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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 10  |  Issue : 1  |  Page : 37-42

Neodymium-yttrium aluminium garnet laser capsulotomy energy levels for posterior capsule opacification


1 Department of Ophthalmology, Laser Eye Clinic, Noida, Uttar Pradesh, India
2 Department of Pathology, Santosh Medical College and Hospital, Ghaziabad, India
3 Department of Ophthalmology, Santosh Medical College and Hospital, Ghaziabad, India
4 Department of Ophthalmology, Indira Gandhi Medical College, Shimla, India

Date of Submission10-May-2013
Date of Acceptance12-May-2014
Date of Web Publication30-Apr-2015

Correspondence Address:
Rahul Bhargava
Laser Eye Clinic, Noida, Uttar Pradesh - 201 301
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2008-322X.156101

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  Abstract 

Purpose: To study factors affecting laser energy levels required for neodymium: yttrium aluminium garnet (Nd: YAG) laser capsulotomy and to evaluate whether any correlation exists between applied laser energy levels and complications.
Methods: The present study examined 474 consecutive patients for a number of factors including age, type of posterior capsule opacification (PCO), material and fixation of intraocular lens (IOL) and complication rates, versus energy levels used for Nd: YAG laser capsulotomy.
Results: Mean patient age was 55.6 ± 8.7 years and mean follow up period was 22.9 ± 4.5 months. IOL biomaterial (KW ANOVA; P = 0.173) and patient's age (P = 0.246) did not significantly influence total laser energy requirement for capsulotomy. However, total laser energy levels were significantly higher (KW ANOVA; P < 0.001) with fibro-membranous and fibrous subtypes of PCO. Complications such as IOL pitting, intraocular pressure (IOP) elevation, uveitis, retinal detachment (RD) and cystoid macular edema (CME) were significantly more common when higher energy levels was used. The mean total energy in patients with RD was 77.7 ± 17.7 mJ as compared to 43.4 ± 26.9 mJ in the rest of the cohort. RD was more common in patients with higher axial length [n = 7 (63%)] (P < 0.001).
Conclusion: Type of PCO significantly influenced laser energy levels required for capsulotomy, whereas IOL biomaterial and fixation did not. Complications such as IOL pitting, uveitis, IOP elevation, RD and CME was significantly more common when total laser energy was higher. It is recommended that the lowest possible single pulse laser energy be used for capsulotomy to minimize complications.

Keywords: Intraocular Lens; Laser Capsulotomy; Posterior Capsule Opacification


How to cite this article:
Bhargava R, Kumar P, Phogat H, Chaudhary KP. Neodymium-yttrium aluminium garnet laser capsulotomy energy levels for posterior capsule opacification. J Ophthalmic Vis Res 2015;10:37-42

How to cite this URL:
Bhargava R, Kumar P, Phogat H, Chaudhary KP. Neodymium-yttrium aluminium garnet laser capsulotomy energy levels for posterior capsule opacification. J Ophthalmic Vis Res [serial online] 2015 [cited 2019 Dec 12];10:37-42. Available from: http://www.jovr.org/text.asp?2015/10/1/37/156101


  Introduction Top


Posterior capsule opacification (PCO) is one of the most common visually disabling complications of cataract surgery. However, due to improvements in surgical technique, intraocular lens (IOL) material, design and selective use of therapeutic agents, there has been a reduction in the incidence of PCO. Having said this, PCO and subsequent Neodymium yttrium aluminium garnet laser (Nd: YAG) capsulotomy rates may be much higher in communities where a sizeable population still do not have access to phacoemulsification and modern IOLs. [1]

Various factors such as age and PCO thickness may affect the required power for Nd: YAG laser to rupture an opacified capsule. While Nd: YAG laser capsulotomy may significantly influence the ability of a vitreoretinal surgeon to visualize the peripheral fundus in patients at risk of retinal detachment (RD) on one hand, it may itself lead to RD and cystoid macular edema (CME), on the other. The precise mechanisms leading to retinal breaks and RD after laser capsulotomy are not known. Many investigators believe that laser energy induces vitreous liquefaction, posterior vitreous detachment or both, which might create new breaks or enable pre-existing asymptomatic breaks to progress to RD. [2],[3] The impact of Nd: YAG laser energy per se on the rate of complications has not been studied extensively and a causal relation has not been established.

