Does Nd:YAG Capsulotomy Increase the Risk of Retinal Detachment? Andrzej Grzybowski, MD, PhD, MBA,* and Piotr Kanclerz, MD, PhD

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1 REVIEW ARTICLE Does Nd:YAG Capsulotomy Increase the Risk of Retinal Detachment? Andrzej Grzybowski, MD, PhD, MBA,* and Piotr Kanclerz, MD, PhD Abstract: Laser capsulotomy is accepted as a standard and effective treatment for posterior capsule opacification. It is generally believed that neodymium:yag (Nd:YAG) capsulotomy is related to an increased risk of retinal detachment (RD). The aim of this study was to evaluate the association between Nd:YAG capsulotomy and risk for developing RD. A PubMed and Medline search was conducted using the terms retinal detachment and Nd:YAG laser capsulotomy. Of the articles retrieved by this method, all publications in English and abstracts of non-english publications were reviewed. The literature analysis presented no convincing evidence supporting the association between Nd:YAG capsulotomy and increased risk for developing RD. The existing discrepancy between some studies might be related to inadequate group sizes, short observation period, and co-existing disorders. We also reviewed the possible risk factors for RD after Nd:YAG capsulotomy and found no association with preceding surgical approach, existing posterior vitreous detachment, and intraocular lens design. Myopic patients should be treated with caution, as it cannot be concluded that Nd:YAG capsulotomy does not increase RD rate in this cohort. Treatment energy should be as low as possible, as high energy levels and anterior hyaloid damage might increase the chance for RD development. Cataract surgery itself is a potential RD risk factor, particularly after intraoperative capsule complications. Key Words: cataract, lasers, solid-state Nd:YAG lasers, posterior capsulotomy, retinal detachment (Asia-Pac J Ophthalmol 2018;7: ) Posterior capsule opacification (PCO) is the most common complication of cataract surgery. It was reported in 25% of patients 2 years after cataract surgery and in up to 50% of eyes in a 5-year observation period. In clear lens exchange for high myopia PCO rates are even higher with 77.89% of patients requiring neodymium:yag (Nd:YAG) laser capsulotomy in a 7-year follow-up. 1,2 Advances in surgical techniques and intraocular lens (IOL) construction have reduced the PCO rate. 3 Several improvements From the *Department of Ophthalmology, University of Warmia and Mazury, Olsztyn; Institute for Research in Ophthalmology, Foundation for Ophthalmology Development, Poznan; and Department of Ophthalmology, Medical University of Gdańsk, Poland. Received for publication June 7, 2018; accepted July 9, A.G. reports grants, personal fees, and non-financial support from Bayer; nonfinancial support from Novartis; nonfinancial support from Alcon; nonfinancial support from Thea; personal fees and nonfinancial support from Valeant; and nonfinancial support from Santen, outside the submitted work. P.K. reports nonfinancial support from Visim. Reprints: Andrzej Grzybowski, MD, PhD, MBA, Gorczyczewskiego 2/3 Poznan, Poland. ae.grzybowski@gmail.com. Copyright 2018 by Asia Pacific Academy of Ophthalmology ISSN: DOI: /APO in IOL materials and designs have been made to reduce anterior capsular opacification and PCO. 4 One example is an increase of biocompatibility, determined by the relationship of the IOL with remaining lens epithelial cells within the capsular bag to inhibit their proliferation, migration, and epithelial-to-mesenchymal transition. The truncated, square edge of the acrylic IOLs causes a blockage of epithelial cells at the optic edge, preventing ingrowth over the posterior capsule. 5 However, a complete elimination of PCO has not been achieved yet, and with recent improvements the overall incidence of PCO was reported as less than 10%. 