerveldt implantation in young patients with complicated glaucomas. METHODS: Charts of all patients with glaucoma who were under 21 years of age, and who underwent Baerveldt implantation between March 1, 1991 and March 1, 1993 with at least a 6-month follow-up (30 eyes of 30 patients) were reviewed retrospectively. RESULTS: The patients' ages ranged from 2 months to 20 years (mean, 6.6 +/- 6.4 years) with follow-up of 6-25 months (mean, 15.0 +/- 6.3 months). Intraocular pressure (IOP) was reduced from a preoperative range of 17-78 mm Hg (mean, 35.5 +/- 13.1 mm Hg) to a range of 6-22 mm Hg (mean, 13.5 +/- 4.2 mm Hg) postoperatively. Six- and 12-month life-table success rates (6 +/- IOP +/- 21 without additional glaucoma surgery or devastating complication) were 93% and 86%, respectively. CONCLUSION: Baerveldt implantation is a useful approach to the treatment of glaucoma in young patients with complicated glaucomas.

Tissue plasminogen activator and glaucoma drainage implants.

PURPOSE: The tube lumen of a glaucoma drainage implant is prone to occlusion by a blood or fibrin clot due to its small caliber, relatively low flow rate, and the plasmoid nature of the aqueous humor passing through it in the early postoperative period. The use of tissue plasminogen activator in the management of drainage tube obstruction is described herein. METHODS: Two cases of drainage tube obstruction in patients with neovascular glaucoma treated with an intracameral injection of tissue plasminogen activator are reported. RESULTS: Resolution of tube obstruction following tissue plasminogen activator administration with spontaneous lowering of the intraocular pressure and bleb formation was achieved in both cases. Differentiation of tube obstruction from other causes of elevated intraocular pressure following installation of glaucoma drainage devices is discussed. CONCLUSION: The intracameral injection of tissue plasminogen activator may relieve drainage tube obstruction secondary to a blood or fibrin clot, even in the absence of any visible clot covering the proximal tube ostium or within the anterior chamber portion of the tube. This approach should be considered, in selected cases, prior to more invasive surgical revision.

Intermediate-term results of a randomized clinical trial of the 350- versus the 500-mm2 Baerveldt implant.

BACKGROUND: The Baerveldt glaucoma implant is a large equatorial aqueous shunting device that is installed through a single-quadrant conjunctival incision. The intermediate-term results of a randomized study comparing the 350- and 500-mm2 Baerveldt implants are reported. METHODS: Seventy-three patients with medically uncontrollable, nonneovascular glaucomas associated with aphakia, pseudophakia, or failed filters were enrolled in a randomized, prospective study comparing 350- and 500-mm2 Baerveldt implants. Surgical success was defined as 6 mmHg < or = final intraocular pressure < or = 21 mmHg without glaucoma reoperation or devastating complication. RESULTS: Of patients with 350- and 500-mm2 implants, 93% and 88%, respectively, achieved surgical success (18-month life-table analysis, P = 0.93). The 500-mm2 implants afforded intraocular pressure control with significantly fewer medications (0.7 versus 1.3; P = 0.006). The postoperative visual acuities remained within one line of the preoperative visual acuities or improved in 62% and 66% of patients in the 350- and 500-mm2 groups, respectively (P = 0.93). Complication rates were statistically similar. The most frequent ones in the 350- and 500-mm2 groups, respectively, were serous choroidal effusion (16% and 32%), strabismus (16% and 19%), anterior uveitis (14% and 11%), and corneal or corneal graft edema (11% each). CONCLUSION: The intermediate-term results of the 350- and 500-mm2 Baerveldt implants were statistically comparable with respect to surgical and visual outcomes, as well as complications, although the larger implant was associated with a higher rate of some complications. However, the 500-mm2 Baerveldt implant afforded intraocular pressure control with fewer medications than the 350-mm2 implant.

Krupin disk implantation for complicated glaucomas.

BACKGROUND: The Krupin Eye Valve with Disk (Krupin disk) is a glaucoma shunt that incorporates a slit valve intended to minimize early postoperative hypotony. METHODS: The medical records of all patients who have undergone Krupin disk implantation at the Doheny Eye Institute between July 1990 and December 1992 (25 eyes of 25 patients) were reviewed. RESULTS: Intraocular pressure (IOP) was reduced from a mean of 36.1 +/- 11.5 mmHg to 15.3 +/- 7.5 mmHg at follow-up intervals of 4 to 19 months (mean, 13.2 months). On the first postoperative day, IOPs ranged from 0 to 40 mmHg. In two eyes (8%), the IOP was less than 6 mmHg, and in five eyes (20%) the IOP was more than 21 mmHg. Serous choroidal effusion and/or choroidal hemorrhage occurred in seven patients (28%). Six- and 12-month life-table success rates (6 < or = IOP < or = 21 mmHg) were 84% and 66%, respectively. CONCLUSION: The Krupin disk lowers IOP in most patients; however, the presence of a slit valve does not eliminate either early postoperative hypotony with its attendant complications or early IOP spikes.

