YAG capsulotomy K.P.SHANTHA SORUBARANI

What is PCO ?? Posterior capsular opacification is opacification / whitening of posterior capsule

Why it occurs ? Due to proliferation of lens epithelial cells from the equator across the posterior capsule

In which type of patient / surgery it is common? Depends on type of IOL (material & edge) Patient factors

When it occurs ? Time interval between surgery and occurrence of PCO varies – months to years

Types of PCO Fibrous Type: Multiple layers of lens epithelium ( fibrous metaplaisia ) migrates and becomes opaque Elschnig Type: Migration of equatorial epithelial cells with formation of small pearl like opacities. Mixed type

Before YAG

Other conditions for which we do laser here??? YAG pigment dispersion YAG membranolysis YAG vitreolysis YAG anterior capsulotomy ( phimosis relaxation ) Capsular Bag Distension Syndrome

How Nd- YAG laser works ?? Principle called - Photo disruption Very intense laser energy is focused into a small area for a very short period of time producing a hole in the opacity

Indications Decreased vision – Due to PCO, Pigments or precipitates on IOL, Capsular phimosis Monocular diplopia or glare. PCO preventing clear view of fundus required for diagnostic and therapeutic purposes.

Contraindications Absolute: - Inadequate visualization of posterior capsule (eg ) Corneal scars , corneal edema. - An un co-operative patient. Relative: - Known / suspected CME. - Active intraocular inflammation. - High risk for RD. – High myopes

Pre – laser assessment Visual acuity Retinoscopy Slit lamp assessment of opacification IOP Fundus evaluation -Direct ophthalmoscopy and indirect – if needed

Preparation of patients Describe the purpose and nature of procedure in detail in his/ her own language Dilate the pupil to about 4 to 5mm facilitating visualization of posterior capsule ( except in vitreolysis – instill pilomine )

Preparation of patients Tell the patient that the procedure is - PAINLESS - Maintenance of STEADY FIXATION No Anesthesia is required If a contact lens is used, administer one drop of 4% lignocaine in the eye to be treated

Technique Can be done with or without a contact lens. Use the smallest amount of energy possible with which the posterior capsule can be cut. - YAG Posterior capsulotomy - 1.3- 2.5 mJ ( post ) - YAG pigment dispersion – 0.4 – 0.8 mJ (ant ) - YAG membranolysis - 0.8- 1.3 mJ (ant ) - YAG vitreolysis - 0.8 mJ (ant ) - YAG anterior capsulotomy -1.3- 1.7 mJ (ant ) ( varies depending upon density of PCO)

Size of posterior capsulotomy The capsulotomy should be as large as the size of pupil in ambient light.

After YAG Elsching’s PCO Fibrous PCO

Timing A YAG Laser posterior capsulotomy is not done less then 6 months after surgery The procedure is only performed when visual acuity significantly diminishes due to posterior capsule opacification Others

Post YAG treatment After the Nd YAG laser capsulotomy , 1% apraclonidine is administered topically to control spikes in IOP Topical ab–steriod four times for-1week Frequency increased depending upon cases Anti glaucoma / diamox if needed If done along with suture removal – NSAID- Antibiotic combination

Post YAG treatment After ½ to 1 hour, repeat refraction and IOP (if needed) Patient is reviewed as per doctor s advice

Complications Elevation of IOP - Use less energy in glaucoma patients - Pre and Post YAG Brimonidine - Check IOP in glaucoma cases Damage to IOL – pitting - Check anterior / posterior - More if fibrous PCO / poor focusing/ un co operative patients

Complications Cystoid macular edema Retinal Detachment – rare , definite risk in myopia patients - use less energy in myopes

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