Downloaded from http://bjo.bmj.com/ on August 21, 2017 - Published by group.bmj.com Clinical science Cataracts induced by neodymium–yttrium- aluminium-garnet laser lysis of vitreous floaters Ellen H Koo, Luis J Haddock, Namita Bhardwaj, Jorge A Fortun

Bascom Palmer Eye Institute, ABSTRACT subcapsular cataract. About 1 week prior, she had University of Miami Miller Background Neodymium–yttrium-aluminium-garnet undergone Nd:YAG laser vitreolysis by her ophtha- School of Medicine, Miami, fl Florida, USA (Nd:YAG) laser vitreolysis has been proposed as a lmologist for symptomatic oaters. Immediately, treatment modality for symptomatic vitreous floaters. The she noticed a decline in vision. Her best-corrected Correspondence to purpose of this paper is to report two cases of cataracts visual acuity (BCVA) was 20/50 at presentation. At Dr Ellen Koo, Bascom Palmer associated with posterior capsular compromise, induced the slit-lamp biomicroscope, she was found to have Eye Institute, Palm Beach by Nd:YAG laser vitreolysis for symptomatic vitreous a large central diamond-shaped opening in the pos- Gardens, 7101 Fairway Drive, floaters. terior capsule, with associated posterior subcapsular Palm Beach Gardens, FL 33458, fi USA; [email protected] Method Case series. cataract ( gures 1 and 2). Besides the presence of Results Two patients who underwent ND:YAG laser vitreous floaters, the retinal examination was Received 12 May 2016 vitreolysis for symptomatic floaters, presented with unremarkable. Revised 20 June 2016 decline in visual acuity in the treated eye after the laser A combined surgical approach was planned Accepted 6 August 2016 procedure. At the slit-lamp biomicroscope, each patient with the anterior segment surgeon and the vitreor- Published Online First 29 August 2016 was found to have a posterior subcapsular cataract in etinal surgeon. Hydrodissection was purposefully the treated eye, with obvious loss of integrity of the avoided. The cataract was successfully removed via posterior capsule. These two patients underwent cataract phacoemulsification. A three-piece acrylic intraocu- extraction by the same surgeon via phacoemulsification. lar lens implant was placed in the sulcus with optic Both eyes were found to have a defect in the posterior capture by the anterior capsulorhexis. A pars plana capsule intraoperatively. In both cases, a three-piece vitrectomy was performed by the vitreoretinal acrylic intraocular lens implant was placed in the sulcus, surgeon for vitreous prolapse through the posterior achieving optic capture. The best-corrected visual acuity capsular defect. At 1 month after the procedure, (BCVA) was 20/20 in both patients, at 1 month patient achieved BCVA of 20/20. At 2 months’ following the surgery. At 2 months, one patient had a follow-up, her BCVAwas 20/15. BCVA of 20/15. The second patient maintained a BCVA of 20/20 at 3 months. Case #2 Conclusions Secondary cataract formation accompanied A 65-year-old white man presented to our facility by loss of integrity of the posterior capsule is a potential to the retina service, for another similar atypical complication of Nd:YAG laser vitreolysis for symptomatic fl posterior subcapsular cataract. About 2 years prior, oaters. he had undergone YAG laser vitreolysis with a dif- ferent laser surgeon than in the aforementioned case, for symptomatic floaters. Soon thereafter, he INTRODUCTION noted a decline in vision, which progressively wor- – Neodymium yttrium-aluminium-garnet (Nd:YAG) sened. His BCVA was 20/70 at presentation. At the laser has become a standard, accepted treatment slit-lamp biomicroscope, he was found to have a fi 1 modality for posterior capsular opaci cation. Nd: large ovoid opening in the posterior capsule, with YAG laser is also deemed to be an effective way to associated posterior subcapsular cataract (figures 3 2 et al3 perform laser iridotomy. Sohajda demon- and 4). Other than vitreous floaters, the rest of the strated that Nd:YAG laser could be effectively used retinal examination was unremarkable. to treat pupillary membranes, especially after cata- A combined surgical approach was planned with ract surgery. the anterior segment surgeon and the vitreoretinal ’ The Nd:YAG laser s application for vitreolysis is surgeon. Hydrodissection was avoided, and the far less commonly described, compared with its fre- cataract was successfully removed via phacoemulsi- quent and accepted usage in the treatment of ante- fication. A three-piece acrylic intraocular lens rior segment pathology. Moreover, there are no implant was placed in the sulcus with optic capture fi large series that report its safety and ef cacy. We by the anterior capsulorrhexis. A pars plana vitrec- report these two cases of patients who developed tomy was performed by the vitreoretinal surgeon posterior capsular rupture and associated posterior for vitreous prolapse through the posterior capsular subcapsular cataract after Nd:YAG laser vitreolysis defect. Similarly, at 1 month after the procedure, fl for symptomatic oaters. To our knowledge, cata- patient achieved BCVA of 20/20. At 3 months’ ract development and posterior capsular comprom- follow-up, his BCVAwas 20/20. ise as a direct complication of Nd:YAG laser has not been reported.

