CATARACT EWAP SEPTEMBER 2023 11 of the eye to where the vitreous can come forward now that there is a hole in the posterior capsule,” he said. Dr. Nattis recommended avoiding the YAG laser if the patient has a cloudy cornea or if you don’t think you’re going to be able to perform the procedure properly. Sometimes you can aim the laser beam so you can see the posterior capsule tangentially and get around a small opacity at the cornea level, she said, but you want to be sure you’re doing a complete procedure and not a partial YAG. Ultimately, these patients with anterior segment haze or scarring may require a surgical capsulotomy if visualization for a laser capsulotomy is poor. “We always check eye pressure before and after doing the laser because in some patients, it can spike,” she added. Dr. Nattis said there’s no specific timeframe within which to do a YAG; it’s when the patient becomes symptomatic. “We tend to do YAG capsulotomies earlier in patients who have multifocal or trifocal IOLs because those patients tend to be more sensitive to glare and halo,” she said. While she doesn’t do surgical posterior capsulotomy often, Dr. Nattis said this might be used for patients who can’t sit at the laser or who find it hard to maintain gaze in a certain direction. Dr. Robert Weinstock said he performs surgical capsulotomy in rare situations. He said he used this approach when he was doing a lot of Crystalens (Bausch + Lomb) implantations because it was prone to capsular contractions, Z-syndrome, and major displacements of the IOL where “you needed to do an IOL exchange and sometimes you couldn’t do that exchange without some damage to the capsule, but you had to get the lens out of there.” He said there are some situations with IOL exchange where the physician might have to do a posterior capsulotomy with a vitrector to have a controlled hole. This is usually avoided because the YAG laser is so easy and safe and is a much more controlled procedure, he said. “One thing that I learned during residency and in fellowship is sometimes it’s easy to miss a little thread of the posterior capsule that might be still attached to the rest of the capsule that you’ve already lasered, and patients may come back and say, ‘I still see something floating in my vision,’” Dr. Nattis said. “Before I tell the patient the procedure is complete, I’ll do a once over to make sure there are no posterior threads hanging on. You can go in and do a touch-up, but it’s good to save yourself and the patient from doing that.” EWAP Editors’ note: Dr. Nattis practices at SightMD, Babylon, New York, and has interests with Alcon. Dr. Robert Weinstock practices at The Eye Institute of West Florida, Largo, Florida, and has interests with Johnson & Johnson Vision, Alcon, Bausch + Lomb, and LENSAR. Dr. Stephen Weinstock practices at The Eye Institute of West Florida and declared no relevant financial interest. T he good news is that the incidence of development of posterior capsular opacification (PCO) and YAG capsulotomy is decreasing as surgical techniques and IOL materials and design have improved over the years. Hydrophobic material and square edge have been shown to reduce PCO formation. But it still remains a significant aftereffect of cataract surgery. In the Asia-Pacific region, the cataract is increasingly seen at younger age. Many of these cataracts have posterior subcapsular plaque. These “intraoperative” posterior capsule plaques are also seen in eyes with uveitis, advanced long-standing as well as mature cataracts. Capsule polishing can remove residual leftover fibers, but these plaques cannot be removed by capsule polishing. These fibrous plaques have become an integral part of the posterior capsule and therefore require surgical maneuvers such as posterior capsulorhexis or capsulectomy with vitrector. Moreover, the impact of even a mild degree of PCO on the performance of IOLs with extended depth of focus, trifocals, etc., could become bothersome to these patients. A good surgical technique leaving behind a “clean” capsular bag and inducing less postoperative inflammation would retard PCO formation. In addition to performing capsulotomy on the posterior capsule, YAG laser is also effective in treating moderate to severe degrees of anterior capsule fibrosis. Eyes with small capsulorhexis, uveitis, retinitis pigmentosa, and eyes with comorbidity are more likely to develop anterior capsule fibrosis. Early treatment with YAG laser would prevent the consequences of capsular fibrosis. As mentioned by the authors, YAG laser remains a very handy tool to deal with capsular opacification. Editors’ note: Dr. Vasavada disclosed no relevant financial information. Abhay Vasavada, MD Director, Raghudeep Eye Hospital, Ahmedabad, India icirc@abhayvasavada.com ASIA-PACIFIC PERSPECTIVES
RkJQdWJsaXNoZXIy Njk2NTg0