May 2015




Pulse of ophthalmology: Survey of clinical practices and opinion

YAG capsulotomy, part 1

by Mitch Gossman, MD

Dr. Gossman

Dr. Gossman will lead the new EyeWorld column Pulse of ophthalmology: Survey of clinical practices and opinion. Source: Mitch Gossman, MD

My first impression was, What could be simpler and less interesting than performing a YAG capsulotomy? After reading YAG capsulotomy, part 1 I cannot wait for the second installment. This article might be the most fascinating piece I have read in a long time. Mitch Gossman, MD, points out the very basic fact that for most anterior segment surgeons the YAG capsulotomy is the second most common surgical procedure we perform and yet so little has been written about the laser technique and the nuances of using a YAG laser for different types of IOLs. He has surveyed 100 practicing ophthalmologists and provided editorial commentary to their results. Most ophthalmologists perform their first YAG capsulotomy as a second year resident and do not change the procedure for their entire career. A good article makes surgeons think about what they do on a regular basis and consider changing their technique. After reading this article, that is exactly what I am going to do and that is the beauty of EyeWorld. When you least expect it, you find a small nugget of information that makes you a better ophthalmologist and makes you think about something you never considered in the past. This is one of those times, and I hope you read this article (and part 2) and enjoy it as much as I have.

Eric D. Donnenfeld, MD, chief medical editor

In most cases, cataract surgery involves removal of the cataract except for the retention of the posterior capsule, which is exploited to enclose the IOL in a secure, sutureless, and physiologic position in the posterior chamber. It also provides a barrier to vitreous prolapse. It is common for opacification to develop on the posterior capsule, occurring between 20% and 40% of the time, depending on the type of lens implant used. Because cataract surgery is one of the most common surgical procedures performed in the world, it follows that YAG capsulotomy is also common. It is interesting to note that there is minimal literature on the particular methods to perform the procedure and clinical practices for postoperative follow-up. It is probably safe to say that most ophthalmologists tend to perform the procedure without considering how others do it and perhaps adhere to methods taught by staff or senior residents during ophthalmology fellowship. Perhaps the inconvenience of filming the procedure detracts from discussion of methods. In the first of this 2-part article, we will explore the various methods and treatments employed around the time of YAG capsulotomy by a cohort of surgeons. I conducted a survey of 100 practicing ophthalmologists who offered to participate from the ranks of physicians on the eyeCONNECTIONS online community and volunteers around the U.S. Responses are anonymous in order to encourage candor.

First question

What method do you use for doing a YAG capsulotomy for a conventional lens, i.e., not Crystalens [Bausch + Lomb, Bridgewater, N.J.]? If it depends on the way the procedure evolves, answer according to how you start to do the case and continue it if it goes normally. Choices and percent answers were: YAG capsulotomy using method The choices offered were based upon observations of methods used in clinical practice and methods personally used at some point, and because no participant selected Other, this may be fairly comprehensive. The goal is to attain a good entrance pupil, a maximum chance of remaining open, as few floaters as possible, minimum lens damage, minimal energy, which may promote postoperative pressure spike, and to stay away from the IOL edge lest vitreous prolapse forward. The most popular method here, the cruciate, has the advantages of minimizing traces of capsule potentially remaining as floaters and speed. Its chief disadvantage is the tendency for the resulting 4 petals to refuse to spread open, although in practice they eventually do in most cases. But occasionally some need a touch up at follow-up. Several participants volunteered that they start the cross at the center of the lens. The spiral method has the advantage of titratability, working around until the opening is of a perfect size, and results in a pleasingly round opening. Its main disadvantage is the tendency to produce tags, sometimes free-floating. Using the hinge method, creating a round opening with a tuna can lid style hinge, can inadvertently produce a free-floating capsule remnant, and the circular method surely will. According to Vamsi Gullapalli, MD, retina consultant in Sartell, Minn., any free-floating fragments, be they small fragments or an entire circular remnant, will tend to settle near the vitreous base, but it is theoretically possible for them to settle in the visual axis and become bothersome, and they do not absorb. It is possible to employ multiple methods. One example (as is my own practice) is to start with a cruciate opening and then, if the leaflets fail to open satisfactorilyespecially if advanced fibrosis is presentto laser the leaflets to produce 5 to 8 separate leaflets while striving to avoid free-floating fragments.

Second question

What method do you use for doing a YAG capsulotomy for a Crystalens? If it depends on the way the procedure evolves, answer according to how you start to do the case and continue it if it goes normally. YAG capsulotomy method for a Crystalens

Note the higher frequency of using the spiral method with the Crystalens. This probably has to do with carefully titrating size lest the lens position and the refractive error change, and to avoid passing over the edge of the small optic and causing vitreous prolapse. It is possible to later make a larger opening to exploit any posterior shift that may occur in cases of undesired myopia or to obtain a larger entrance pupil. A pitfall of this method is the possibility of damaging the central lens with the initial laser shots, so careful titration of power should be used.

Third question

Do you use a contact lens in most cases for an acrylic or collamer lens? table

The Abraham contact lens has the advantage of stabilizing the globe, preventing blink, and focusing laser energy, allowing lower energy settings to disrupt the posterior capsule, thus minimizing lens damage and pressure issues. Disadvantages are the time required, need for topical anesthetic, postoperative blur and stickiness, and potential for iatrogenic corneal abrasion.

Fourth question

Do you use a contact lens in most cases for a silicone lens other than Crystalens?

Interesting that the results are the same with silicone lenses, suggesting the main reason to use a contact lens is not the greater sensitivity to damage with silicone. It is also possible that the use of contact lens is habit, i.e., many or most never having tried it without a lens. For those who have not tried capsulotomy without a contact lens, particularly with the intraocular lenses that are more resistant to pitting, do consider trying it.

Fifth question

Do you use a contact lens in most cases for a Crystalens? Again, there are very similar results with Crystalens. The purpose of the question was to determine if more surgeons use a lens for Crystalens because of the potentially more significant repercussions with compromised vision from the pitting or greater finesse required to do a perfect Crystalens capsulotomy. This conjecture may be in part cancelled by a desire to avoid postoperative blur in the possibly more discerning Crystalens patient. See the June issue of EyeWorld for part 2 of this article.

Editors note: Dr. Gossman is in private clinical practice at Eye Surgeons& Physicians, St. Cloud, Minn. The physicians have no financial interests related to their comments.

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Related articles:

YAG capsulotomy, part 2 by Mitch Gossman, MD

Simulation of neodymium: YAG posterior capsulotomy for ophthalmologists in training by Elad Moisseiev, MD, Adi Michaeli, MD

New realities of YAG capsulotomy by Maxine Lipner Senior EyeWorld Contributing Editor

Post-op YAGs and standard of care by J. E. “Jay” McDonald II, M.D.

Medicares medical necessity issues for cataract and YAG surgery Riva Lee Asbell

Managing endophthalmitis after a YAG capsulotomy by J.E. “Jay” McDonald II, M.D.

YAG capsulotomy, part 1 YAG capsulotomy, part 1
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