By Paul Barney, OD   |  PCLI—Anchorage, AK

Ami Halvorson, OD

PCLI—Portland, OR

From the EDITOR   As YAG laser capsulotomy becomes part of optometric practice in more states, staying informed is essential. In this issue, Paul Barney offers guidance on handling complex cases. He and fellow ODs at PCLI perform YAG laser capsulotomies, along with other anterior segment laser and surgical procedures, bringing experience that supports optometry’s expanding role in surgical eye care.

Use Caution

Sulcus-fixated IOLs are generally less stable than those placed within the capsular bag and are more prone to dislocation. The energy released and capsular disruption caused by YAG capsulotomy can precipitate a sudden and rapid dislocation. Therefore, caution is advised, and laser energy levels should be lowered.

Significant zonular compromise may contraindicate YAG capsulotomy until stabilization has been achieved. The patient shown in the image above had loose zonules. Although the IOL was successfully placed within the capsular bag and appeared well-centered and stable on follow-up, the patient presented two years later with posterior capsular opacification (PCO), a decentered IOL, zonular dehiscence, and pseudophacodonesis. Surgical stabilization using scleral-fixated haptics was needed before a capsulotomy could be safely and successfully performed.

Managing Other Capsule Issues

Capsular distention and anterior capsular contraction (phimosis) require special consideration. Capsular bag distention syndrome arises from fluid accumulation between the IOL and posterior capsule, which can occur early (within days or weeks) or late (months or years) after cataract surgery.

A well-placed IOL that became decentered in a patient with loose zonules.

Opaque turbid fluid between the IOL and posterior capsule in late capsular bag distention syndrome.

Radial slits in the anterior capsule will stop the contraction from progressing and widen the capsulorhexis.

Phimosis is characterized by fibrosis of the anterior capsule and contraction of the capsulorhexis. While phimosis typically develops slowly, it can occur rapidly within weeks after cataract surgery, especially in cases of excessive post-op inflammation. Treatment involves YAG laser anterior capsulotomy. Ideally, this should be performed before the contraction affects the line of sight. The strategy is to create radial slits in the anterior capsule to stop the contraction and widen the diameter of the capsulorhexis. If the fibrosis has not encroached upon the line of sight, completely removing the anterior capsule is not necessary. Removing portions of the anterior capsule may lead to those fragments dropping into the anterior chamber angle, while making radial slits will not.

Other Tips

The anterior capsule is anatomically thicker than the posterior capsule and often requires higher laser energy to penetrate. My typical starting settings for a YAG laser anterior capsulotomy are a 100µm to 200µm anterior offset and 2.5 mJ to 3.0 mJ. I make four to six radial slits in the anterior capsule, which stops capsular contraction and enlarges the diameter of the capsulorhexis.

Conclusion

Implementing a careful approach and these strategies for complex YAG capsulotomy cases will facilitate smoother procedures, leading to improved patient care and outcomes.

• Early syndrome – arises from incomplete removal of viscoelastic material, leading to anterior IOL displacement, a myopic shift, shallowing of the anterior chamber, and increased IOP. In instances of significant displacement, surgical removal of the viscoelastic is preferred. If there is no IOL displacement, YAG capsulotomy will release accumulated fluid and alleviate distention.

• Late syndrome – occurs when lens epithelial cells produce collagen and extracellular material, which accumulates as an opaque, turbid fluid between the IOL and the posterior capsule. In this case, it is not uncommon for the posterior capsule to appear relatively clear despite symptoms consistent with PCO. Since the fluid is opaque, visualization of the posterior capsule can be difficult. Therefore, it is best to first create a small inferior capsular opening, which will allow gravity to pull the turbid fluid into the lower vitreous, where it will be absorbed. Pausing for a moment to let the fluid settle will clear the view for the remaining capsulotomy to be completed. Because the released material can provoke mild inflammation and transient IOP elevation, a topical steroid should be used for 1-2 weeks post-procedure.

YAG laser capsulotomy  is becoming a bigger part of optometric care as more states advance their scope of practice. Studies have shown that optometrists performing these procedures deliver safe and effective outcomes, significantly expanding the availability of treatment.

Managing Complex Cases

While most YAG capsulotomy cases involve single-vision IOLs that are well-positioned in the capsular bag, this article focuses on more challenging scenarios, such as:

• Presbyopia-correcting IOLs
• Malpositioned IOLs
• Atypical capsular fibrosis and contraction

Pre-op Assessment

It is essential to thoroughly evaluate the IOL type and position, the integrity of the lens capsule, and the extent of capsular opacification. These factors can significantly influence the choice of technique and help ensure optimal outcomes.

With some presbyopia-correcting IOLs, subtle capsular opacification creates visual symptoms and prompts earlier consideration of YAG capsulotomy compared to single-vision IOLs. Diffractive multifocal and some extended depth-of-focus (EDOF) IOLs also generate more reflections than single-focus IOLs, which patients may perceive as dysphotopsia. These reflections can complicate the visualization of the posterior capsule, necessitating extra caution to avoid creating IOL pits. Yellow-tinted IOLs and those with excessive glistening can pose similar challenges.

Procedural Tips

Placing the first laser shots in the peripheral capsule superiorly is advisable. Should lens pits occur, they will be unlikely to affect vision. Although laser pits rarely cause visual problems, they should be avoided near the line of sight.

Using a laser capsulotomy lens stabilizes the eye and lids, enhances visualization, and allows for increased illumination without patient photophobia and blepharospasm interference. Once several shots have been placed and a capsular opening is created, the capsule becomes easier to visualize despite IOL reflections, tints, and glistening.

IOL Position Considerations

IOL position can also affect capsulotomy technique. Ideally, both the optic and haptics should be placed in the capsular bag during cataract surgery. While significant IOL displacement is uncommon, mild displacement with the optic and haptics clearly in the capsular bag should not be concerning. However, if the IOL is significantly decentered, its cause should be assessed, as this could indicate capsular or zonular issues, potentially leading to instability during YAG laser capsulotomy.