6 With that, the annual volume of cataract surgery is still increasing. Nd:YAG laser capsulotomy is accepted as a standard and effective treatment for PCO. One problem that needs to be taken into account is the presumed risk of retinal detachment (RD) related to YAG capsulotomy. The aim of this study was to evaluate the association between Nd:YAG capsulotomy and risk for developing RD. MATERIALS AND METHODS PubMed and Medline were the main resources used to conduct the medical literature search. An extensive search was performed to identify relevant articles concerning retinal detachment and Nd:YAG laser capsulotomy up to September 30, The following keywords were used in various combinations: posterior capsule opacification, capsulotomy, Nd:YAG, neodymium:yttrium-aluminum-garnet, laser, phacoemulsification, cataract surgery, cataract extraction, complications, retinal detachment, retinal break. The search identified 411 unique articles. Of the studies retrieved by this method, we reviewed all publications in English and abstracts of non-english publications. The reference lists of the analyzed articles were also considered as a potential source of information. We included publications that described the incidence, etiopathogenesis, RD risks, and PCO treatment. Emphasis was placed on articles published since the review by Karahan et al, 7 but we included earlier articles that provided a more comprehensive understanding of PCO. Studies were critically reviewed to create an overview and guidance for further search. No attempts to discover unpublished data were made. In addition to the Medline and PubMed searches, selected chapters from relevant textbooks were included. RESULTS Association Between Nd:YAG Capsulotomy and Development of RD Uncomplicated cataract extraction itself is assumed to manifest a low risk of postoperative RD, particularly after intraoperative posterior capsule tear Other risk factors include Asia-Pacific Journal of Ophthalmology Volume 7, Number 5, September/October

2 Grzybowski and Kanclerz Asia-Pacific Journal of Ophthalmology Volume 7, Number 5, September/October 2018 longer axial length, myopia, history of RD or lattice degeneration, younger age, and ocular trauma after cataract surgery. 11,12 Several studies did not present an association between the RD risk and Nd:YAG capsulotomy, both after extracapsular cataract extraction () 13 and phacoemulsification cataract surgery (PCS). 5,12,14 16 Articles demonstrating the prevalence of RD after Nd:YAG capsulotomy are presented in Table 1. Min and associates 16 reported no RDs in 77 eyes after YAG capsulotomy within the observation period of 15 months. In another study, 1 out of 526 eyes after Nd:YAG capsulotomy developed RD. 14 The follow-up of the cohort was 21 months, and the exact relationship between the 2 events was presented as unclear. Powell and Olson 15 claim that the RD rate after uncomplicated PCS (0.75%) is similar to that of phacoemulsification and Nd:YAG laser capsulotomy (0.82%). Their study comprised 1092 patients (1168 eyes) with a minimum of 12-month follow-up, and posterior capsule rupture with anterior vitrectomy during PCS was the only risk factor for RD. Nielsen and Naeser 13 found no association between RD and YAG capsulotomy in a 39-month observation period. Of 1726 consecutive cases, RD developed in only 1 of 345 eyes after YAG capsulotomy; these were not statistically significant. In a study by Van Westenbrugge and others, 17 2 of the 198 YAG cases (1.0%) and 1 of the 198 eyes after cataract surgery (0.5%) developed RD, with no significant difference. Shah et al 18 claim that the risk for RD after Nd:YAG capsulotomy is low, although rises if a surgical discission of the posterior capsule is performed. It should be underlined that the cumulative risk for pseudophakic RD continues to increase for years after cataract surgery. 19 On the other hand, Ambler and Constable 20 presented an elevated risk of developing RD after Nd:YAG capsulotomy in 6 months of follow-up. The study assessed 862 patients undergoing Nd:YAG capsulotomy after with or without IOL implantation. It was noted that 38% of RDs occurred within the first 2 months and 69% within the first 6 months after capsulotomy. Wesolosky and others 21 reported that the cumulative risk for retinal tear or detachment at 3, 6, 9, and 12 months was 0.21%, 0.30%, 0.36%, and 0.43% and 0.60%, 0.96%, 1.19%, and 1.39%, respectively. It was concluded that there was an increased risk for RD in the first 5 months after Nd:YAG with a return to a baseline plateau thereafter. However, as only billing records were analyzed, the methodology of this study might be questioned. Possible Risk Factors for Retinal Detachment After Nd:YAG Capsulotomy Anterior Hyaloid Damage and Higher Energy Levels Özyol et al 22 conducted a cross-sectional study on 277 pseudophakic eyes of 216 patients treated with Nd:YAG laser capsulotomy for PCO. The anterior hyaloid damage (AHD), AHDrelated Nd:YAG laser parameters, and retinal complications were assessed. A localized retinal detachment occurred in 1 eye and the risk of retinal complications in patients with AHD was 12.7 times higher than in patients without AHD. It was noted that high pulse number, pulse energy, and total energy were risk factors for AHD. The basic power settings of Nd:YAG laser and treatment energy levels are proportional to PCO thickness and density. 