[Four-year changes in ganglion cell complex thickness in homonymous hemianopia].

PURPOSE: Aquired transsynaptic retrograde degeneration of the human visual system can be identified using magnetic resonance imaging (MRI) and optical coherence tomography (OCT), which can reveal optic tract atrophy, retinal nerve fiber layer loss, and ganglion cell complex (GCC) thinning. We investigated GCC changes in the first 4 years following post-geniculate lesions. METHODS: Nine patients with congruous homonymous hemianopia were scanned with OCT. A 6-mm circle centered on the macula was divided vertically into hemianopia (H) and unaffected (U) sides. GCC and retinal thicknesses were calculated using an average for both eyes and compared with the hemianopia/unaffected side (H/U) ratio. The relationship between the H/U ratio of GCC and time elapsed since occipital damage was evaluated. RESULTS: The average GCC thicknesses was 89.1 and 96.6 microm, and of the retina 295.7 microm and 292.7 microm in the H and U sides, respectively. The H/U ratio of GCC at 0.92 was significantly lower than of the retina at 0.99 (p=0.042). Regression analysis revealed a negative linear relationship (linear regression r= -0.868, p= 0.012) described by the equation: H/U ratio of GCC = 0.99 - 0.004 x elapsed time (months). CONCLUSION: For 4 years following post-geniculate damage, GCC on the hemianopia side decreased approximately 5% per year while the retinal thickness was almost unchanged.

Long axial length as risk factor for normal tension glaucoma.

BACKGROUND: The high prevalence of normal tension glaucoma (NTG) in the Japanese requires special screening tests other than measurements of only the intraocular pressure (IOP). This study was carried out to determine whether there is a significant association between the axial length of the eye and the presence of NTG. METHODS: We reviewed the medical records of all patients who were scheduled to undergo cataract surgery alone or combined with glaucoma surgery at the same time. There were 87 patients with NTG, 137 with POAG, and 978 non-glaucomatous control cases. The axial length, IOP, curvature of the anterior corneal surface, age, and gender were determined at the time of the operation. If both eyes had surgery, data from only the right eyes were analyzed. An association of these parameters with NTG and POAG was analyzed by logistic regression analysis. The three groups were analyzed for differences in the axial length using the Kruskal-Wallis test followed by the Mann-Whitney U test. RESULTS: The axial length was significantly associated with NTG (odds = 1.24, P = 0.002) and POAG (odds = 1.28, P = 0.001). The incidence of either POAG or NTG was significantly higher in patients with axial lengths >or=25.0 mm (odds = 2.29, P < 0.001, Fisher's exact test). The age at the time of cataract surgery was weakly but significantly correlated negatively with the axial length (r = -0.24, P < 0.001, Pearson's correlation coefficient test). Men had significantly longer axial lengths than women. CONCLUSIONS: Long axial lengths can be considered a risk factor for NTG and POAG, and patients with long axial lengths need to be carefully examined for glaucoma.

Risk factors for uncontrolled intraocular pressure after phacoviscocanalostomy.

PURPOSE: To determine factors affecting the outcome of phacoviscocanalostomy in patients with cataract and primary open-angle glaucoma. METHODS: Factors for controlling intraocular pressure (IOP) were investigated in 180 patients using Cox multivariate proportional hazards survival regression. RESULTS: The mean preoperative IOP of 20.2+/-3.8 mm Hg decreased significantly (P<0.0001) to 15.3+/-2.6 mm Hg for 5 years postoperatively. The success probabilities defined as an IOP of 17 mm Hg or less or a 20% or greater reduction were 47.2% with or without medications and 31.4% without medications at 5 years. Preoperative IOP level [P=0.0013; odds ratio (OR), 1.14] and age (P=0.037; OR, 0.97) were risk factors in the success probability with or without medications. In the analysis without medications, the preoperative IOP (P<0.001; OR, 1.12), the preoperative number of antiglaucoma medications (P=0.033; OR, 1.27), age (P=0.003; OR, 0.96), and IOP spikes (P=0.028; OR, 1.22) were associated with failure. Sex, peeling of juxtacanalicular tissue, ruptured Descemet membrane, fibrin formation, and hyphema did not affect surgical outcomes. CONCLUSIONS: High preoperative IOP, the number of preoperative medications, postoperative IOP spikes (>30 mm Hg) increased the risk of failed IOP control after phacoviscocanalostomy. Increasing patient age decreased the risk of failure.