To cite: Koo EH, DISCUSSION Haddock LJ, Bhardwaj N, Case #1 Symptomatic vitreous floaters are due to molecular et al. Br J Ophthalmol A 63-year-old white woman presented to our faci- changes that occur within the vitreous body that 2017;101:709–711. lity to the retina service, for an atypical posterior result in liquefaction of the vitreous gel, with

Koo EH, et al. Br J Ophthalmol 2017;101:709–711. doi:10.1136/bjophthalmol-2016-309005 709 Downloaded from http://bjo.bmj.com/ on August 21, 2017 - Published by group.bmj.com Clinical science

Figure 1 Patient was found to have a large central diamond-shaped opening in the posterior capsule with associated posterior subcapsular cataract. Slit-beam photograph. Figure 3 A large ovoid opening in the posterior capsule with associated posterior subcapsular cataract.

Figure 2 Patient was found to have a large central diamond-shaped opening in the posterior capsule with associated posterior subcapsular cataract. Retroillumination photograph. Figure 4 A large ovoid opening in the posterior capsule with associated posterior subcapsular cataract. Retroillumination photograph. subsequent aggregation of the collagen fibrils that are able to scatter light. Most patients with symptomatic floaters typically present after the onset of a posterior vitreous detachment, as Nd:YAG laser vitreolysis, showed that only 38% of the eyes had the posterior cortical vitreous has a higher density of collagen a moderate improvement in their symptoms. fibrils, which are even more likely to scatter light. According to the Treatment Guidelines for the Ellex Ultra Q The incidence of symptomatic vitreous floaters is more than Reflex laser (available at Ellex.com), the recommendation is to likely to be under-reported and is likely more prevalent than start the treatment with a single pulse per shot and to set the previously thought.4 This has led to the pursuit of additional energy level at between 2–2.5 mJ. These guidelines also recom- treatment modalities for symptomatic floaters such as Nd:YAG mend that most treatments are performed at between 2.5– laser vitreolysis. Nd:YAG laser treatment for vitreous floaters 4.5 mJ energy and to use 500 as the upper limit of number of remain off-label and is not Food and Drug Administration shots per session.6 (FDA) approved. A literature search shows very few cases that The safety report of Nd:YAG laser vitreolysis is lacking as report about the effectiveness of Nd:YAG laser vitreolysis. The there are no clinical trials or large series available. In fact, there purported rates of successful resolution of floaters range are no reports of cataract development after Nd:YAG vitreolysis between 0% and 100%; however, both peer-reviewed literature in the literature. The Treatment Guidelines for the Ellex Ultra and assertions on web-based non-peer-reviewed laser vitreolysis QReflex laser mention traumatic cataract as a possible com- sites remain to be substantiated, and at present, only pars plana plication and suggest to avoid doing the laser initially in phakic vitrectomy has proven to be effective.4 The largest and most patients to avoid this risk while the technique is mastered6 recent series by Delaney et al5 of 39 eyes that underwent but does not mention incidence or specific cases. Other

710 Koo EH, et al. Br J Ophthalmol 2017;101:709–711. doi:10.1136/bjophthalmol-2016-309005 Downloaded from http://bjo.bmj.com/ on August 21, 2017 - Published by group.bmj.com Clinical science

