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Two Different Patterns and Outcome of Neodymium YAG Capsulotomy

Two Different Patterns and Outcome of Neodymium YAG Capsulotomy

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*Address for Correspondence: Sudeep Navule Two different patterns and outcome of Siddappa, Department of , Hassan Institute of Medical Sciences, Hassan, Karnataka, India, Tel: +91 7975077601, 7411490633; neodymium YAG Email: [email protected] Submitted: 08 January 2020 Sudeep Navule Siddappa*, Darshan Shivaura Mahalingu, Approved: 24 February 2020 Rakesha Anjenappa and Tintu Susan Joy Published: 25 February 2020 How to cite this article: Siddappa SN, Mahalingu Department of Ophthalmology, Hassan Institute of Medical Sciences, Hassan, Karnataka, India DS, Anjenappa R, Joy TS. Two different patterns and outcome of neodymium YAG capsulotomy. Introduction Int J Clin Exp Ophthalmol. 2020; 4: 012-014. DOI: dx.doi.org/10.29328/journal.ijceo.1001027 Visual impairment is a global health problem. is Copyright: © 2020 Siddappa SN, et al. This responsible for 50% of blindness worldwide [1]. is an open access article distributed under the Creative Commons Attribution License, Posterior capsular opaciication is the most common late which permits unrestricted use, distribution, complication of as a result of proliferation and reproduction in any medium, provided the of residual lens epithelial cells overall 25% of patients original work is properly cited. undergoing extra-capsular cataract surgery develops visually signiicant PCO within 5 years of the operation [2].

Nd: YAG laser provides the advantage of cutting the OPEN ACCESS posterior lens capsule, thereby avoiding and minimizing infection, wound leaks, and other complication of intraocular 1. Evident posterior capsular thickening/opaciication on surgery. Thus Nd:YAG laser capsulotomy is noninvasive, examination with . effective and relatively safe technique [3]. 2. Post-op cataract surgery, decrease in vision by at least However, this procedure is associated with complications 3 lines on Snellen’s chart. such as- postoperative increased intraocular pressure (IOP), cystoid macular edema (CME), disruption of the anterior 3. At least 3 months interval between cataract surgery vitreous surface, uveitis, lens subluxation, increased incidence and development of posterior capsular opaciication. of and pitting of the IOL [4]. 4. PCO following complicated . Laser shots can be applied in several patterns such as “Cruciate or Cross pattern”, “Can opener”, inverted “U-Method” 5. Pre-existing posterior capsular opaciication (present and in a “Circular pattern”. Many authors promote the use of before cataract surgery). a cruciate pattern in the Centre of the visual axis, with the clinician starting off on both axes away from the Centre to Exclusion criteria avoid pitting the lens centrally [5]. Following patients will be excluded from the study: This study mainly aims to analyze the effect of various 1. Patients < 5 years age. forms of PCO capsulotomy openings on visual function after Nd: YAG capsulotomy. 2. with subluxated .

Materials and methods 3. Includes severe coexisting ocular disease, Source of data The materials for the present study drawn from patients attending the outpatient department of ophthalmology. After Corneal opacity considering the below criteria, patients were selected into the study. Inclusion criteria Age-related macular degeneration and other macular pathologies. All patients presented with diminution of vision due toposterior capsular opacity, Retinal detachment

https://doi.org/10.29328/journal.ijceo.1001027 https://www.heighpubs.org/hceo 012 Two different patterns and outcome of neodymium YAG capsulotomy