The purpose of the present study was to analyze the impact of factors such as patient's age, IOL biomaterial, IOL fixation and PCO subtypes on laser energy levels required for capsulotomy and to evaluate whether any correlation exists between the amount of laser energy applied and complications rates.


  Methods Top


This study was performed at Indira Gandhi Medical College and Hospital and Laser Eye Clinic Noida, India and included a cohort of 474 consecutive eyes with visually significant PCO, referred for Nd: YAG laser capsulotomy, from February 2008 to November 2010. More than 70% of Nd: YAG laser capsulotomies of the region and 90% retinal detachment surgeries are performed at this referral hospital. Written informed consent was obtained from all patients based on the Helsinki protocol. The local ethics committee and institutional review boards approved the trial.

Patients were enrolled if there was reduction in corrected distance visual acuity (CDVA) by two or more Snellen lines, glare disabilities or monocular diplopia. As a rule, patients with PCO were considered for capsulotomy after a minimum period of 3 months following uneventful cataract surgery. Patients with history of retinal detachment (RD) in the fellow eye, peripheral retinal degenerations, retinal breaks, past history of vitreoretinal surgery, diabetic retinopathy and follow up less than 9 months were excluded.

The preoperative protocol included recording corrected distance visual acuity (CDVA). The pupils were dilated with tropicamide 0.5% and phenylephrine 10% drops. Fixation of IOL was noted in each case. The posterior pole was examined with a 90 diopter (D) lens while the peripheral retina was evaluated by binocular indirect ophthalmoscopy using a 20 D lens with scleral indentation.

The impact of factors such as age, subtype of PCO, and type and fixation of IOL on energy levels used for Nd: YAG laser capsulotomy was studied. We also evaluated whether any correlation exists between laser energy delivered to the treatment site and complications rates.

Technique

A Q-switched Nd: YAG laser system (Visulas YAG II plus , Carl Zeiss, Germany), with wavelength of 1064 nm and pulse length of <4 ns (2-3 ns) was employed for this study. Nd: YAG laser capsulotomy was performed using an Abraham lens with hydroxypropyl methylcellulose as the coupling agent.

Before starting the procedure, one drop of 4% xylocaine was instilled into the conjunctival cul-de sac. The pupils were fully dilated and the aim was to create a capsulotomy of about 4 mm in size. A central cruciate pattern in an upward-downward direction was used. [4] The aiming beam was focused slightly posterior to the posterior capsule. The optical center of the IOL was matched with the center of the opening. The starting initial energy level (0.3-10 mJ), number of pulses used to create capsulotomy and summated laser energy was noted in each case.

Patients were visited the on first, third and seventh postoperative days, then weekly for two weeks, monthly for two months and every three months thereafter. The postoperative regimen included topical betamethasone 0.1%, every two hours, tapered over 2-3 weeks depending on the inflammatory response. Antiglaucoma medications were not given prior to capsulotomy to any patient. At each follow up visit, CDVA was checked and intraocular pressure (IOP) was measured by Goldmann applanation tonometry. Detailed fundus examination including indirect ophthalmoscopy was one week and one month after laser capsulotomy and repeated at three month intervals.


  Results Top


A total of 42 patients could not complete the study due to death, health or social reasons. Records of 474 patients who received Nd: YAG laser capsulotomy were evaluated; these included 244 (51%) female and 230 (49%) male subjects. Mean follow-up period was 22.9 ± 4.5 months.

