Background: To analyse the rate of complicationsassociated with Nd YAG posterior capsulotomy.Methods: This prospective clinical study wasconducted in Holy Family Hospital over a six-monthperiod. It included five hundred and fifty patients in outdoor Eye Department, Holy Family Hospital treated withNd YAG laser capsulotomy due to posterior capsularopacification after cataract surgery. The complicationswere noted.Results: There was a transient rise of IOP in 27%,mild anterior uveitis in 7%, pits and cracks in 4%, macularedema in 3% and retinal detachment in 2% cases.Complications were managed accordingly and post YAGvisual acuity improved in majority of cases.Conclusions: Nd. YAG is an effective instrumentused in non-invasive procedure of capsulotomy in patientswho are having gross disturbances of vision such asdecreased visual acuity, glare and uniocular diplopia.The posterior capsulotomy does have some seriouscomplications after YAG. One can avoid thesecomplications and get the best results

Ali Raza, Ali Raza

English

Journal of Rawalpindi Medical College

Journal of Rawalpindi Medical College (JRMC); 2007; 11(1): 27-29  27 Complications after Nd YAG Posterior Capsulotomy  Ali Raza  Department of Ophthalmology, Holy Family Hospital and Rawalpindi Medical College, Rawalpindi.   Abstract  Background:  To analyse the rate of complications associated with Nd YAG posterior capsulotomy.  Methods:  This prospective clinical study was conducted in Holy Family Hospital over a six-month period.  It included five hundred and fifty patients in out door Eye Department, Holy Family Hospital treated with Nd YAG laser capsulotomy due to posterior capsular opacification after cataract surgery.  The complications were noted.  Results:  There was a transient rise of IOP in 27%,  mild anterior uveitis in 7%, pits and cracks in 4%, macular edema in 3% and retinal detachment in 2% cases. Complications were managed accordingly and post YAG visual acuity improved in majority of cases.  Conclusions:  Nd. YAG is an effective instrument  used in non-invasive procedure of capsulotomy in patients who are having gross disturbances of vision such as decreased visual acuity, glare and uniocular diplopia.   The posterior capsulotomy does have some serious complications after YAG.  One can avoid these complications and get the best results.   Introduction  Cataract is the chief cause of avoidable blindness in the world1.  Extra capsular cataract extraction (ECCE) with posterior chamber intraocular lens implant (PCIOL) is the most frequent surgical technique since the past decade2.  High quality, high volume cataract surgery is needed in community eye care centers to effectively manage the large back-log  of cataract blindness2. Cataract extraction with PCIOL is most frequent performed surgical technique and the  most common complication is posterior capsular opacification which results in decreased visual performance of the patient.  One should understand the factors contributing to the development of posterior capsular opacification by the help of retro illumination photography3.  Visual acuity restored  by ECCE with PCIOL is threatened by posterior capsular opacification seen in 50% of eyes within 5 years.  Posterior capsular opacification is characterized by proliferation, transformation, and migration of lens epithelial cells remaining on the margin of anterior capsule which form plaque on the non-epithelial posterior capsule4. The posterior capsular opacification (plaque) has optical characteristics which often requires posterior capsulotomy with YAG laser although  IOL materials and designs have been generated to avoid posterior capsular opacification5. Because of the revival of ECCE with opacification of posterior capsulotomy, this has been the commonest cause of post operative reduction of vision following cataract surgery. Nd YAG laser posterior capsulotomy can  be associated with significant complications.  Potential problems include IOL optic damage / pitting, post operative raised intra ocular pressure (IOP), uveitis, macular edema, retinal detachment and lens subluxation6, 7. In 1980 Aron Rosa first reported the  use of YAG for posterior capsule.  