10 EWAP SEPTEMBER 2023 CATARACT use a topical anesthetic because the procedure is not painful, there’s nothing touching the eye when doing the procedure, and no incisions are made. “I do tell the patients they will be blurry for 30–60 minutes or longer after the laser, but by that evening or the next day, their vision will clear up significantly,” she said. “I warn patients that it might make their floaters more noticeable.” The techniques that have been developed to prevent opacification are great, Dr. Robert Weinstock said. For example, the square-edge lenses are proven to reduce the migration of lens epithelial cells, which are often the source of the opacification. Good cortical cleanup with I/A and polishing of the capsule is another technique that can slow the process of capsular opacification, he said. However, even with these options, the majority of patients will ultimately need a YAG capsulotomy. There are some patients who have fibrosis of the capsule itself during cataract surgery. Sometimes you can polish off some of the opacity at the posterior capsule. Other times patients have had previous surgery, like retina surgery, and there is scarring in the vitreous and posterior plaques of fibrosis on the capsule. Those can’t be removed at the time of cataract surgery, so those patients require a YAG fairly quickly because once the cataract is gone and the new lens is in, it’s cloudy, Dr. Robert Weinstock said. “I’m not a fan of doing a posterior capsulotomy at the time of cataract surgery,” he said. “I think it introduces the potential for vitreous to come through into the anterior segment, and the YAG is so safe and easy. In my opinion, it’s easier to stage the procedures.” Dr. Robert Weinstock said that he will tell patients after surgery that the capsule was opacified, and the safest move is to let the eye heal for a month or so, then do the YAG capsulotomy. Dr. Robert Weinstock noted that a lot of lenses in the premium cataract surgery arena are sensitive to PCO. The performance of these lenses can be degraded by small amounts of PCO, whereas patients might not notice as much with a monofocal. “Some surgeons are turning to earlier YAGs in the premium IOL patients to improve the performance of the IOL,” he said. The other thing to note is even with the best biometry and the best surgical technique, there are still cases of patients who are off target after surgery. When these patients have paid for premium cataract surgery, your goal is to get them out of glasses, and sometimes you must come back and do a surface ablation to fine tune the vision. Dr. Robert Weinstock said he typically likes to do the YAG capsulotomy first because there can be small changes of the refraction after the YAG. “There can be minor changes to the lens position after you release some of the tension on the posterior capsule,” he said. “In my mind, it’s best to do the YAG capsulotomy first, let the eye heal for a couple weeks, then bring the patient back, refract them, and move on to PRK or LASIK to fine tune the vision and reduce any residual refractive error.” For the routine YAG, it’s standard, he said. When you don’t put a contact lens on the eye, you need more energy. The contact lenses focus the energy, and you need less energy. But if you crank up the energy and don’t put the contact lens on, it’s just as effective, he explained. “There are cases where we see contraction of the anterior capsule coming over the optic, and sometimes it’s even squeezing the lens and causing it not to be in the right location inside the eye,” he said. “If you use the YAG to make little nicks in the anterior capsule, it can release the tension of the capsule and let the lens [settle into] a more natural position.” Dr. Robert Weinstock cautioned against doing a YAG too early, particularly in patients having problems with multifocals or EDOF lenses. The issue could be neuroadaptation, he said, but some jump to doing a YAG early. The patient might end up needing the lens explanted, depending on how they adapt, he said. “It’s a more complicated and risky procedure to explant a lens if the capsulotomy has already been done by the laser because there is a continuation Editors’ note: Dr. Fram practices at Advanced Vision Care, Los Angeles, California. Dr. Kim is in private practice with Professional Eye Associates, Dalton, Georgia. Neither disclosed relevant financial interests. Dr. Robert Weinstock discussed another way he uses the YAG laser. He said it can be used for breaking up vitreous strands behind the capsule in the anterior vitreous. It is a YAG laser, but the light focuses with that laser. “You can focus a little more precisely into the vitreous. For people who suffer from anterior vitreous floaters that are stuck in their vision and are causing haze, we do YAG laser vitreous photolysis,” he said. That often helps a patient who suffers from bad floaters. “We will use the YAG because of its optics to disrupt some of these fibrotic strands of vitreous that are right in the vision, and it will break them up, much like you break up the capsule, then gravity will help them drift out of the way,” he said. “We’ve had great success in avoiding vitrectomies for floaters.”
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