Journal of Medicine and Medical Research

Vol. 1(4): 23-27, December, 2013

ISSN: 2350-1502

www.resjournals.org/JMMR

Visual outcome of Patients with Posterior Capsular

Opacification Treated with Nd: YAG Laser
Ajite K.O., Ajayi I.A., Omotoye O.J and Fadamiro C.O.
Department of Ophthalmology Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria

E-mail for Correspondence: bidemi_kayode@yahoo.com

ABSTRACT

Neodymium: Yttrium Aluminium Garnet (Nd: YAG) laser is used in the treatment of posterior capsule
opacification (PCO) to improve visual acuity. PCO causes significant reduction in visual acuity in
patients that had cataract surgery. This study is aimed at determining the visual outcome of patients
who received Nd YAG laser following PCO. The medical records of patients seen at the eye clinic of
Ekiti State University Teaching Hospital, Ado Ekiti between January 2010 and June 2012 with the
diagnosis of posterior capsular opacification (PCO) after cataract extraction and had Nd YAG laser
capsulotomy were reviewed. Demographic data, pre and post laser visual acuity, type of cataract
surgery and the period of interval between surgery and diagnosis of PCO were extracted and analysed.
A total of 90 patients (109 eyes) were seen over the study period. There was no sex predilection among
the patients who developed PCO and were treated with Nd YAG laser. Males were 47(52.2%) and
females 43(47.8%) M:F=1.1. The age range of the patients was 17years to 87years. Most patients (77.8%)
were in the 41-80years age range. Nineteen (21.1%) of the patients had bilateral eye involvement. A
large proportion of these patients 59(65.6%) had the diagnosis of PCO between 3-12 months post-
surgery. Majority of the patients, 67 (74.4%) presented with visual acuity of <3/60 (blindness) before the
laser procedure while this reduced to 5(5.6%) post laser procedure. This study suggests that Nd YAG
laser procedure can improve distant visual acuity among patients with posterior capsular opacification.

Keywords: Laser, posterior capsular opacification, visual impairment, cataract, complications.

INTRODUCTION

Posterior capsule opacification (PCO), otherwise also known as secondary cataract, or after cataract is a late
complication of extracapsular cataract extraction (ECCE) or small incision cataract surgery (SICS) or
phacoemulsification with or without intraocular lens (IOL) implantation. It is one of the most frequent complications of
cataract surgery (Pandey et al, 2004). It was reported in their study that twenty eight percent of patients who had
cataract surgery developed posterior capsular opacification within 5years of surgery. The higher incidences obtained in
young patients is due to an age related effect of basic fibroblast growth factor on the proliferation of human lens
epithelial cells (Oner FH, Gunenc U and Ferliel ST. 2000; Knorz MC et al 1991), PCO can also be caused by lens
epithelial cells retained in the capsular bag following surgery. These proliferate, migrate and transform to myofibroblasts
causing opacification.(Spalton DJ, 1991). There is a gradual deterioration of visual function which ultimately becomes
symptomatic in the form of decreased visual acuity, decreased contrast sensitivity, glare or even monocular diplopia
(Claesson M, et al 1994; Sunderraj P et al,1992). The PCO develops in months to years postoperatively. It has been
seen to develop earlier in younger age groups while the incidence declines with age. (Hasan KS et al 1996). It causes
significant reduction in post-operative visual acuity. PCO can be treated surgically with either primary or secondary
capsulotomy or capsulectomy, depending on how fibrous and how thick the capsule is. This may however be associated
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with some complications.

With the introduction of laser especially Neodymium: Yttrium Aluminium Garnet (Nd:YAG) laser, treatment of PCO to
improve visual acuity has been made easier. It is an effective and non-invasive technique but expensive to acquire and
maintain. The Nd-YAG laser is an optically pumped solid-state laser that can produce very high-power emissions, (Davis
Christopher C, 1996). The lasing medium is the colourless, isotropic crystal Y2Al5O12 (Yttrium-Aluminium Garnet - YAG)
(Davis Christopher C, 1996). When used in a laser, about 1% of the Yttrium is replaced by Neodymium. The energy
levels of the Nd3+ ion are responsible for the fluorescent property that creates the hole when it is fired, i.e., active
particles in the amplification process, (Davis Christopher C, 1996). The hole created in the posterior capsule restores
clear media for light to reach the retina. Although recent modifications in surgical techniques, intraocular lens materials,
and designs have reduced the PCO rate, it is still a significant problem following cataract surgery and could be a major
problem, especially when Nd:YAG laser is not available. The aim of this study is to determine the visual outcome of
patients who received Nd YAG laser capsulotomy following PCO.