Visual Acuity

Snellen visual acuity was converted to logMAR units for comparisons. Mean preoperative CDVA was 0.85 ± 0.22, mean visual acuity on day one was 0.27 ± 0.18 logMAR and mean final CDVA was 0.21 ± 0.21 logMAR. There was a significant improvement in vision after the procedure (P < 0.001) [Table 1]. At final follow-up, 95.6% of patients had CDVA of 0.5 or better (≥6/12). CDVA remained less than 6/60 due to cystoid macular edema and retinal detachment. [Table 1] shows the percentage of patients at each level of CDVA.
Table 1. Percentage of patients at each level of corrected distance visual acuity


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Laser Energy and Age

Mean age was 55.6 ± 8.7 (range, 40-76) years. Although laser energy levels were slightly higher in younger subjects, the difference between various age groups was not significant (P = 0.246).

Laser Energy and PCO Subtypes

There was a significant difference in the initial and total laser energy levels required for capsulotomy with different subtypes of PCO. The mean starting initial energy (single pulse) for membranous (pearl form), fibrous and fibro-membranous PCO was 1.8 ± 1.1, 2.8 ± 1.1 and 2.5 ± 0.8 mJ respectively (Mann Whitney test; P < 0.001). [Table 2] shows there was a significant difference in mean total energy levels in these subtypes (KW ANOVA: P <0.001).
Table 2. Mean total laser energy levels (mJ) for subtypes of posterior capsule opacification


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Laser Energy and IOL Biomaterial

The IOL biomaterial (silicone, hydrophobic acrylic, hydrophilic acrylic and PMMA) did not significantly influence the total laser energy required to create a capsulotomy (KW ANOVA; P = 0.173). On the contrary, the damage thresholds of IOLs were significantly different (silicone < acrylic < PMMA). [Table 3] shows that for equivalent total laser energy levels, silicone IOLs were more vulnerable to pitting and damage.
Table 3. Mean total laser energy levels for different types of intraocular lenses


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Laser Energy and IOL Fixation

Out of 474 patients, 390 (82.3%) had in-the-bag IOL fixation, 50 (10.5%) had sulcus IOL fixation and 34 (7.2%) had sulcus-bag IOL fixation, respectively. Mean laser energy levels for in-the-bag, sulcus-sulcus and sulcus-bag fixated IOLs were 44.3 ± 27.1 mJ, 46.4 ± 23.7 mJ and 49.7 ± 18.2 mJ, respectively (P = 0.783).

Laser Energy and Complications

The total energy required to create the capsulotomy was compared with complications observed during the course of the study [Table 4]. There was a significant association between laser energy levels and complications such as IOP spikes, uveitis, hyaloid face rupture, IOL pitting, retinal detachment and cystoid macular edema (P < 0.001). In general, mean laser energy was significantly higher (66.3 ± 25.5 mJ) in eyes developing complications as compared to the group without any complications (36.6 ± 23.7 mJ) (Mann Whitney test; P < 0.001).
Table 4. Mean total laser energy in groups with and with­out complications


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IOL Pitting

The incidence of IOL pitting was 7.8%. The mean total laser energy level in eyes with IOL pitting (n = 37) was 61.6 ± 26.4 mJ as compared to 42.8 ± 26.7 mJ in eyes without IOL pitting (n = 437). Silicone IOLs had a higher incidence of pitting as well as a lower threshold for laser induced damage [Table 4] (P < 0.001).

IOP Elevation

The incidence of IOP elevation was 12.6%. Overall, 1.3% patients had medically controlled glaucoma prior to capsulotomy. Mean IOP on the post-operative day one was 21.5 ± 6.6 mmHg. Mean laser energy in the subgroup with IOP elevation (n = 60) was 57.8 ± 26.8 mJ as compared to 42.3 ± 26.6 mJ in eyes with no IOP elevation (n = 414) (P < 0.001). IOP returned to normal limits at 2 weeks in most patients following topical treatment with 0.5% apraclonidine eye drops twice daily. Out of 6 patients who developed sustained IOP elevation, two had medically controlled glaucoma. These were referred to the glaucoma clinic for further management.