Phacoviscocanalostomy versus cataract surgery only in patients with coexisting normal-tension glaucoma: midterm outcomes.

PURPOSE: To compare the midterm efficacy and safety of phacoviscocanalostomy (viscocanalostomy, phacoemulsification, and intraocular lens [IOL] implantation) and cataract surgery (phacoemulsification and IOL implantation) in patients with normal-tension glaucoma (NTG) and cataract. SETTING: Sensho-kai Eye Institute, Kyoto, Japan. METHODS: Thirty-one eyes had phacoviscocanalostomy, and 35 eyes had uncomplicated cataract surgery only. The intraocular pressure (IOP), postoperative antiglaucoma medications, and visual outcomes were compared between groups. RESULTS: The mean follow-up was 34.9 months+/-19.8 (SD) (range 7 to 78 months). At 36 months, the mean preoperative IOP and postoperative IOP were 17.2+/-1.5 mm Hg and 14.1+/-1.6 mm Hg, respectively, in the phacoviscocanalostomy group and 16.7+/-1.4 mm Hg and 15.6+/-3.4 mm Hg, respectively, in the cataract surgery only group. The differences between groups were significant at all time points (P<.05). The success probabilities of the phacoviscocanalostomy group achieving 20% and 30% IOP reductions with (or without) medications were 78.5% (67.4%) and 35.5% (37.4%) at 24 months and 58.0% (44.2%) and 28.0% (26.6%) at 48 months, which were significantly better than the probabilities in the cataract surgery only group, which were 16.0% (9.5%) and 5.7% (2.9%) at 24 months (P<.001 for each comparison, Kaplan-Meier life-table analysis with log-rank test). Based on the modified Aulhorn-Greve classification, the visual acuity and visual fields did not deteriorate in the phacoviscocanalostomy group; the visual fields deteriorated in 6 eyes in the cataract surgery only group during the follow-up (P=.024). CONCLUSION: Phacoviscocanalostomy lowered IOP and maintained postoperative visual outcomes; it was safe and effective in elderly patients with coexisting NTG and cataract.

Prospective evaluation of factors associated with post-LASIK corneal birefringence with scanning laser polarimetry.

PURPOSE: To identify factors that affect corneal birefringence, such as the corneal polarization axis (CPA) and corneal polarization magnitude (CPM), after laser in situ keratomileusis (LASIK) using scanning laser polarimetry with a variable corneal polarization compensator. METHODS: The CPA and CPM from 42 patients (42 eyes) who underwent LASIK and 24 normal untreated subjects (24 eyes) were measured 1 week before and 1 week after LASIK. Changes in the CPA and CPM after LASIK were studied using Student t test and Pearson correlation coefficient. RESULTS: In the LASIK group, the post-LASIK CPA and CPM significantly changed, whereas both values did not change in normal subjects. Among 5 candidate factors [preoperative CPA (pre-CPA), preoperative CPM (pre-CPM), age, change in corneal curvature, and ablation depth], the change in CPA was significantly correlated with the pre-CPA (r=-0.793) and pre-CPM (r=0.339). The change in CPM was correlated with the pre-CPA (r=-0.455) and pre-CPM (r=-0.411). Over 83% case of postoperative corneal birefringence can be explained by only 2 parameters with regression analysis. CONCLUSIONS: The pre-CPA and pre-CPM are strongly associated with LASIK-induced changes in CPA and CPM. Variations in age, changes in corneal curvature, and ablation depth do not contribute to changes in either parameter.

Phaco-viscocanalostomy versus phaco-trabeculotomy: a middle-term study.

