Cataract: Best practices
July 2023

by Ellen Stodola
Editorial Co-Director

Following cataract surgery, patients may experience blurry vision. A posterior capsulotomy with the YAG laser is often employed by physicians as a solution to help patients achieve their desired vision. “A YAG capsulotomy has to be one of the most commonly performed procedures for a cataract and refractive surgeon,” said Robert Weinstock, MD. “Fortunately, it’s a safe, easy, and efficient technology.”

Prior to YAG capsulotomies and the invention of the YAG laser, this was a much more challenging condition because it required going back into the eye and doing a surgical procedure, with the risk of infection. In addition, when you rip the capsulotomy, it’s not controlled, vitreous can come forward, and there can be PVD and retinal detachment, Dr. Robert Weinstock said. “I think the YAG was one of the greatest inventions in the history of ophthalmology,” he said. “It has made our lives so much better having the technology.”

Dr. Robert Weinstock noted that his father, Stephen Weinstock, MD, was one of the first surgeons in the U.S. to have a YAG laser. “When I started practicing 20 years ago, he taught me how to become an artist with the YAG.” 

We’re trained to put this contact lens on the eye, use low power, and punch out the capsule. “But for standard YAGs, [my father] taught me that you don’t need to put a lens on the eye. You can use higher power and do a couple of shots with the laser, and it splits it open without creating a big, punched out posterior capsule that floats around in the vitreous,” he said. “We use higher power with less shots now, which is much faster. … It’s become a much less invasive procedure. This makes it more efficient and takes only a couple of seconds.” 

Dr. Stephen Weinstock discussed his experience with YAG, noting that he estimates around 30–40% of patients develop PCO and need a YAG capsulotomy, no matter the precautions taken during surgery. It’s difficult to get 100% of lens epithelial cells removed during a cataract procedure, he said.

Earlier YAG capsulotomies were more traumatic and less refined, he said. It wasn’t as powerful or fine-tuned, and there were slightly more complications (the main complication was lens dislocation into the vitreous). “Physicians were trying to figure out how to reduce the need for posterior capsulotomy,” Dr. Stephen Weinstock said. “As the laser was refined, I found that it was much easier to perform it with precision so that we could guide how large of an opening we were going to create.” He said he’s seen very few complications in the past 15–20 years. 

“Prior to that, when I was doing cataract surgery, I used to spend a lot of time during the case vacuuming the posterior capsule,” he said. “I started thinking it was foolish to do this when there are so few complications post-YAG.

“It used to be difficult when I would see a patient who had a posterior capsular cataract because many of them did not come off the posterior capsule,” Dr. Stephen Weinstock said. “They could require needling of the posterior capsule and/or a second procedure, with a higher risk profile and worse outcomes. When the YAG was invented, it was like a breath of fresh air because we didn’t have to worry about going back into the eye. It was a paradigm shift in our approach to cataract surgery,” he said. “I think this was one of the great advancements in surgery, and it led to other types of lasers being developed for glaucoma and other conditions.”

Alanna Nattis, DO, uses the YAG laser frequently in her practice. “I do several per week, whether on my own patients or those referred after having cataract surgery several years ago,” she said. “It’s a successful and straightforward procedure for our patients and very gratifying because it restores vision to what it was right after they had cataract surgery.”

She said the literature indicates that about 20–50% of patients will have PCO after surgery. A lot of surgeons polish the posterior capsule, and that can help prevent PCO, but sometimes it doesn’t, she said. 

“I like to explain to patients that it’s almost like scar tissue has formed, and it can make the vision blurry. It can give them glare and halos, and if that happens, we can do a laser procedure to help clear the central visual axis again,” she said, adding that it only takes a few minutes to do the procedure, and she does not use a contact lens with the YAG laser. “I aim the laser at the posterior capsule and try to make a large symmetric opening in the central visual axis of the posterior capsule with as little energy and as few shots as possible,” she said. 

While the YAG laser procedure is not high risk, Dr. Nattis noted that there is a small risk of retinal injury and retinal detachment. “That is not common today with the lasers that we have, [but] I do always counsel my patients about that, especially in those who have had prior retinal detachments.”

Dr. Nattis said she doesn’t 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 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.” 

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About the physicians

Alanna Nattis, DO
SightMD
Babylon, New York

Robert Weinstock, MD
The Eye Institute of West Florida
Largo, Florida

Stephen Weinstock, MD
The Eye Institute of West Florida
Largo, Florida

Relevant disclosures

Nattis: Alcon
Robert Weinstock: Johnson & Johnson Vision, Alcon, Bausch + Lomb, LENSAR
Stephen Weinstock: None 

Contact

Nattis: asn516lu@gmail.com
Robert Weinstock: rjweinstock@yahoo.com
Stephen Weinstock: smweye@gmail.com