Uveitis

The incidence of anterior segment inflammation on post-operative day one was 9.9%. Overall, 1.9% of the patients had a history of prior uveitis. Mean total laser energy in the subgroup with uveitis (n = 47) was 64.9 ± 24.8 mJ as compared to 42.0 ± 26.4 mJ in eyes without uveitis (n = 427). Betamethasone 1% eye drops, tapered over 2-3 weeks, resulted in resolution of inflammation in all but 4 eyes. Out of these, two patients had prior uveitis. Oral prednisolone 1 mg/kg/day (tapered over 5 days) resulted in resolution of uveitis.

Cystoid Macular Edema

The incidence of CME was 2.9%. The mean total laser energy in eyes with CME (n = 14) was 77.8 ± 17.7 mJ versus 42.2 ± 26.2 mJ in the group without clinical CME (n = 460) (P < 0.001)

Retinal Detachment

Out of 474 eyes, 11 patients developed rhegmatogenous RD during follow up (2.3%). The mean duration of RD after capsulotomy was 11.7 ± 0.8 months. RD was more common in patients with higher axial length [n = 7 (63%)] (P < 0.001). Mean total laser energy in the RD group (n = 11) was 70.2 ± 20.0 mJ as compared to 43.4 ± 26.9 mJ in the group with normal retina (n = 463) (P < 0.001). [Table 5] shows baseline characteristics of patients with RD.
Table 5. Baseline characteristics of patients with retinal detachment


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  Discussion Top


Nd: YAG laser capsulotomy is the mainstay of treatment for PCO. [5] However, surgical peeling and aspiration of pearls may be an alternative in myopic eyes. [6] There has been a reduction in the overall rate of complications following Nd: YAG laser capsulotomy. This could be attributed to better understanding of the mechanisms of laser induced damage and recognition of the fact that one should limit the total amount of laser energy delivered to the treatment site. [7],[8]

The aim of capsulotomy in the present study was to clear the visual axis by creating an opening in the opacified posterior capsule by focusing Nd: YAG laser pulses of a few millijoules (mJ) in energy with duration of 2-3 nanoseconds, posterior to the posterior capsule. There are only a few published studies in the literature which have evaluated the effects of laser energy per se on complication rates, and the effect of factors such as IOL type and fixation, and type of PCO on energy levels. This prospective study evaluated the effect of these factors on the level of energy used for capsulotomy and the correlation between total laser energy levels and the rate of complications.

Nd: YAG capsulotomy is associated with significant anterior and posterior segment complications. Some studies recommend that side effects are more pronounced when higher single pulse energy levels are used rather than higher total laser energy. [9]

In a retrospective study on 215 eyes with PCO, Bhargava et al found that different PCO subtypes required different initial and total laser energy levels depending on thickness of the posterior capsule (1.8, 3.1 and 2.7 mJ for membranous, fibrous, fibro-membranous opacities respectively). The authors recommended lower single pulse energy levels rather than higher total energy in order to minimize the rate of complications. [10] The starting mean initial energy in the present study was 1.8 mJ and 2.8 mJ for pearl and fibrous forms of PCO respectively, which was comparable to the results of the study by Bhargava et al There was also a significant difference (P < 0.001) in the total laser energy levels required to create capsulotomy in fibrous and pearl subtypes of PCO. This finding is similar to the observation by Bhargava et al Hawlina G and Drnovsek-Olup performed capsulotomy in 53 eyes with an initial energy of 1.6 mJ. Mean total energy in their study was 104.72 mJ, which is comparable to our study. [11] Hood et al described the use of Nd: YAG laser to lyse residual cortex after phacoemulsification with mean pulse energy of 1.7 ± 0.5 mJ and total energy of 159 ± 114 mJ.