MATERIALS AND METHODS

The medical records of patients who were seen at the eye clinic of Ekiti State University Teaching Hospital, Ado
Ekiti,Nigeria between January 2010 and June 2012 who previously had cataract surgery and diagnosed to have
posterior capsular opacification (PCO) and subsequently had Nd YAG laser procedure were reviewed. Approval for the
study was obtained from the institution’s ethical review board. All patients were evaluated clinically using pen torch, slit
lamp, ophthalmoscope and Goldman applanation tonometer. Patients with comorbidities such as corneal opacities
before or after surgery, glaucoma, macular diseases, retinopathies and optic nerve diseases diagnosed before
development of PCO were excluded from the study. All the patients included for the study had demographic data, pre
and post laser distance visual acuity, and the period of interval between surgery and diagnosis of PCO extracted from
the records. Pre and post laser visual acuity were done with Snellens chart and patient seated 6m away from the chart.
NIDEK YC-1800 Neodymium-YAG laser was used for capsulotomy. The red 2 point laser beam was used for accurate
aiming and focusing of the invisible therapeutic beam. The laser was delivered through a slit lamp delivery system. The
capsulotomy was performed by applying a series of punctures either cruciate or circular pattern. The inflammation was
controlled with topical steroids after laser therapy. Final corrected post laser Visual Acuity (VA) was recorded 4 weeks
later with the Snellen chart. Data analysis was done using SPSS version 16 (SPSS Illinois, Chicago) and results
presented by frequency tables and charts.
The hospital’s laser capsulotomy protocol is as follows:
Minimum post operative period required for the laser procedure is 3months. Laser power range is 1.5-5.0mJ depending
on the thickness of the posterior capsular opacification.

Pre laser assessment

Patient must have been attending post-operative follow up clinic for at least 3months,or has a referral letter from another
hospital indicating when the surgery was carried out.
Pre laser visual acuity was measured with Snellen chart and documented.
Slit lamp examination was done and findings documented, intraocular pressure measured with Goldman applanation
tonometer.
1% Tropicamide (Alcon made) instilled into the lower fornix to dilate the pupil.
Cornea anaesthesia was achieved by instilling topical Tetracaine hydrochloride (Alcon made).
Patient positioned behind the Nd YAG laser machine properly.
A 2.5-3mm hole is made in a cruciate or circular fashion on the posterior capsule.
Power range of 1.5-5mJ per pulse is used depending on the density of the PCO.

Post laser care

Patient’s IOP measured 1hr after the procedure, if >21mmHg, Timolol maleate 0.5% twice daily prescribed except
contraindicated in the patient.
Topical Dexamethasone 4 times a day for a week, to control post laser inflammation.
Post laser Visual Acuity with Snellen chart is documented.
Patient is seen subsequently at 1week for assessment, if the hole is assessed and not adequate a repeat laser is
 25

40 41.1%
35 36.7%
30
25
FREQUENCY 20
15
10% 8.9%
10
5 3.3%
0
<21years 21-40years 41-60years 61-80years >80years
AGE RANGE

Figure 1. Age distribution of patients treated with Nd YAG laser

Table 1. Time interval of developing pco after surgery

DURATION(MONTHS) FREQUENCY PERCEN T (%)

≤3 18 20.0
>3-6 32 35.6
>6-12 27 30.0
>12 13 14.4
TOTAL 90 100

Table 2. Visual acuity pre and post laser 4 weeks

Visual acuity WHO categories Pre laser Post laser

n (%) n (%)
6/4 – 6/18 Good vision - 20 (22.2)
<6/18 – 6/60 VI - 49 (54.4)
<6/60 – 3/60 SVI 23 (25.6) 16 (17.8)
<3/60 – HM Blindness 67 (74.4) 5 (5.6)
Total 90 (100) 90 (100)

*VI=visual impairment, SVI= severe visual impairment, HM= Hand movement

scheduled. Otherwise patient is seen 4weeks later for refraction to obtain Best Corrected Visual Acuity (BCVA).