4. Un-co-operative subjects. Eg: patients with mental Post procedure Tab Acetazolamide 250mg BD, retardation, neurological problems. Moxiloxacin with Dexamethasone drops QID, Nepafenac eye drops BD depending on the inlammatory response and 5. Aphakic eyes. raised IOP. Antiglaucoma medications were not given prior to Methodology capsulotomy to any patient. Study was initiated after obtaining approval from the Follow up Institutional Ethics Committee,Study conducted in about 100 Patients were visited on irst, third and seventh PCO patients fulilling the inclusion criteria after obtaining the postoperative days, then weekly for two weeks, monthly for informed consent from the participants are subjected to- two months and on third month. Each visit patients visual acuity, refraction, fundoscopy and IOP were examined and • A detailed clinical history includes date of cataract analysed. More frequent follow up visits may be considered in surgery, interval between cataract surgery and onset patients with complications. of defective vision, history of glaucoma, history of any systemic illnesses or surgery, history of any other Result s and observations ocular conditions. After a study for 18 months Dec 2017- May 2019 the • Detailed examination of both eyes along with general following observations were made, 100 patients were . identiied having posterior capsular opacity, These patients were divided into group A and group B, group A underwent • Visual acuity testing with Snellen’s chart. cruciate and group B underwent circular pattern capsulotomy • Examination of anterior segment of eye by slit lamp (Table 1). biomicroscopy. Graph 1 showing both circular and cruciate pattern • Measurement of intraocular pressure using applanation capsulotomy have almost same outcome. tonometer (Perkins). Table 1: Comparison of different pattern of PCO capsulotomy with post laser vision. Post laser vision Pattern of PCO Total Examination of posterior segment of eye by 2/60- 6/60 6/36- 6/18 6/18-6/6 (direct and indirect) and +90 D biomicroscopy. 6 21 23 50 Circular 12.0% 42.0% 46.0% 100.0% 6 22 22 50 A Q-switched Nd: YAG laser system (YAG IIplus, Appa Cruciate swamy, India), with wavelength of 1064 nm and pulse length 12.0% 44.0% 44.0% 100.0% 12 4 45 100 Total of < 4 ns (2-3 ns) was employed for this study. Before starting 12% 43% 45% 100% the procedure, one drop of 4% xylocaine was instilled into the conjunctival cul-de sac. 23 25 22 22 21 The were fully dilated and the aim was to create a 20 capsulotomy of about 4 mm in size. 15 10 Axis Axis Title 6 6 In cruciate pattern posterior capsulotomy laser shot is 5 irst aimed superiorly at near 12 Clock in the location of ine 0 2/60 - 6/60 6/36 – 6/18 6/12 - 6/6 tension lines and progressing downwards towards the 6 o’ Axis Title clock position, shots are then placed at the edge of the capsule Circular Cruciate opening, progressing laterally towards the 3 and 9 o’ clock positions. In circular pattern a circle of laser shots put starting Graph 1: Comparison of different pattern of PCO capsulotomy with post laser vision. from 6 o’ clock position with a diameter of 4-5 mm. Table 2: Comparison of different pattern of PCO capsulotomy with complications. Pattern of PCO capsulotomy Complications Total The aiming beamwas focused slightly posterior to the Circular Cruciate posterior capsule. Theoptical center of the IOL was matched 32 36 68 Nil with the centerof the opening. Initial setting of 1mJ and 47.1% 52.9% 100.0% 9 11 20 IOP spikes subsequent increase of 0.5 mJ as necessary used to make an 45.0% 55.0% 100.0% opening in the posterior capsule. 5 1 6 IOL pitting 83.3% 16.7% 100.0% 3 1 4 Uveitis 75.0% 25.0% 100.0% 1 0 1 Cystoid macular edema 100.0% .0% 100.0% 0 1 1 Ant Hyaloid face rupture .0% 100.0% 100.0% 50 50 100 Total 50.0% 50.0% 100.0%

https://doi.org/10.29328/journal.ijceo.1001027 https://www.heighpubs.org/hceo 013 Two different patterns and outcome of neodymium YAG capsulotomy

In cases who underwent circular pattern complications glare and light scattering and be visually disabling. Thus, the like IOL pitting and uveitis are common compared cruciate circular technique can prevent any damage near the visual axis pattern, where IOP spikes is a common complication (Table 2). of IOL and generate suficiently large size of the capsulotomy to restore contrast sensitivity and overcome glare disability. There was a single case of CME found in circular pattern In patients who underwent circular pattern capsulotomy and single case of ant hyaloid face rupture found in patients there was an immediate improvement of VA compared to undergone cruciate pattern of capsulotomy. these who underwent conventional cruciate method.

