EyeWorld Asia-Pacific June 2012 Issue

34 EWAP CATARACT/IOL June 2012 New realities of YAG capsulotomy by Maxine Lipner Senior EyeWorld Contributing Editor How modern technique is forestalling complications A lot of people fondly remember the “good old days” when you could fill up your car for a dollar or so a gallon and go to the movies for just a few dollars. But when it comes to YAG capsulotomy these are the good old days, according to Steven G. Safran, MD , private practice, Lawrenceville, NJ, USA. Thanks to modern phaco technique and improved lenses, practitioners are much less likely to be faced with significant post-YAG complications than ever before. “In the old days when extracapsular surgery was done, the lens was in the sulcus, and when we did a YAG capsulotomy there was a gap between the implant and the anterior hyaloid face,” Dr. Safran said. “So when we would rupture the anterior capsule and the anterior hyaloid face, the vitreous would come forward, which would cause vitreoretinal traction, and that could lead to retinal detachments, cystoid macular edema (CME), and all kinds of problems.” Now with the lens in the bag, it tamponades the vitreous, he finds, and there is no movement forward if the YAG is done properly. “In my experience I don’t see any increased risk of retinal detachment or CME after YAG capsulotomy.” Performing earlier YAGs Another factor has to do with when the YAGs are currently done. “People used to wait until the posterior capsule looked like bloody hell to YAG and that would lead to pressure spikes,” Dr. Safran said. “I can say that we YAG earlier now, especially with premium IOLs.” He finds that some of the lenses themselves can even help the process. For instance the Crystalens (Bausch + Lomb, Rochester, NY, USA) is pushing on the posterior capsule back, which tends to be under tension anyway, and can Removing a floater after YAG capsulotomy may be one of the few remaining complications with which to contend. Source: Kevin Miller, MD YAO Ke, MD Chief and Professor, Eye Center Second Affiliated Hospital, School of Medicine, Zhejiang University No. 88 Jiefang Road, Hangzhou, China Tel. no. +86-571-87783897 Fax no. +86-571-87783897 xlren@zju.edu.cn I agree that complications after YAG capsulotomy declined significantly year by year as modern phaco techniques and lens designs improved, with the estimated YAG ratio at 10% of 8,000 cataract surgical cases each year, among them at least 3% early YAG for premium IOLs in our Zhejiang University Eye Center. Now YAG complications are fairly rare in our eye center although we tell patients about nine kinds of complications before YAG. In the last 5 years, we have not had patients experience retinal detachment or cystoid macular edema 1 month after YAG. The main complication in adult patients is the transient sense of floaters caused by debris 2 weeks after YAG. Several decades ago, I would occasionally see patients with PCO after extracapsular surgery because of congenital cataract. In these cases, the PCO is extremely dense with much proliferated cortex, one of them having pressure spikes after YAG. For these patients whose cortex remains in most quadrants, it is highly recommended that patients be reminded to come back to the doctor if eye pain occurs or to take antihypertension drugs home. For patients with premium IOLs, YAG will be performed earlier. Especially for diffractive multifocal lenses, the lens itself diffuses light which influences the judgment of surgeons, so it gets more difficult for YAG. The severe opacity even makes surgeons feel that it is a tough thing to deal with; moreover, patients with multifocals are sensitive to opacity, so earlier YAG is necessary. Lens pitting as a new complication is mainly correlated with proper operation and experience of surgeons. It will not affect patients’ vision but the contrast sensitivity or glare sensitivity can be changed. Of course, severe lens pitting can still affect the patients’ vision. So, surgeons at our eye center need to be trained before YAG capsulotomy. They need to perform laser peripheral iridotomy for 50 cases. After they can place the focal points precisely, they then move on to capsulotomy. Editors’ note: Prof. Yao has no financial interests related to his comments. Views from Asia-Pacific make it possible to use very little YAG energy. “A couple of shots and the thing sort of unzips,” Dr. Safran said. “There’s usually no debris and it’s very rare to see a pressure spike these days. For patients who have premium lenses, surgeons can’t wait until they are 20/100 (6/30) to perform a YAG. “They paid for something extra, and they lost what they paid for and more well before then.” This is especially true for those with multifocal IOLs. “Their vision is very labile with the multifocal— it doesn’t take much to spoil it,” Dr. Safran said. Likewise with the Crystalens surgeons can’t wait to YAG because it interferes with the ability to accommodate. William B. Trattler, MD , director of cornea, Center for Excellence in Eye Care, Miami, Fla., USA, agreed. “With premium IOLs, especially the multifocals, they’re sensitive to opacities—even if it’s