The incidence of IOP rise was significantly more in the group with higher total energy levels (226 ± 233 mJ). [12] In a series of 30 patients with PCO, Ari et al evaluated the effect of energy levels for Nd: YAG laser capsulotomy on IOP and macular thickness and found that the severity and duration of IOP rise was less when the total energy was less than 80 mJ. [13],[14] In another study, Karahan et al evaluated the effect of capsulotomy size on IOP and macular thickness. IOP rise was significantly greater in the large capsulotomy group (with higher laser energy), i.e. 3.4 ± 0.3 versus 4.6 ± 0.5 mmHg. [15] The results of these studies further substantiate the observations of the present study.

The present study suggests that neither age nor the type of IOL (silicone, hydrophobic acrylic, hydrophilic acrylic and PMMA) have a significant effect on the total laser energy required to create a capsulotomy. However, different IOL materials had different damage thresholds and consequent pitting and cracks (PMMA > acrylic > silicone). IOL damage following capsulotomy has been attributed to faulty focusing of laser beam, close proximity of the IOL to the posterior capsule and inherent properties of IOL materials. However, laser energy per se also had a significant effect on IOL damage. This was evident by the fact that total laser energy was significantly higher (P < 0.001) in the group of eyes in which pitting was seen. A similar observation was made by Saffra et al in an in-vitro analysis of Nd: YAG laser damage to hydrophilic IOLs. [16] Thus, we advise focusing the laser beam posterior to the posterior capsule, and setting the laser beam to the minimum possible energy level.

Auffarth et al analysed energy levels of Nd: YAG laser capsulotomy for secondary cataracts in a series of 172 patients and found that the total laser energy was significantly higher with sulcus fixated IOL's. [17] This observation was similar to the results of the present study.

The incidence of CME following Nd: YAG laser capsulotomy ranges from 0.6-4.4%. Total laser energy levels in the present study were significantly higher in the group of eyes with CME. On the contrary, only two of the eleven eyes with CME had increased post-procedural inflammation. Altiparmak et al measured foveal thickness with optical coherence tomography following Nd: YAG laser capsulotomy in a series of 54 eyes. The authors did not find any correlation between foveal thickness and total laser energy or any change in foveal thickness at 12 months. [18] Smaller sample size in their study could explain this difference.

The results of the present study suggest a significant relation between laser energy levels and retinal detachment. Mean total energy was significantly higher in patients with RD (77.7 ± 17.7 versus 43.4 ± 26.9 mJ). Although RD was more common in patients with longer axial length (>24 mm), patients with normal axial length (22-24 mm) and without any pre-existing retinal breaks but higher total laser energy levels (mean, 89.6 ± 4.26 mJ) also developed RD [Table 5]. Alimanović-Halilović analysed complications in the posterior segment after Nd: YAG laser capsulotomy and found a significant association between total laser energy levels and complications such as RD and CME, and the collative connections were positive and strong. [19] It appears that high total laser energy may be an independent risk factor for RD following laser capsulotomy. However, studies on a larger sample size may be required to further substantiate this observation. It is advisable to avoid large size capsulotomies in patients with high axial length.

In conclusion, the results of the present study suggest that a correlation exists between total Nd: YAG laser energy levels delivered to the treatment site and the rate of intraocular complications. We recommend lower starting single pulse energy levels for capsulotomy to minimize the incidence of adverse effects.


  Acknowledgements Top


Dr. Puneet Gupta for statistical analysis.

 
  References Top

1.
Bhargava R, Kumar P, Sharma SK, Sharma S, Mehra N, Mishra A. Peeling and aspiration of elschnig pearls! An effective alternative to Nd: YAG laser capsulotomy! Indian J Ophthalmol 2013;61:518-520.  Back to cited text no. 1
    
2.
Ranta P, Tommila P, Kivelä T. Retinal breaks and detachment after neodymium: YAG laser posterior capsulotomy: Five-year incidence in a prospective cohort. J Cataract Refract Surg 2004;30:58-66.  Back to cited text no. 2
    
3.
Powell SK, Olson RJ. Incidence of retinal detachment after cataract surgery and neodymium: YAG laser capsulotomy. J Cataract Refract Surg 1995;21:132-135.  Back to cited text no. 3
    