PURPOSE: To compare the surgical outcomes between phaco-viscocanalostomy and phaco-trabeculotomy in open-angle glaucoma. PATIENTS AND METHODS: In a nonrandomized, retrospective clinical study, 110 eyes underwent phaco-viscocanalostomy (VCS group), and 110 eyes underwent phaco-trabeculotomy (LOT group). The mean follow-up was 857+/-409 (+/-SD) days (P=0.4777). RESULTS: The mean preoperative treated intraocular pressure (IOP) values were 20.2+/-3.5 mm Hg in the VCS group and 20.9+/-3.5 mm Hg in the LOT group (P=0.3377). The postoperative IOPs in the VCS group were 15.0+/-3.0 and 16.1+/-3.0 mm Hg at 1 and 3 years, and in the LOT group 16.3+/-2.9 mm Hg (P=0.0088) and 16.5+/-3.3 mm Hg (P=0.4993), respectively. The number of medications used in the VCS group was significantly lower than in the LOT group during the observation periods (P< or =0.0130). The probabilities of achieving IOPs< or =21 mm Hg at 3 years in the VCS group were 92.0% with or without mediations and 58.2% without medications, and were significantly better than those of the LOT group (84.7% and 36.0%, P=0.0334 and P<0.0001 by log-rank test, respectively). The probabilities of achieving IOPs< or =16 mm Hg at 3 years in the VCS group were 30.5% with or without mediations and 30.3% without medications, whereas those in the LOT group were 27.5% (P=0.1799) and 19.4% (P=0.0010), respectively. The visual outcome was similar between the groups. Postoperative hyphema (> or =2 mm) and IOP spikes (> or =30 mm Hg) occurred significantly less in the VCS group (2.7 and 3.6%, respectively) than in the LOT group (26.4 and 28.2%, respectively; P<0.0001). In 13 eyes (11.8%) of the LOT group, the highest IOP level was recorded 40 mm Hg or higher. Vitreous hemorrhage and central visual loss occurred in 1 case each in the LOT group. CONCLUSIONS: After a middle-term observation, phaco-viscocanalostomy provides better IOP control and a lower incidence of vision-threatening complications than phaco-trabeculotomy.

Diabetes-associated retinal nerve fiber damage evaluated with scanning laser polarimetry.

PURPOSE: To evaluate retinal nerve fiber layer (RNFL) thickness in patients with diabetes mellitus compared with age-matched normal control subjects, to assess the correlation between the RNFL thickness and the severity of retinopathy, and to investigate whether diabetes mellitus is a potential source of abnormal results in glaucoma screening or evaluation with scanning laser polarimetry (SLP). DESIGN: Cross-sectional analysis of normal and diabetic eyes. METHODS: setting: Institutional clinical study. patients: One hundred twenty-eight subjects with type 2 diabetes mellitus and 50 age-matched normal control subjects without glaucoma or glaucoma-suspect. All patients underwent imaging with SLP and repeatable automated perimetry. Subjects with diabetes mellitus were classified into four stages on the basis of the severity of retinopathy that was assessed by dilated funduscopic examination, high-quality fundus color photography, and fluorescein angiography. MAIN OUTCOME MEASURES: The SLP (GDx VCC software, version 5.5.0) parameters. RESULTS: The RNFL thickness in patients with diabetes mellitus was reduced significantly compared with age-matched normal control eyes (P < .01). Moreover, all RNFL thickness parameters of the GDx VCC software decreased significantly as an exacerbation of diabetic retinopathy (P = .0019, P = .0045, P = .0010 for temporal-superior-nasal-inferior-temporal (TSNIT) average, superior average, inferior average, respectively). The nerve fiber indicator also increased significantly (P < .0001), despite an absence of glaucomatous optic nerve damages. CONCLUSION: The RNFL thickness in type 2 diabetes mellitus, which was measured by GDx VCC software, significantly decreased with the severity of diabetic retinopathy. The presence of diabetes mellitus can be a source of false-positive results and overestimation of glaucomatous optic neuropathy when eyes are screened with GDx VCC software.

Does the adjunctive peeling of juxtacanalicular tissue affect the outcome of two-site phaco-viscocanalostomy?