Aqueous tube shunt to a preexisting episcleral encircling element in the treatment of complicated glaucomas.

PURPOSE: The treatment of glaucoma after scleral buckling surgery is often problematic. The authors investigated a series of patients in whom a silicone tube was implanted to shunt aqueous from the anterior segment to the fibrous capsule surrounding a previously placed silicone episcleral encircling element. METHODS: Thirteen patients were retrospectively reviewed. In each patient, a silicone tube was inserted through a small incision into the fibrous capsule overlying the scleral explant. In most patients, no attempt was made to secure the distal end of the tube to the silicone band. The proximal end of the tube was inserted into the eye via a needle track. RESULTS: Successful control of intraocular pressure (IOP) (6 mm Hg < or = final IOP or < 21 mmHg with or without medication) was ultimately achieved in 11 (85%) of 13 patients (3 of the successful patients underwent one or more surgical revisions to relieve obstruction of the proximal and/or distal tube opening). Follow-up in these patients ranged from 8 to 49 months (mean +/- standard deviation, 21.7 +/- 14.1 months). The final postoperative visual acuities were within one line of the preoperative visual acuities or had improved in 11 (85%) patients. Complications included serous choroidal detachment (3 patients; 23%), conjunctival wound leak (2 patients; 15%), hyphema (1 patient; 8%), and tube obstruction by lens, iris, vitreous, or episcleral fibrous tissue (4 patients; 31%). CONCLUSION: Aqueous tube shunt to a pre-existing episcleral encircling element is useful in treating complicated glaucomas after scleral buckling surgery. Fibrous obstruction of the external tube opening is a frequent complication in the early postoperative period, but it may be relieved by surgical revision.

Epithelial ingrowth and glaucoma drainage implants.

BACKGROUND: The authors report four cases of conjunctival epithelial invasion into the fibrous capsule surrounding a Baerveldt glaucoma implant. All cases were associated with concurrent or recent prior scleral buckling surgery. METHODS: Three patients had postoperative conjunctival wound leaks, one in the immediate postoperative period and the other two at 9 and 17 days postoperatively after release of the tube ligature. In the fourth patient, a fistulous tract developed over the implant after a first-stage insertion. Histopathologic confirmation of subconjunctival epithelialization was obtained in two of these patients. RESULTS: Surgical revision was performed in all patients. Excision and debridement of all epithelium-lined subconjunctival tissues and extensive bipolar cautery were used in the three patients with wound leaks. Implant removal also was performed in one of these. Fistulectomy and bipolar cautery were used in the fourth patient. No recurrent wound leaks or other adverse sequelae were noted. CONCLUSIONS: Epithelial invasion of the subconjunctival space and inner bleb wall after implantation of glaucoma drainage devices can lead to breakdown of the conjunctival wound and persistent aqueous leak. Prior or concurrent scleral buckling surgery may predispose to this occurrence. Surgical revision involving epithelial debridement, cautery, and meticulous wound closure, with or without implant removal, has been used successfully in the management of this complication.

Glaucoma drainage implants.

Glaucoma drainage implants provide a useful option in the management of complicated glaucomas for which the risk of failure of conventional filtering surgery is high. The basic design of these devices is similar; a silicone tube shunts aqueous humor from the anterior chamber to a fibrous capsule surrounding a synthetic plate or band positioned at the equatorial region of the globe. The capsule serves as a reservoir for aqueous drainage. Drainage implants have been used in the treatment of various refractory glaucomas, including those associated with aphakia and pseudophakia, prior unsuccessful filtering surgery, anterior segment neovascularization, trauma, youth, uveitis, epithelial downgrowth, iridocorneal endothelial syndrome, vitreoretinal disorders, and penetrating keratoplasty. Modifications in implant design and surgical technique have been developed to limit the occurrence of postoperative complications such as hypotony and its related sequelae, and strabismus.

Ocular findings in Treacher Collins syndrome.

We examined 14 patients from nine families referred with the diagnosis of Treacher Collins syndrome. We noted seven significant ocular findings including the following: a subnormal horizontal palpebral fissure length and inferomedial displacement of the lateral canthus in primary gaze; further medial displacement (4.0 mm or more) of the lateral canthus with resultant shortening of the horizontal fissure length on forced eyelid closure (fissure narrowing sign); partial-thickness eyelid colobomata localized to the nasal one half to two thirds of the lower eyelids; bilateral absence of the inferior lacrimal puncta; bilateral blepharoptosis; inferior displacement of the palpebral fissures; and regular astigmatism without any consistent orientation of the axis of astigmatism relative to the lower eyelid defects, blepharoptosis, or lateral canthus. The fissure narrowing sign correlates with known anatomic deficiencies in the Treacher Collins syndrome and may prove valuable in confirming the diagnosis in patients who lack certain typical features.