This procedure  is associated with a number of complications.  The purpose of this study was to analyze the rate of complications associated with YAG capsulotomy.  Patients and Methods  The study included 550 patients selected from Eye Out-door Department of Holy Family Hospital  or referred from other attached teaching hospitals of Rawalpindi Medical College.  The inclusion criteria were post operative reduction of vision of more than one line, complaint of diplopia, glare and evident capsular thickening on examination with slit lamp  plus other indications for YAG capsulotomy, as fundus examination, laser therapy in diabetics or other retinopathies and in vitreo retinal surgery. For this procedure, pre YAG best corrected visual acuity, IOP, anterior and posterior segment Journal of Rawalpindi Medical College (JRMC); 2007; 11(1): 27-29  28 examination with slit lamp and indirect ophthalmoscopy were carried out.  Pre and post  YAG photographs were taken with anterior segment camera attached with slit lamp. Topical anesthesia was given with 0.5% proparacaine hydroxide eye drops.  Then with the  help of Abraham’s posterior capsulotomy lens, YAG capsulotomy was done. Abraham’s lens provided proper focusing, stabilized the eye and proper delivery of Nd YAG.  YAG laser of Zeiss Q. switched was  used in all cases.  The focus red dots of helium  neon focusing beam was used so that one dot was found on posterior capsule to protect the IOL.  Pulses with minimal energy level (0.5 – 1mj) were used initially and increased gradually.  An opening in posterior capsule up to 2mm was produced.  Where  a large capsulotomy to 3mm or more was required  the pupil was pre operatively dilated, as when  vitreo retinal surgery or Argon laser treatment of retinopathies was desired. Patients follow up was done on second day,  at two weeks and then when required.  On each follow up day visual acuity, IOP, anterior segment and posterior segment detailed examination was done and complications noted.  Results  Of the 550 patients included 46% were male (253) and 54% were female (297).  The age ranged  from 20 to 80 yrs (Table 1).  The minimum period  for posterior capsulotomy after surgery was four months and the maximum four years.  Among the patients 440 (80%) were pseudophakic and 110 (20%) were aphakic. Pre YAG visual acuity in 302 (55%) patients was 6/60 or less, 6/60 to 6/24 in 110 (20%) patients and 6/24 to 6/9 or 6/6 in 138 (25%) patients.  Visual acuity improved to 6/60 in 49 (09%) cases, to 6/12 in 390 (71%) cases and 6/9 to 6/6 partial in 110 (20%) cases. (Table 2).  Table 1:  Age Range of Patients  (n=550)  Age (Years) Patients Percentage 20-40 106 19% 41-60 280 51% 61-80 164 30% Journal of Rawalpindi Medical College (JRMC); 2007; 11(1): 27-29  29 Table 2:  Post YAG Visual Acuity  Visual acuity No. of cases Percentage 6/60 49 9% 6/12 390 71% 6/6P 110 20%  Incidence of various complications after  YAG capsulotomy were, mild anterior uveitis in  39 (07%) cases, raised IOP in 149 (27%) cases, pits  and cracks of IOL in 22 (04%) cases, macular edema  in 17 (03%) cases and retinal detachment in 11 (02%) cases (Table 3). Transient non-infective anterior uveitis after YAG capsulotomy was seen in 29 cases which responded with mild steroids topically along with diclofenac sodium eye drops.  Raised IOP was seen  in 149 cases (27%) and controlled with beta blocker  eye drops 0.5% levobunolol and in some cases tablet acetazolamide (diamox) four times daily for at least two days and up to one week in a few cases. Post YAG cystoids macular edema was observed in 17 cases (03%).  We used topical steroid along with diclofenac sodium eye drops and that improved.  Table 3:  Complications of YAG Capsulotomy  Complications No. of cases Percentage Increased IOP > 5mm Hg 149 27% Anterior Uveitis 39 7% Pits / Cracks 22 4% Macular Edema 17 3% Retinal detachment 11 2%  In 11 cases there was retinal detachment out  of which 5 were high myopic and 3 cases were  due to advanced diabetic retinopathy.  