PURPOSE: To compare the surgical outcomes of combined corneal-incision cataract surgery and viscocanalostomy (phaco-VCS) with or without the adjunctive peeling of juxtacanalicular tissue (JCT) in 136 patients of open-angle glaucoma or ocular hypertension. METHODS: In a prospective clinical trial, 63 eyes underwent phaco-VCS (Peeling (-) group), and 73 eyes underwent phaco-VCS with the peeling of JCT (Peeling (+) group). The postoperative IOP, the probability of successful IOP reduction without medications, and postoperative complications were compared between the two groups. RESULTS: The mean preoperative IOP of 19.9 +/- 3.3 (+/-SD) mm Hg in the Peeling (-) group decreased significantly to 13.9 +/- 6.8 at 3 days, 14.6 +/- 3.1 at 12 months, and 15.5 +/- 2.3 mm Hg at 24 months. The IOP of 20.2 +/- 3.2 mm Hg in the Peeling (+) group decreased significantly to 11.4 +/- 5.1 at 3 days, 14.9 +/- 3.0 at 12 months, and 15.9 +/- 2.1 mm Hg at 24 months. There was no significant difference in IOP levels between the two groups (P >/= 0.1512) except for the IOP level at 3 postoperative days (P = 0.0265). The probabilities of achieving IOPs without medications under 21 mm Hg and 15 mm Hg at 24 months in the Peeling (-) groups were 61.0% and 10.4%, and those in the Peeling (+) group were 61.7% and 23.9% (P >/= 0.4389). The incidences of IOP spike more than 30 mm Hg (7.9%) and fibrin formation (15.8%) in the Peeling (-) group were higher than in the Peeling (+) group (0%; P = 0.0195, 5.5%; P = 0.1907). Slit-lamp microscopic hyphema, which included red blood cells in the anterior chamber was observed in about half, and bleb formation more than 1 month was less than 5% in both groups. CONCLUSION: Postoperative IOPs were significantly decreased in both groups. Although the peeling of JCT was not enhanced in long-term reduction of the IOP, it lowered IOP at postoperative 3 days and the incidence of IOP spike. The adjunctive procedure would be beneficial to glaucoma patients in phaco-VCS.

Ultrasound biomicroscopy of intrascleral lake after viscocanalostomy and cataract surgery.

PURPOSE: To assess anatomic changes at the sclerectomy site after combined viscocanalostomy and cataract surgery associated with POAG or OH and cataract. METHODS: In a prospective, noncomparative, longitudinal study, we performed ultrasound biomicroscopy (UBM) of the sclerectomy site in 84 eyes at 3, 6, and 12 months after the surgery. Four parameters in UBM findings (area, radial longitudinal length, height of intrascleral space, and meridional length of window) were measured and the IOP level, the number of antiglaucoma medications, and bleb formation were observed for 12 months. RESULTS: Intraocular pressure decreased from 19.8 +/- 3.5 (+/- SD) mm Hg preoperatively to 15.5 +/- 3.0 mm Hg 12 months postoperatively (P < 0.0001). Blebs were formed in 2 of 84 eyes (2.4%) at 1 month, and 1 of 84 eyes (1.2%) after 3 months. The IOP decreased at 3, 6, and 12 months postoperatively by 5.8, 4.8, and 4.3 mm Hg, respectively (P = 0.0016). A significant difference was observed between 3 months and 12 months in area (0.17 and 0.13 mm, respectively, P = 0.0127 using the Bonferroni/Dunn test), longitudinal length (0.89 and 0.72 mm, P = 0.0059), and height (0.21 and 0.15 mm, P < 0.0001), but not in meridional length (0.41 and 0.33 mm). The lake was present in 66.7% of cases at 12 months. CONCLUSION: Combined viscocanalostomy and cataract surgery lowered IOP without bleb formation. Postoperatively, the size of the lake and IOP decreased, suggesting parallel reduction of the two. The lake was undetected ultrasonographically in one third of the cases 1 year postoperatively.

Innervation of rat iris by trigeminal and ciliary neurons expressing pChAT, a novel splice variant of choline acetyltransferase.

We have recently discovered a splice variant of choline acetyltransferase (ChAT) mRNA and designated the variant protein pChAT because of its preferential expression in peripheral neuronal structures. In this study, the presence of pChAT in rat iris was examined by immunohistochemistry and Western blot using a pChAT antiserum, in combination with RT-PCR analysis and ChAT enzyme assay. For comparison, the conventional ChAT (cChAT) was studied in parallel. By pChAT immunohistochemistry, intense labeling was found to occur in nerve fibers of the iris and in neurons of the ciliary and trigeminal ganglia. Denervation studies, analyzed by semiquantitative morphometry, indicated that these iridial pChAT fibers originated about half from the ciliary ganglion and the other half from the trigeminal ganglion. The presence of pChAT protein in the iris and trigeminal ganglion was confirmed by Western blot. The expression of pChAT mRNA in the ciliary and trigeminal ganglia was proved by RT-PCR. Although cChAT protein and mRNA were detected in the ciliary ganglion, neither was detectable in the trigeminal ganglion. The contributions of the ciliary and trigeminal ganglia to the iridial ChAT enzyme activity were verified by the present ChAT assay. Here, we provide evidence that iridial pChAT nerves are composed of postganglionic parasympathetic efferents from the ciliary ganglion and, more interestingly, somatic sensory afferents of the trigeminal ophthalmic nerve.

