Eyeworld

38 | EYEWORLD | JULY 2023 ATARACT C Contact Nattis: asn516lu@gmail.com Robert Weinstock: rjweinstock@yahoo.com Stephen Weinstock: smweye@gmail.com Relevant disclosures Nattis: Alcon Robert Weinstock: Johnson & Johnson Vision, Alcon, Bausch + Lomb, LENSAR Stephen Weinstock: None capsulotomy with a vitrector to have a con- trolled hole. This is usually avoided because the YAG laser is so easy and safe and is a much more controlled procedure, he said. "One thing that I learned during residen- cy and in fellowship is sometimes it's easy to miss a little thread of the posterior capsule that might be still attached to the rest of the capsule that you've already lasered, and patients may come back and say, 'I still see something floating in my vision,'" Dr. Nattis said. "Before I tell the patient the procedure is complete, I'll do a once over to make sure there are no posterior threads hanging on. You can go in and do a touch-up, but it's good to save yourself and the patient from doing that." and risky procedure to explant a lens if the capsulotomy has already been done by the laser because there is a continuation of the eye to where the vitreous can come forward now that there is a hole in the posterior capsule," he said. Dr. Nattis recommended avoiding the YAG laser if the patient has a cloudy cornea or if you don't think you're going to be able to perform the procedure properly. Sometimes you can aim the laser beam so you can see the posterior cap- sule tangentially and get around a small opacity at the cornea level, she said, but you want to be sure you're doing a complete procedure and not a partial YAG. Ultimately, these patients with anterior segment haze or scarring may require a surgical capsulotomy if visualization for a laser capsulotomy is poor. "We always check eye pres- sure before and after doing the laser because in some patients, it can spike," she added. Dr. Nattis said there's no specific timeframe within which to do a YAG; it's when the patient becomes symptomatic. "We tend to do YAG cap- sulotomies earlier in patients who have multifo- cal or trifocal IOLs because those patients tend to be more sensitive to glare and halo," she said. While she doesn't do surgical posterior capsulotomy often, Dr. Nattis said this might be used for patients who can't sit at the laser or who find it hard to maintain gaze in a certain direction. Dr. Robert Weinstock said he performs surgical capsulotomy in rare situations. He said he used this approach when he was doing a lot of Crystalens (Bausch + Lomb) implantations because it was prone to capsular contractions, Z-syndrome, and major displacements of the IOL where "you needed to do an IOL exchange and sometimes you couldn't do that exchange without some damage to the capsule, but you had to get the lens out of there." He said there are some situations with IOL exchange where the physician might have to do a posterior continued from page 37 Dr. Robert Weinstock discussed another way he uses the YAG laser. He said it can be used for breaking up vitreous strands behind the capsule in the anterior vitreous. It is a YAG laser, but the light focuses with that laser. "You can focus a little more precisely into the vitreous. For people who suffer from anterior vitreous floaters that are stuck in their vision and are causing haze, we do YAG laser vitreous photolysis," he said. That often helps a patient who suffers from bad floaters. "We will use the YAG because of its optics to disrupt some of these fibrotic strands of vitreous that are right in the vision, and it will break them up, much like you break up the capsule, then gravity will help them drift out of the way," he said. "We've had great success in avoid- ing vitrectomies for floaters."

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