RESULTS

A total of 90 patients (109 eyes) were seen during the study period with 47(52.2%) being males and 43(47.8%) females
and a male to female ratio of 1:0.9. Figure 1 shows that the age range of the patients was 17years to 87years. Most of
the patients (77.8%) were in the 41-80years age range with a mean age of 67.8years +/- 8years. Nineteen (21.1%) of
the patients had bilateral eye involvement. A moderate proportion of these patients 59(65.6%) had a diagnosis of PCO
between 3-12 months post-surgery (Table 1). Majority of the patients, 67 (74.4%) presented with visual acuity of <3/60
(blindness) before the laser procedure and this reduced to 5(5.6%) post laser procedure, P<0.0001, this improvement was
statistically significant.( Table 2). Immediate complications following Nd:YAG laser is shown in table 3.Complications were
 26

Table 3. Immediate complications after Nd: YAG

COMPLICATIONS NO OF EYES (%)

n=90
Raised intraocular pressure 9 (10)
Hyphema 4 (4.4)
Damage to intraocular lens 2 (2.2)
Vitreous in anterior chamber 2 (2.2)
Uveitis 2 (2.2)
No complication 71(78.9)
Total 90 (100)

seen in 21.1% of the patients while 78.9% had no complications from the procedure. Raised intraocular pressure was
seen in 10% and Hyphema was seen in only 4.4 %.

DISCUSSION

The emergence of Nd YAG laser in the management of PCO, has improved the visual outcome of cataract surgeries
(Mohammad YK et al, 2006). A total of 90 patients (109eyes), was seen over the study period, nineteen (21.1%) of the
patients had bilateral eye involvement, there was no sex predilection among the patients who developed PCO and were
treated with Nd YAG laser. Cataract, the leading cause of blindness worldwide occurs equally among male and female
(Pandey SK et al, 2004), therefore when routine cataract surgery are performed, complications such as PCO can also
occur in equal proportions. In our study, males were 47(52.2%) and females were 43(47.8%). Age range of the patients
was 17years to 87years. Most patients were in the 41-80years age range. This is perhaps the age at which patients with
age related cataract present to the Ophthalmologist due to visual incapacitation (Mohammad YK et al, 2006; Niranjan A,
Suqin G and Wagner B 2009). A large proportion of the patients studied 59(65.6%) had the diagnosis of PCO between
3-12 months post-surgery. It was observed from our study that most patients presented early with reduced visual acuity
post-surgery, this timing appears earlier than 30months reported by (Hassan et al, 1996) and 23months reported by
(Mohammad YK et al, 2006). This may be due to the fact that people who had received visual restoration after initial
cataract surgery would have become so dependent on the good vision and so would be visually disabled when PCO
sets in, hence the early presentation. It may also be as a result of the surgical techniques employed by the surgeons or
the nature of the intra ocular lenses implanted promoting the early development of PCO.
Majority of the patients in our study, 67 (74.4%) presented with visual acuity of <3/60 (blindness) before the laser
procedure and this reduced to 5(5.6%) post laser procedure. Overall, 94.4% of the patients studied had visual
improvement. In a study,(Panezai MN, Shawani MA and Hameed K 2004), pre laser visual acuity (VA) was between
hand movements and 6/36 in 80% of cases and post laser VA was between 6/18 and 6/6 in 91% of cases. Mohammed
YK et al, 2006) in a study also reported a visual improvement of 88% in 58 patients studied. However 5% of the patients
did not have visual improvement post laser in our study. Hossain and Hossain reported that 4% of the patients in their
study did not have any improvement in vision following laser capsulotomy (Hossain MI, Hossain MA and Hossain MJ
2009). The non-improvement in vision may be attributable to the presence of media opacities or other ocular pathology
not detected earlier before the procedure.
Patients underwent this procedure with one form of complications or none at all. Raised intra ocular pressure and
hyphema were the commonest seen as was similarly reported by Hossain and Hossain in their study (Hossain MI,
Hossain MA and Hossain MJ 2009), however, we had expected the IOP not to become raised if they all had pre laser
instillation of Apraclonidine eyedrops.

CONCLUSION

The posterior capsule opacification is a common complication after cataract surgery worldwide and it can be managed
safely as a clinic procedure by Neodymium-YAG laser posterior capsulotomy. Nd YAG laser procedure can improve
visual acuity among patients with posterior capsular opacification and relatively associated with minimal complications, it
may however require augmentation with optical correction. Availability of Nd:YAG laser in treating this complication of a
 27

straightforward uncomplicated cataract surgery is important.

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