4.
Murrill CA, Stanfield DL, Van Brocklin MD. Capsulotomy. Optom Clin 1995;4:69-83.  Back to cited text no. 4
    
5.
Aslam TM, Devlin H, Dhillon B. Use of Nd: YAG laser capsulotomy. Surv Ophthalmol 2003;48:594-612.  Back to cited text no. 5
    
6.
Janknecht P, Funk J. Surgical aspiration of secondary cataract. Success quotas and complications. Ophthalmologe 1992;89:291-294.  Back to cited text no. 6
    
7.
Awan MT, Khan MA, Al-Khairy S, Malik S. Improvement of visual acuity in diabetic and nondiabetic patients after Nd: YAG laser capsulotomy. Clin Ophthalmol 2013;7:2011-2017.  Back to cited text no. 7
    
8.
Longmuir S, Titler S, Johnson T, Kitzmann A. Nd: YAG laser capsulotomy under general anesthesia in the sitting position. J AAPOS 2013;17:417-419.  Back to cited text no. 8
    
9.
Aslam TM, Patton N. Methods of assessment of patients for Nd: YAG laser capsulotomy that correlate with final visual improvement. BMC Ophthalmol 2004;4:13.  Back to cited text no. 9
    
10.
Bhargava R, Kumar P, Prakash A, Chaudhary KP. Estimation of mean ND: Yag laser capsulotomy energy levels for membranous and fibrous posterior capsular opacification. Nepal J Ophthalmol 2012;4:108-113.  Back to cited text no. 10
    
11.
Hawlina G, Drnovsek-Olup B. Nd: YAG laser capsulotomy for treating posterior capsule opacification. J Laser Health Acad 2013;1:S34-S35.  Back to cited text no. 11
    
12.
Hood CT, Shtein RM, Mian SI, Sugar A. Neodymium-yttrium-aluminum-garnet laser lysis of retained cortex after phacoemulsification cataract surgery. Am J Ophthalmol 2012;154:808-813.e1.  Back to cited text no. 12
    
13.
Ari S, Cingü AK, Sahin A, Çinar Y, Çaça I. The effects of Nd: YAG laser posterior capsulotomy on macular thickness, intraocular pressure, and visual acuity. Ophthalmic Surg Lasers Imaging 2012;43:395-400.  Back to cited text no. 13
    
14.
Barnes EA, Murdoch IE, Subramaniam S, Cahill A, Kehoe B, Behrend M. Neodymium:yttrium-aluminum-garnet capsulotomy and intraocular pressure in pseudophakic patients with glaucoma. Ophthalmology 2004;111:1393-1397.  Back to cited text no. 14
    
15.
Karahan E, Tuncer I, Zengin MO. The effect of ND: YAG laser posterior capsulotomy size on refraction, intraocular pressure, and macular thickness. J Ophthalmol 2014;2014:846385.  Back to cited text no. 15
    
16.
Saffra N, Agarwal S, Enin J, Werner L, Mamalis N. In vitro analysis of Nd: YAG laser damage to hydrophilic intraocular lenses. Ophthalmic Surg Lasers Imaging 2012;43:45-49.  Back to cited text no. 16
    
17.
Auffarth GU, Nimsgern C, Tetz MR, Völcker HE. Analysis of energy levels for Nd: YAG laser capsulotomy in secondary cataract. Ophthalmologe 2000;97:1-4.  Back to cited text no. 17
    
18.
Altiparmak UE, Ersoz I, Hazirolan D, Koklu B, Kasim R, Duman S. The impact of Nd: YAG capsulotomy on foveal thickness measurement by optical coherence tomography. Ophthalmic Surg Lasers Imaging 2010;41:67-71.  Back to cited text no. 18
    
19.
Alimanović-Halilović E. Complications in the posterior eye segment after Nd-YAG laser capsulotomy. Med Arh 2004;58:7-9.  Back to cited text no. 19
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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