Here are my answers: 1. No steroids 2. No IOP check 3. Return visit in one week—no dilation unless symptoms warrant it. I’ve been thinking about dispensing with the one-week visit, but I haven’t for the following reasons. For us, a YAG laser capsulotomy is the most benign, non-invasive, and easy treatment we do. But still, to the patient, it’s a big “operation,” and I enjoy seeing the patients and talking with them about how their vision has improved. If you approach the follow-up visit correctly, it’s a practice builder, although probably medically unnecessary. Medicolegally, however, it’s a good idea to do it, although in 15 years of practice I have never seen a YAG cause a retinal tear or a retinal detachment.

Richard Schulze, M.D.
Savannah, Ga.

I place the patient on Lotemax (loteprednot atabonate ophthalmic suspension 0.5%, Bausch & Lomb, Rochester, N.Y.) four times a day and Alphagan (brimonidine tartrate ophthalmic solution 0.15%, Allergan) twice a day for four days and then discharge.

I follow up at one month with a dilated exam. I have had no issues with this routine.

Douglas Mazzuca, D.O. 
Pennsville, N.J.

I do not use any tears. I see the patient at two weeks for validation that we helped their vision and to do a refraction. For those in premium channel lenses, if they have any residual astigmatism or defocus, we then take care of that with an incisional touch up.  The warning signals of a retinal detachment are given.  Of course if there is something unusual about the YAG situation, we may vary that approach. For example, the patient with previous cystoid macular edema will be managed with a nonsteroidal anti-inflammatory drug. Otherwise, what I described is for a routine YAG.

I describe it to the patient as truly one of the miracles of medicine. There is instant gratification, low risk, and it is pain free.  In the past we used steroid drops, but I really think we are past this concern unless there is some extraneous issue.

J. E. “Jay” McDonald, M.D.

1. No steroids (or any drops). We used to routinely prescribe post-YAG steroids but stopped this practice about eight years ago with no problems at all.
2. No IOP check after YAG.
3. One week post-op visit done by optometrist. No dilation except if symptoms.

Clive Novis, M.B.B.Ch. 
South Africa

Coming out of training, I was giving steroids, checking the IOP afterward, and used glaucoma drops only if pressure was high at one hour post-op. My partners have taken an approach similar to that of Dr. Novis for years. I was skeptical at first, but patients seem to do just fine so far with no problems such as photophobia, red eye, blurry vision, etc.

D. Brian Kim, M.D. 
Dalton, Ga.

I used to do it with a one-hour post-op check, but after legions of pressures in normal range or trivially high, I stopped doing this. I then see them at the three- to four-week point to get a better quality refraction (and in some cases materially different by virtue of lens shift, I suppose, or just better subjective responses). I do dilate patients for liability reasons—if the patient returns later with a detachment, whether related to the YAG itself or just the usual risk factors or random chance (YAG being a risk factor for retinal detachment is controversial), not having dilated the patient at the follow-up appointment could be a negative. No post-op drops are used other than a single drop of Alphagan. I sometimes check one-hour pressure in glaucoma patients, especially with pseudoexfoliation syndrome.

Mitchell Gossman, M.D.
St. Cloud, Minn.

I do one eye at a time, use no post-op drops except Iopidine (apraclonidine, Alcon, Fort Worth, Texas) or Alphagan, or something similar immediately after, and I check the IOP one hour later. The patient returns to the clinic at one week, no dilation routinely, and I change the prescriptions as needed. The patient is again dilated at six months.

Does anyone regularly do bilateral same-day YAGs?

Jeffrey Horn, M.D. 
Nashville

In our rural area, most patients are from out of town and may drive 80 miles to get here, so I always do both eyes (if both need it, of course), one after the other.

The patient waits for 30 minutes or so at the surgicenter, then a tech checks to make sure caps are widely open with no strands, etc, remaining. Vision and pressure are checked at that time. I prescribe prednisolone acetate 1% four times a day for one week (probably not necessary).

I also use one drop of Alphagan pre-laser, and I always use an Abraham contact lens.

Out-of-town patients see their optometrist in the next week for evaluation, and local patients see me.

Glaucoma patients, of course, are followed more closely, depending on amount of disc damage.

Luther Fry, M.D.
Garden City, Kan.

Several responders have said that they do dilated exams a week or two after YAG capsulotomy for “medico-legal reasons.” If this is the only reason you do a dilated exam after YAGs, you do not need to do so. In a practice pattern booklet on YAG capsulotomy, the American Academy of Ophthalmology has stated that dilated exams are not routinely required after YAG capsulotomy unless a patient complains of symptoms (e.g., new onset flashes, floaters). You can do the dilated exam if you want, but nobody can fault you for following Academy guidelines and not doing them routinely. I no longer routinely see YAG capsulotomy patients post-op, and it has freed space in my clinic day for other patients you can actually bill for.

Michael Graham, M.D. 
Orlando

Dr. Graham makes an excellent point—and one that needs to be pushed higher in our hierarchy of professional concerns.

There are no such things as “medico-legal reasons.” There are only medical reasons. We have allowed ourselves to be cowed into performing all kinds of “defensive medicine” activities that waste time, provide little if any improvement in patient quality outcomes, and ultimately don’t even really protect us from lawsuits.

J.Trevor Woodhams, M.D.
Atlanta