YAG laser capsulotomy, an unusual complication

There was no proprietary interest in this piece of work.

M Vella1, S Wickremasinghe1, N Gupta1, P Andreou1 and A Sinha1

1
Department of Ophthalmology Broomfield Hospital, Court Road, Chelmsford CM1 7ET, UK

Correspondence: M Vella, Tel: +44 1245 440761x4362; E-mailvellam@freeconnections.co.uk

Sir,

Posterior capsule opacification (PCO) is the commonest cause of diminished visual acuity
following cataract extraction. Visually significant PCO may occur in up to 25% of patients
over a 5-year period.1

PCO is readily treated by the use of the neodymium yttrium aluminium garnet (NdYAG)
laser to cause photodisruption of the thickened posterior capsule, and thereby clear the
visual axis.

We report a patient with an uncommon complication following uneventful NdYAG

capsulotomy and describe a potential treatment.

Top

Case report
A 71-year-old Caucasian lady presented 12 months after uncomplicated right cataract
surgery with a gradual reduction in vision of the operated eye. On examination, her best-
corrected visual acuity was noted to be 6/18 in the right eye, and slit-lamp bimicroscopy
revealed PCO. NdYAG laser capsulotomy was performed using a circular pattern of laser
treatment. Following treatment, an optically clear visual axis was seen and the patient was
commenced on G dexamethosone drops four times a day.
The patient returned to the eye clinic 1 week later complaining of a persistent, large
'floater' in the right eye, which was distressing her. This 'floater' became apparent on
moving her eyes in any direction and slowly disappeared on keeping her eyes still. Her
best-corrected visual acuity had improved to 6/6, but slit-lamp examination revealed a
large freely mobile remnant of her posterior capsule floating within the retrolental
space, Figure 1. An attempt to directly disrupt the remnant was made with further NdYAG
laser treatment, with the patient moving her eyes until the fragment crossed the visual
axis and laser being applied as it did so.

Figure 1.

Posterior capsule remnant floating in retrolental space.

Full figure and legend (162)

Despite limited success in obliterating the offending fragment, the patient's symptoms
completely subsided the following day.

Slit-lamp examination 6 weeks later revealed no evidence of the posterior capsular

remnant.

Top

Comment
NdYAG capsulotomy is generally a safe and successful method in relieving the symptoms
of posterior capsular opacification. Documented complications include, transient rise in
intraocular pressure,2 retinal detachment,3 lens subluxation or dislocation,4lens
pitting,5 and exacerbation of local endophthalmitis.6 Free-floating fragments have
previously not been documented.

Several techniques for NdYAG laser delivery have been described.7These include cruciate,
circular, horseshoe, or spiral delivery. Each technique has its own advantages and
disadvantages. Circular application of laser was used in this case, in order to avoid pitting
of the lens within the visual axis. However, it was because of this method that probably led
to the free-floating remnant, since the other techniques cause contraction of the capsule
or lead to the lasered portion 'flopping' out of the visual axis.

NdYAG capsulotomy, in addition to causing photodisruption of the posterior capsule,

causes disruption of the anterior vitreous face in about 33% of cases.8 It is likely that in
many cases, where isolated remnants of the posterior capsule remain, these fragments
settle into the vitreous cavity. In our case, it is likely that the anterior vitreous face was
undisturbed after the initial laser treatment. As a result, the fragment was freely mobile in
the retrolental space and unable to move into the vitreous cavity. After the second laser
session, despite only minimal damage to the fragment itself, disruption of this anterior
hyaloid face may have allowed the fragment to settle into the vitreous cavity and thereby
move out of the visual axis.

This case illustrates the aetiology and treatment for one potential complication of circular
application of laser in NdYAG capsulotomy.