Only one had prolapsed vitreous through the capsulotomy hole resulting in retinal detachment in later stages. In 22 patients there were pits due to  out focusing of YAG laser beam but these were  not associated with decreased visual acuity or  visual problems.  In some cases surgeons applied increased power due to the thick posterior capsule  or quality of IOL.  There were cracks in IOL.  This resulted in glare and decreased visual acuity in some cases.  Discussion  Transient rise of IOP after YAG has been reported and well documented in literature which  is 0.5% to 03%6.  Immediate rise of IOP after YAG capsulotomy in previous studies was due to  absence of posterior chamber IOL and use of high energy YAG laser which caused prolapse of vitreous8.  In our study transient rise of IOP was seen in  27% including mild to severe rise of IOP in patients after YAG where simple cataract extraction without PCIOL was due to the prolapse of vitreous in anterior chamber. Potential risk factors for glaucoma after YAG capsulotomy are due to the ECCE without PCIOL  and use of high energy YAG for capsulotomy8.  PCIOL creates a barrier in anterior chamber and posterior chamber even after posterior capsulotomy.  In this study rise of IOP was observed in majority of aphakic patients. Mild uveitis was seen in 39 cases (07%) and managed with topical steroid and diclofenac sodium eye drops.  This is comparable with the study of Latif who reported a 5.5% incidence of uveitis9. Pits and cracks on PCIOL were seen in 22 patients (4%) due to the faulty focus and increased power of YAG and is comparable to the study by Latif where the same percentage of pits and cracks of PCIOL were noted9. One of the serious complications of YAG capsulotomy is its leading to cystoid macular  edema and retinal detachment.  In our study macular edema was seen in 17 cases (3%) and retinal detachment in 11 cases (2%) which is less compared   Journal of Rawalpindi Medical College (JRMC); 2007; 11(1): 27-29  30 to a previous study where these were 4.9% and 3.6% respectively10.  Recommendations  Minimum period for posterior capsulotomy after surgery should not be less than four months.  Optimum energy / pulses required at the to start is  0.5 – 4mj.  Use of Abraham’s lens is recommended.  The beam should be focused behind the lens.  Opening of posterior capsulotomy should not be more 2 to 3mm in diameter.  Use of topical steroids and beta blocker eye drops is usually required.  Follow up should be regular and meticulous fundus examination should be done before and after posterior capsulotomy.   References  1. Thylefors B, Negrel AD, Pararajasegram R.  Global data on blindness.  Bull World Health Organ  1996; 74: 319 – 24. 2. Natchiar G, Robin AL, Thulasira R.  Attacking the backlog of India’s curable blind; the Arvind Eye Hospital model.  Arch Ophthalmol  1994; 112: 987 – 93. 3. Buehl W, Findl O, Menapace R.  Reproducibility of standardized retro illumination photography for quantification of posterior capsule opacification.  J Cataract Refract Surg  2002; 28: 265-70. 4. Ulrike Sponer.  Nd YAG laser posterior capsulotomy.  J Cataract Refract Surg  2005; 31: 595-606. 5. Ursell PG, Spalton DJ.  Relationship between intraocular lens biomaterials and posterior capsule opacification.  J Cataract Refract Surg  1998; 24:352-60. 6. Ficker LA Steele AD. Complications of Nd YAG laser posterior capsulotomy.  Trans Ophthalmol Soc U.K  1985; 104: 529 – 32. 7. MacEwen CJ, Dutton GN.  Nd YAG laser in the management of posterior capsular opacification complications and current trends.  Trans Ophthalmol  Soc U.K  1986; 105: 307 – 44. 8. Schubert HD.  Vitreoretinal changes associated with rise in IOP after Nd YAG capsulotomy Ophthalmic Surg  1987; 18: 19 – 22. 9. Latif M.  Treatment of post operative pupillary membranes Nd YAG laser.  Pak Journ Ophthalmol  1996; 12(1): 8-12. 10. Winslow RL, Taylor BC.  Retinal complications following YAG laser capsulotomy.  Ophthalmology  1985; 92:  785-89.  

Complications after Nd YAG Posterior Capsulotomy

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Complications after Nd YAG Posterior Capsulotomy

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