Graph 2 showing complication rate is more with the Mahmood Soni Wali et al study done on 58 patients were cruciate pattern capsulotomy compared to circular pattern. divided into two groups. In one group cruciate pattern of laser 24.5% of cases under gone circular pattern of capsulotomy shots were given and in the 2nd group circular pattern of laser were complaining of loaters compared to cruciate only 10% shots was used. Immediate visual outcome on 1st day was (Table 3). better with circular pattern. The incidence of IOP spike was less with circular pattern as compared to cruciate pattern. This is not statistically signiicant but cruciate pattern have The IOL Lens pitting, CME and retinal detachment were not less chances of loaters compared to circular. observed in patients who underwent circular pattern laser [6]. Graph 3 showing circular pattern have higher chances of having loaters compared to cruciate pattern capsulotomy. In our study in cases who underwent circular pattern complications like IOL pitting (83.3%), uveitis (75%) and Discussion CME (100%) are common compared cruciate pattern IOP The circular pattern laser shots avoid the visual axis which spikes (55%) and Hyaloid face rupture (100%) is common in resulted in decreased frequency of IOL Pitting which can cause cruciate pattern compared to circular pattern. Co nclusion 18 17 Y 16 M

O The cruciate pattern Nd: YAG posterior laser capsulotomy

T 14 O L 12

U can be performed safely but visual prognosis is better in P

A 10 8 C

circular pattern of capsulotomy. Complications like IOL

F 8 O

N 6 pitting, uveitis and CME are common in cases who underwent R

E 4 T 2 1.8 T 1.429 1.5 1.3 1.5 1 1.2 circular pattern compared to cruciate pattern IOP spikes and A 2

P 00 0 Hyaloid face rupture is common in cruciate pattern. Nil IOP spikes IOL piƫng UveiƟs Cystoid Ant Hyaloid macular edema face rupture COMPLICATIONS References

Circular Cruciate 1. Steinberg EP, Javitt JC, Sharkey PD, Zuckerman A, Legro MW, et al. The content and cost of cataract surgery. Arch Ophthalmol. 1993; 111: Graph 2: Comparison of different pattern of PCO capsulotomy with complications. 1041-1049. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/8352686 Table 3: Comparison of different pattern of PCO capsulotomy with fl oaters. 2. Sawusch MR, Guyton DL. Optimal astigmatism to enhance depth of Pattern of PCO Total focus after cataract surgery. Ophthalmology. 1991; 98: 1025-1029. Yes No PubMed: https://www.ncbi.nlm.nih.gov/pubmed/1891208 12 38 50 Circular 24.5% 75.5% 100.0% 3. Gardner KM, Straatsma BR, Pettit TH. Neodymium: YAG laser posterior 5 45 50 capsulotomy: the fi rst 100 cases at UCLA. Ophthalmic Surg. 1985; 16: Cruciate 10.0% 90.0% 100.0% 24-28. 17 82 99 PubMed: https://www.ncbi.nlm.nih.gov/pubmed/3838376 Total 17.2% 82.8% 100.0% 4. Aron-Rosa D, Aron JJ, Griesemann M, Thyzel R. Use of the neodymium- YAG laser to open the posterior capsule after lens implant surgery: a preliminary report. J Am Intraocul Implant Soc. 1980; 6: 352-354. Cruciate 29% PubMed: https://www.ncbi.nlm.nih.gov/pubmed/7440377

5. Kim Y, Park J. The effect of two different opening patterns of neodymium: YAG laser posterior capsulotomy on visual function. J Circular Korean Ophthalmol Soc. 2012; 53: 390-395. 71% 6. Kara N, Evcimen Y, Kirik F, Agachan A, Yigit FU. Comparison of two laser Circular Cruciate capsulotomy techniques: cruciate versus circular. Semin Ophthalmol. 2014; 29: 151-155. Graph 3: Comparison of different pattern of PCO capsulotomy with fl oaters. PubMed: https://www.ncbi.nlm.nih.gov/pubmed/24475914s

https://doi.org/10.29328/journal.ijceo.1001027 https://www.heighpubs.org/hceo 014

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