Top

References
1. Schaumberg DA, Dana MR, Christen WG, Glynn RJ. A systematic overview of the
incidence of posterior capsule opacification. Ophthalmology 1998; 105(7): 1213–
1221. | Article | PubMed | ChemPort |
2. Slomovic AR, Parrish RK. Acute elevations of intraocular pressure following Nd : YAG
laser posterior capsulotomy.Ophthalmology 1985; 92(7): 973–976. | PubMed |
3. Ranta P, Kivela T. Retinal detachment in pseudophakic eyes with and without Nd :
YAG laser posterior capsulotomy.Ophthalmology 1998; 105(11): 2127–
2133. | Article | PubMed |
4. Framme C, Hoerauf H, Roider J, Laqua H. Delayed intraocular lens dislocation after
Nd : YAG Capsulotomy. J Cataract Refract Surg 1998; 24(11): 1541–
1543. | PubMed |
 5. Mamalis N, Craig MT, Price FW. Spectrum of Nd : YAG laser-induced intraocular lens
damage in explanted lenses. J Cataract Refract Surg 1990; 16(4): 495–
500. | PubMed |
6. Abrahams IW. Proprionibacterium acnes endophthalmitis, an unusual manner of
presentation. J Cataract Refract Surg1989; 15(6): 698–701. | PubMed |
7. Nd : YAG photodisruptors. Am Acade Ophthalmologists —Ophthalmol
1993; 100(11): 1736–1742.
8. Smith RT, Moscoso WE, Trokel S, Auran J. The barrier function in neodymium–YAG
laser capsulotomy. Arch Ophthalmol 1995; 113(5): 645–652. | PubMed |
SUMMARY
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described risks persistent
of this procedure.
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have listed aabove
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the retina
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of the laser this at less
all aggressive Doctor posture
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ophthalmologists
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believe thisperiphery
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is a better of procedure
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policy eye.overall.
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sometimes in difficulty
elusive andeye
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inefficiency
Because He
floaters. many (delivering
has patients
enjoyedcome less
a very energy our than
to high office
success desired).
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because laser
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a localsmall
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providerand
approach tothat made
each can more
treatment.
provide
to the natural
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follow needed. Foreyes. instance,Floaters to beinable the periphery
to check your of the eye eye are veryshould
pressure, difficult you toexperience
treat and even any though
unusualwe may see after
symptoms themyour quite
aggressive
clearly, theand
procedure treatment
laser energy
after (release
may be
returning more microscopic protein debris)
so diminished that very little happens when the laser is activated. Some of this challenge can be compensated
home.
If
fora bypotential
FLOATER
a skilled patient exhibits some
SITUATED
and experienced TOO
laserof these
CLOSE
specialist, or otherTObut characteristics
not WE FINE
UNTREATED
SYNERESIS
SAME
NORMAL
THE
always. CAN
POSSIBLE we
MICROSCOPIC
FLOATER
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PRODUCTION
FLOATER
SYNERESIS
TREAT mayEYE
EXPLANATION
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AFTER them
FURTHER
AND
FLOATERS
TYPE
FLOATERS atFOR
FLOW OFhigher arerisk, we may modify the treatment
THE
OF
strategy
2. INABILITY or choose
LENS isTO not
an TREATto treat
exampleSOME at all. One
of the vitreous modified
FLOATERS: floater approach another
VITREOUS
TREATMENT
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CAUSE
LOCATED is to
AQUEOUS treat
example
OFTOO at
ELEVATED
FLOATER.much
with
mayof
CLOSE
HUMOR lower
floaters
re-formation,
continueThis
EYE
TO IN energy
located
THE
is
with
THE
PRESSURES
a large,
re-
the levels
LENS.
too
FRONT‘3-4
close at the first treatment session to assess how
the
Theeye responds.
located
treatment oftooWeclose
eye havetoobserved
floaters aisdelicate
highly that if the patient
structure
individualized withinand does anot
todynamic.
diffuse,
aggregation,
steps
OF
AFTER
Legend: THE respond
delicate
forward
cloud-like
LASER
(a.)
EYE. with
Itstructure.
Lens,
and
andSpecial a steps
TREATMENT.
clumping
impossible 1-2
floater
(b.) pressure
In
Laser
cells
this
tothat
ofback.iselevation
located
energy,
case,
remaining
predict commonly
NotContinued
itexactly
at(c.)
is theafter
all(a.) howthe thefirst treatment,
floaters then it is
will behave. Thatvery
unlikely they
the eye.
unpredictability willisThe
have
more red asoproblem
dotted
in younger with
line subsequent
demarcates
patients. thetreatments
There retina.
seen
collagen
exists inregardless
re-formation
produce
patients
treatmentthe This
our
are
aprotein
demarcation
watery
distinctpractice.
is
atofarisk of
smaller
very how
fragments
saline
for
possibilityThey
commonaggressive.
elevated
line,
fuzzy
and are
despite
(d.)
electrolyte
that linear
more
situation
eyefocus
despite an There
pressure
gradual
strand
adequate
ofour
with isbest,
laser inthe most
possibility
dedicated that the
andeye pressureeffort,
meticulous may
not come down
there mayapproximate with
be some residual treatment
regionmaterial which
safe to treat. could
that simply require
In general, long
cannot be term
younger
onset,
and
may
solution
after
where safely use
aggressive
continue
treatment.
and
energy of
called eye
patients,
appear
treated, is
until pressure
aqueous
first
There
delivered.
meaning
orasthere
treatment.
a appears
large
remains medications
humor.
is those
less
‘gauze’,
to
Thematerial,
This
younger
beaggregated
inaccessible. or
afluid
haze,or possibly
than the need
orthe are some examples:
Here for further surgery.
the floater must be at least 2 mm away lens. Some about across
cloud
floater
remaining
works
combination 30
floaters
its
most to
way
material
35often
the
oflocated
forward
years
risk
vision.
appears
isfactors
ofnot
near
past
age.bothersome,
as
the
involved.
the
Youa lens
‘fuzzy’
lens
cancan and
read
This
or
linearno
more
See section #4 “Cataract” below. about material
strand.
more
through
illustration
sometimes that
Although
theHERE.
be
shows
pupil
momentarily
reforms.
there
into
a large, the
isThere
much
space
dense,
movedislessbetween
nosyneresis
away
way
material tofrom
the
involved,
predict
iris
type
the lens
andfloater
how
the
where
these
cornea
(a.)
many the
floaters
Located
treatments
laser
calledcan inthethe
still
beanterior
itfront
safely
takes
be quite one
to
chamber
fired.
get
third to
bothersome.
these
(b.).
of
This theThis
is‘endpoints’
eye
an fluid
advanced
combined flow as it is
technique
with
varies
shown a treatment
from
asand (c.).eye
notThe that
to eye.fluid
eventually
releases
recommended microscopic
drains foratdoctorstheprotein
“angle”
new fragments
toand theby the (b.)
junctionmay
Which
procedure. of the findcornea
their way in theinto iris.the The front fluid part of
drained
the eye (c.). out the If thestructure
drainage calledpathway, the trabecularthe
meshwork.meshwork
trabecular It is the balance is clogged of the with production
this
of this fluid in
microscopic debris,
the drainage
it may decrease of this fluid outflow which of
determines
the normal aqueous the regular fluid.pressure
This may of the beeye. the
cause of elevated eye pressures in a few of our
patients.