EyeWorld is the official news magazine of the American Society of Cataract & Refractive Surgery.
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EW CATARACT 30 May 2015 Pulse of ophthalmology: Survey of clinical practices and opinion 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 ophthal- mologists who offered to participate from the ranks of physicians on the eyeCONNECTIONS online commu- nity and volunteers around the U.S. Responses are anonymous in order to encourage candor. First question "What method do you use for doing a YAG capsulotomy for a conven- tional lens, i.e., not Crystalens [Bausch + Lomb, Bridgewater, N.J.]? If it depends on the way the proce- dure evolves, answer according to how you start to do the case and continue it if it goes normally." Choices and percent answers were: I n most cases, cataract surgery involves removal of the cata- ract 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 opacifi- cation 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 per- formed 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 postopera- tive follow-up. It is probably safe to say that most ophthalmologists tend to perform the procedure without considering how others do it and YAG capsulotomy, part 1 by Mitch Gossman, MD Cruciate (starting superiorly and incise from 12 to 6 and then incise from 3 to 9, creating a Maltese cross) 44% Star (linear incisions creating 5 or more "flaps") 14% Spiral (start centrally and work your way around un- til opening the desired width) 12% Hinged (circular opening with a hinge on one side to avoid a free-floating circular capsule in vitreous) 7% Circular (round opening with free capsular circle to descend into vitreous) 20% Other 0% The choices offered were based upon observations of methods used in clinical practice and methods personally used at some point, and because no participant selected "Other," this may be fairly compre- hensive. The goal is to attain a good entrance pupil, a maximum chance of remaining open, as few floaters as possible, minimum lens damage, Dr. Gossman will lead the new EyeWorld column "Pulse of ophthalmology: Survey of clinical practices and opinion." Source: Mitch Gossman, MD minimal energy, which may pro- mote postoperative pressure spike, and to stay away from the IOL edge lest vitreous prolapse forward. The most popular method here, the "cru- ciate," has the advantages of mini- mizing traces of capsule potentially remaining as floaters and speed. Its chief disadvantage is the tendency for the resulting 4 "petals" to refuse to spread open, although in practice they eventually do in most cases. But occasionally some need a "touch up" at follow-up. Several participants volunteered that they start the cross at the center of the lens. The "spiral" method has the advantage of titratability, working around until the opening is of a perfect size, and results in a pleasingly round opening. Its main disadvantage is the tendency to pro- duce tags, sometimes free-floating. Using the "hinge" method, creating a round opening with a "tuna can lid" style hinge, can inadvertently produce a free-floating capsule remnant, and the "circu- lar" method surely will. According to Vamsi Gullapalli, MD, retina consultant in Sartell, Minn., any free-floating fragments, be they small fragments or an entire circular remnant, will tend to settle near the vitreous base, but it is theoretically possible for them to settle in the visual axis and become bothersome, and they do not "absorb." It is possible to employ multiple methods. One example (as is my own practice) is to start with a cruci- ate opening and then, if the leaflets fail to open satisfactorily—especially if advanced fibrosis is present—to laser the leaflets to produce 5 to 8 separate leaflets while striving to avoid free-floating fragments Second question "What 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." 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 oph- thalmologists perform their first AG 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 inform - tion that makes you a better ophthal- mologist 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