Combined viscocanalostomy and cataract surgery compared with cataract surgery in Japanese patients with glaucoma.

PURPOSE: To compare intraocular pressure (IOP) and the incidence of complications after combined viscocanalostomy and cataract surgery with cataract surgery alone in 206 Japanese eyes with POAG or OH. PATIENTS AND METHODS: In a nonrandomized comparative, clinical study, 103 eyes underwent viscocanalostomy and cataract surgery (VCS group), and 103 eyes underwent cataract surgery alone (CSA group) (follow-up, 6-24 months). Reductions in IOP and medications, the probability of successful IOP reduction visual acuity changes, and complications were compared between the 2 groups. RESULTS: The reductions in IOP and number of medications in the VCS group were significantly greater than in the CSA group (P < or = 0.0038 and P < or = 0.0259, respectively). The probabilities of achieving IOPs less than 21, 18, and 15 mm Hg at 24 months in the VCS groups were 85.0%, 53.6%, and 17.2% with medications, and 61.1%, 43.9%, and 16.2% without medications, and significantly better than in the CSA group (P < 0.0002). The visual outcomes were similar in both groups. Postoperative complications such as hyphema and fibrin formation, although more frequent in the VCS group, were not vision threatening. CONCLUSION: Combined viscocanalostomy and cataract surgery provides good postoperative visual acuity with minimal complications and significantly greater IOP reduction than cataract surgery alone for Japanese patients with glaucoma.

Two cases of intraoperative anterior chamber angle observation using ophthalmic endoscope in viscocanalostomy.

PURPOSE: To report endoscopic findings in the anterior chamber angle during injection of viscoelastic material in viscocanalostomy (VCS). DESIGN: Observational case reports. METHODS: Two cases of primary open-angle glaucoma were treated with VCS and cataract surgery. Immediately before and during injection of viscoelastic material into Schlemm's canal, the anterior chamber angle was observed using an ophthalmic endoscope. RESULTS: In both cases, we observed viscoelastic material in Schlemm's canal and leakage of viscoelastic material and blood from Schlemm's canal into the anterior chamber away from the injection site of the viscoelastic material. In one case, indocyanine green-stained viscoelastic material was not in Schlemm's canal the day after surgery. CONCLUSIONS: In VCS, Schlemm's canal was filled and was disrupted after viscoelastic material injection. Disruption of the inner wall of Schlemm's canal and juxtacanalicular connective tissues may contribute to the intraocular pressure reduction associated with VCS.

Demonstration of cholinergic ganglion cells in rat retina: expression of an alternative splice variant of choline acetyltransferase.

Acetylcholine acts as a neurotransmitter in the retina. Although previous physiological studies have indicated that some retinal ganglion cells may be cholinergic, several immunohistochemical studies using antibodies to choline acetyltransferase (ChAT) have stained only amacrine cells but not ganglion cells. Recently, we identified a splice variant of ChAT mRNA, lacking exons 6-9, in rat peripheral nervous system. The encoded protein was designated as ChAT of a peripheral type (pChAT), against which an antiserum was raised. In the present study, we examined expression of pChAT in rat retina, both at the protein level by immunohistochemistry using the antiserum and at the mRNA level by RT-PCR. Immunohistochemistry revealed that although no positive neurons were found in untreated intact retinas, many neurons became immunoreactive for pChAT after intravitreal injection of colchicine. Damage of the optic nerve was also effective in disclosing positive cells. Such positive neurons were shown to be ganglion cells by double labeling with a retrograde tracer that had been injected into the contralateral superior colliculus. Western blot analysis and RT-PCR revealed a corresponding band to the pChAT protein and to the amplified pChAT gene fragment, respectively, in retinal samples. In addition, ChAT activity was definitely detected in retinofugal fibers of the optic nerve. These results indicate the presence of cholinergic ganglion cells in rat retina.

Morphologic study of neuronal death, glial activation, and progenitor cell division in the hippocampus of rat models of epilepsy.

