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Pulse of ophthalmology: Survey of clinical practices and opinion YAG capsulotomy, part 1by Mitch Gossman, MD |
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![]() 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 questionWhat 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: Second questionWhat 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. 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 questionDo you use a contact lens in most cases for an acrylic or collamer lens? 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 questionDo 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 questionDo you use a contact lens in most cases for a Crystalens? 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. Contact information 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. |