complications from YAG vitreolysis have been reported. Cowan vitrectomy and enlargement of the posterior capsular rent in et al7 recently described three eyes that underwent Nd:YAG comparison with a pars plana approach. vitreolysis, which consequently developed open-angle glaucoma In conclusion, given the observation of this very serious and that was refractory to glaucoma laser treatment and maximal undesirable complication of secondary cataract with posterior medical therapy. capsular compromise, we recommend that the Nd:YAG laser We herein demonstrated that secondary cataract formation vitreolysis should probably be a contraindication (be it absolute accompanied by loss of integrity of the posterior capsule is a or relative) in phakic patients. complication of Nd:YAG vitreolysis for symptomatic floaters. It remains unclear in our cases as to whether the posterior Acknowledgements We would like to thank James Crowell for contributing the slit-lamp photographs. capsule rupture occurred due to the laser being focused directly onto the posterior capsule, or due to another mechanism dir- Contributors All the four listed authors meet all of the following criteria, as quoted per the International Committee of Medical Journal Editors (ICMJE) ectly related to laser energy or spot size, since we did not guidelines for authorship: substantial contributions to the conception or design perform the laser and did not have the laser parameters used in of the work; or the acquisition, analysis or interpretation of data for the work, these treatments. Loss of integrity of the posterior capsule poses drafting the work or revising it critically for important intellectual content, final a challenge during phacoemulsification, as capsular loss could approval of the version to be published and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of lead to a range of complications, including the lack of support any part of the work are appropriately investigated and resolved. for the intended posterior chamber intraocular lens. Competing interests None declared. As there are no prior guidelines, or ‘precedents’ in terms of approaching YAG-induced cataracts with posterior capsular Patient consent Obtained. rupture, the phacoemulsification was undertaken as a com- Provenance and peer review Not commissioned; externally peer reviewed. bined surgical approach with a vitreoretinal surgeon. Vitreous prolapse becomes almost inevitable in such scenarios. In both of these cases, the cataract was removed successfully with REFERENCES fi 1 Karahan E, Er D, Kaynak S. An overview of Nd:YAG laser capsulotomy. Med phacoemulsi cation without posterior migration of lens frag- Hypothesis Discov Innov Ophthalmol 2014;3:45–50. ments. Hydrodissection was purposefully omitted, and only 2 Del Priore LV, Robin AL, Pollack IP. Neodymium:YAG and argon laser iridotomy. hydrodelineation was performed to allow for the phacoemulsifi- Long-term follow-up in a prospective, randomized clinical trial. Ophthalmology cation of the cataract; we recommend this approach during 1998;95:1207–11. 3 Sohajda Z, Békési L, Berta A. In ophthalmology new possibilities for the use of Nd: the cataract extraction of a similar Nd:YAG-induced cataract YAG laser. Acta Chir Hung 1997;36:331–3. to prevent posterior migration of the lens fragments during 4 Milston R, Madigan MC, Sebag J. Vitreous floaters: Etiology, diagnostics, and phacoemulsification. management. Surv Ophthalmol 2016;61:211–27. Pars plana vitrectomy was performed by the vitreoretinal 5 Delaney YM, Oyinloye A, Benjamin L. Nd:YAG vitreolysis and pars plana vitrectomy: fl – surgeon for vitreous prolapse through the area of posterior cap- surgical treatment for vitreous oaters. Eye (Lond) 2002;16:21 6. 6 Treatment Guidelines for the Ellex Ultra Q Reflex™ laser. http://www.ellex.com/ sular defect. While the anterior segment surgeon can success- wp-content/uploads/sites/9/Ellex-YAGLaserVitreolysis-TreatmentGuidelines-IssueB- fully perform a limbal anterior vitrectomy (LAV) for vitreous electronic.pdf (accessed Jun 2016). prolapse, if the approach had been planned in conjunction with 7 Cowan LA, Khine KT, Chopra V, et al. Refractory open-angle glaucoma after the vitreoretinal surgeon, the vitreoretinal surgeon may perform neodymium-yttrium-aluminum-garnet laser lysis of vitreous floaters. Am J Ophthalmol 8 2015;159:138–43. the vitrectomy from a pars plana approach. Gillig and Springs 8 Gillig T, Springs C. Comparison of limbal versus pars plana subtotal anterior demonstrated that while LAVoffers the ease of a limbal incision, vitrectomy in managing posterior capsular rupture during phacoemulsification. Invest it was associated with longer surgical times, more extensive Ophthalmol Vis Sci 2006;47:631.

Koo EH, et al. Br J Ophthalmol 2017;101:709–711. doi:10.1136/bjophthalmol-2016-309005 711 Downloaded from http://bjo.bmj.com/ on August 21, 2017 - Published by group.bmj.com

Cataracts induced by neodymium− yttrium-aluminium-garnet laser lysis of vitreous floaters Ellen H Koo, Luis J Haddock, Namita Bhardwaj and Jorge A Fortun

Br J Ophthalmol 2017 101: 709-711 originally published online August 29, 2016 doi: 10.1136/bjophthalmol-2016-309005

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