PURPOSE: To clarify the relationship of neuronal death to cellular responses, we studied neuronal death as well as reactions of glia and progenitor cells in the hippocampus of two rat models of epilepsy. METHODS: Seizures were induced by either kainic acid (KA) administration or electrical kindling. Neuronal degeneration was assessed by in situ DNA fragmentation analysis. Reactions of glial cells were studied by immunohistochemistry. Progenitor cell division was evaluated using the bromodeoxyuridine (BrdU) labeling method. RESULTS: DNA fragmentation and reactive microglia were observed in the CA1, CA3, and hilus region for 24 h to 4 weeks after KA injection, but not detected in the kindling model. Reactive astrocytes and enhancement of progenitor cell division were seen in both animal models. The number of BrdU-positive cells began to increase on day 3 after KA injection, peaked on day 5, and returned to baseline on day 10. After kindling, the number of BrdU-positive cells began to increase after five consecutive experience of stage I seizures. CONCLUSIONS: These observations show that neuronal degeneration is not necessary for triggering the upregulation. Microglial activation is closely related to the neuronal death process induced by KA.

Comparison of surgical outcomes of combined viscocanalostomy and cataract surgery with combined trabeculotomy and cataract surgery.

PURPOSE: To compare the outcomes of combined viscocanalostomy, phacoemulsification, and intraocular lens (IOL) implantation with combined trabeculotomy, phacoemulsification, and IOL implantation in patients with primary open-angle glaucoma (POAG). DESIGN: Nonrandomized clinical trial. METHODS: Fifty-seven eyes (57 POAG patients) that underwent viscocanalostomy, phacoemulsification, and intraocular lens (IOL) implantation between March 2000 and April 2001 and were followed for over 6 months postoperatively comprised the viscocanalostomy (VCS) group. Fifty-seven of 105 eyes (105 POAG patients) that underwent trabeculotomy, phacoemulsification, and IOL implantation between April 1995 and February 2000 and were followed for over 6 months and < 2 years comprised the trabeculotomy (LOT) group. The reductions of postoperative intraocular pressure (IOP) and antiglaucoma medication use in both groups were compared. Best-corrected visual acuity (VA) and complication rates were secondary outcomes. The success probabilities related to postoperative IOP level in both groups were evaluated by Kaplan-Meier life-table analysis with log-rank test. RESULTS: Significant reductions of IOP and antiglaucoma medication use occurred in both groups up to 1 year postoperatively, but were not significantly different between the two groups. The success probabilities of the VCS group for IOP control under 21, 17, and 15 mm Hg were 95%, 74%, and 44%, respectively, at 6 months, 95%, 67%, and 32% at 1 year, and not significantly different from the LOT group. All eyes in the VCS group had VA equal to or better than baseline 3 months postoperatively. The incidences of postoperative fibrin reaction (14 eyes, 25%) and microperforations of the Descemet membrane (14 eyes, 25%) in the VCS group were higher than in the LOT group (P =.0004 and P <.0001, respectively). CONCLUSIONS: Intraocular pressure reduction and VA improvement after the two procedures were similar in Japanese patients with POAG and cataract.

[Outcome of combined phacoemulsification, intraocular lens implantation and viscocanalostomy].

PURPOSE: To assess the pressure-lowering effect, visual acuity, and intra- and postoperative complications of combined cataract surgery, intraocular lens(IOL) implantation and viscocanalostomy. METHODS: Combined viscocanalostomy, phacoemulsification, and IOL implantation was performed on 45 eyes, which were followed for more than 6 months after surgery. The average preoperative intraocular pressure(IOP) was 20.2 +/- 3.1(mean +/- standard deviation) mmHg, and the average medication number was 1.7. A prospective study of these cases was performed. RESULTS: IOP was significantly reduced after surgery, being 13.6 mmHg at 3 months and 15.1 mmHg at 6 months postoperatively. The visual acuity was improved more than 2 lines in 38 eyes. Disruption of Descemet's membrane was noted in 5 eyes and microperforation in 9 eyes as intraoperative complications. Postoperative complications were not vision threatening and included short term hyphema in 34 eyes, fibrin deposition in 5 eyes and IOP spike(> 5 mmHg) in 5 eyes. There were no cases of hypotony, choroidal detachment, or endophthalmitis. CONCLUSION: Combined viscocanalostomy, cataract extraction, and IOL implantation was a safe and efficacious way to reduce IOP.