Eyeworld

FEB 2012

EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.

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February 2012 EW CATARACT 45 New realities of YAG capsulotomy by Maxine Lipner Senior EyeWorld Contributing Editor How modern technique is forestalling complications A lot of people fondly re- member the "good old days" when you could fill up your car for a dollar or so a gallon and go to the movies for just a few dollars. But when it comes to YAG capsulotomy these are the good old days, accord- ing to Steven G. Safran, M.D., pri- vate practice, Lawrenceville, N.J. Thanks to modern phaco technique and improved lenses, practitioners are much less likely to be faced with significant post-YAG complications than ever before. "In the old days when extracap- sular surgery was done, the lens was in the sulcus, and when we did a YAG capsulotomy there was a gap between the implant and the ante- rior hyaloid face," Dr. Safran said. "So when we would rupture the anterior capsule and the anterior hyaloid face, the vitreous would come forward, which would cause vitreoretinal traction, and that could lead to retinal detachments, cystoid macular edema (CME), and all kinds of problems." Now with the lens in the bag, it tamponades the vitreous, he finds, and there is no movement forward if the YAG is done properly. "In my experience I don't see any increased risk of retinal detachment or CME after YAG capsulotomy." Performing earlier YAGs Another factor has to do with when the YAGs are currently done. "Peo- ple used to wait until the posterior capsule looked like bloody hell to YAG and that would lead to pressure spikes," Dr. Safran said. "I can say that we YAG earlier now, especially with premium IOLs." He finds that some of the lenses themselves can even help the process. For instance the Crystalens (Bausch + Lomb, Rochester, N.Y.) is pushing on the posterior capsule back, which tends to be under ten- sion anyway, and can make it possi- ble to use very little YAG energy. "A couple of shots and the thing sort of unzips," Dr. Safran said. "There's usually no debris and it's very rare to see a pressure spike these days. For patients who have premium lenses, surgeons can't wait until they are 20/100 to perform a YAG. "They Mark Packer, M.D., clinical as- sociate professor of ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, cred- its the factors put forth some time ago by David Apple, M.D., and his group as reducing the amount of posterior capsule opacification (PCO). This includes things such as continued on page 46 Removing a floater after YAG capsulo- tomy may be one of the few remaining complications with which to contend Source: Kevin Miller, M.D. paid for something extra, and they lost what they paid for and more well before then." This is especially true for those with multifocal IOLs. "Their vision is very labile with the multifocal—it doesn't take much to spoil it," Dr. Safran said. Likewise with the Crystalens surgeons can't wait to YAG because it interferes with the ability to accommodate. William B. Trattler, M.D., director of cornea, Center for Excellence in Eye Care, Miami, agreed. "With premium IOLs, espe- cially the multifocals, they're sensi- tive to opacities—even if it's a very small opacity that wouldn't affect a patient with a monofocal, but it can affect someone with a multifocal," he said. "The need for a laser occurs at a much earlier rate with multifo- cals and the accommodating IOL." With the Crystalens, in addition to enhancing the quality and range of vision, performing a YAG can also help block the occurrence of z-syn- drome. "This is basically a capsular contraction syndrome where the capsule can get fibrosed and start to contract and make the lens move in position," Dr. Trattler said. "Perform- ing a YAG capsulotomy can help to prevent that condition from occur- ring." Declining complications When it comes to complications such as retinal detachment, cystoid macular edema, and pressure spikes, Dr. Trattler finds these are rare. "I think that the risk of those compli- cations is exceptionally low," he said. "I don't think that the data currently supports that there's an increased risk of those complications occurring in patients—that may have been related to other factors in the past." Get There Faster with EYEJET CTR Approved FDA Pre-loaded to Save Time Between Surgeries Single Use Pre-loaded Capsular Tension Ring Disposable Unit Eliminates Sterilization Procedure Available with Standard Morcher CTRs Only Choose Right or Left Insertion For more information, visit fci-ophthalmics.com or call 800.932.4202. ®

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