23 In the study by Bhargava et al, 24 patients with fibromembranous and fibrous subtypes of PCO required higher treatment energy compared with membranous PCO (pearl form). In their study, patients that developed RD had longer ocular axial length and were treated with higher laser energy (77.7 mj, compared with 43.4 mj in eyes without RD). 24 However, Steinert et al 25 reported no correlation between RD risk and the numbers of laser pulses and energy delivered. Longer Axial Length Dardenne and collaborators 26 reported that the highest risk for RD after YAG capsulotomy (12.3%) is manifested in eyes with an axial length of 26.1 mm to 28.0 mm. Rickman-Barger et al 27 revealed that patients with axial myopia of at least mm, lattice degeneration, or previous RD manifest increased risk of RD after Nd:YAG capsulotomy. Olsen and Olson 5 noted that eyes with axial lengths of 24 mm or longer had an elevated risk for RD. Koch and others 28 described elevated risk of retinal tear or detachment in eyes with axial myopia, preexisting vitreoretinal disease, male, younger age, vitreous prolapse into the anterior chamber or spontaneous extension of capsulotomy. Ranta and associates 29 reported that the hazard ratio of RD after Nd:YAG capsulotomy increases linearly with each millimeter of axial length, and 25 millimeters was the strongest cut-off. Surgical Approach In general the surgical approach influences the rate of postoperative RD, with PCS having a lower risk of developing RD than intracapsular cataract extraction and. 5 Similarly, the same study revealed that RD rates after Nd:YAG capsulotomy were lower after PCS than (3.1% versus 1.0%). 5 This was not confirmed by Dardenne and collaborators, 26 with similar RD rates in and PCS (l.64% versus 1.59%, respectively). Other Factors As posterior vitreous detachment (PVD) contributes to alterations of the vitreous base and leads to a retinal tear or detachment, Sheard and coworkers 30 analyzed the association between Nd:YAG capsulotomy and new PVD. At baseline the prevalence of PVD was higher in pseudophakic than in phakic eyes. However, after a 12 month follow-up the incidence of new PVD in phakic eyes with no treatment, and pseudophakic eyes with or without Nd:YAG capsulotomy was 17.1%, 17.9%, and 11.4%, which was not statistically significant. Smith and Aleman 31 reported a trend towards a reduced rate of RD with high A-constant IOLs, with no statistical significance. It was presumed that IOLs having rigid haptics, with an A constant greater than or equal to 118.5, show a higher degree of posterior angulation and rest more posteriorly in the eye. Therefore, anterior vitreous support is reestablished when the crystalline lens is removed and this design may help prevent excessive vitreoretinal traction that could lead to RD. Fechner 32 claimed that the IOL configuration significantly influences the risk for RD after capsulotomy. In a lens with its convexity directed toward the retina (plano-convex configuration) Nd:YAG laser capsulotomy would not cause a deprivation of the barrier between the anterior and posterior segments of the eye. In these cases the Nd:YAG capsulotomy causes an optical opening, not permitting fluid to pass through it, in contrast to the eye with a convexplano IOL where fluid can often be seen streaming through the new YAG opening. The authors expected that the risk of this complication could be reduced by implanting a plano-convex intraocular lens Asia-Pacific Academy of Ophthalmology

3 Asia-Pacific Journal of Ophthalmology Volume 7, Number 5, September/October 2018 Nd:YAG Capsulotomy Increases Risk of RD? TABLE 1. Incidence of Retinal Detachment After YAG Capsulotomy, Sorted by Surgical Approach and Publication Date Preceding Cataract Study Year Procedure RD Rate (Average Follow-Up, If Presented) Risk Factors Conclusions Ambler and Constable 20 Koch et al 28 Rickman-Barger et al 27 Steinert et al 25 Javitt et al 34 Nielsen and Naeser 13 Tielsch et al 9 Keates et al 35 Shah et al 18 Ficker et al 33 Dardenne et al 26 Smith et al 31 Olsen and Olson or or phaco or phaco 1.4%: 12/862 (6 mos) 1.6%: 2/121 (1 y) 3.5%: 2/55 (2 y) 3.6%: 13/366 (17.9 mos) 0.89%: 8/ %, based on 13,709 records (3 y) 0.29%: 1/345 eyes (1.78 ± 1.08 y) Nd:YAG laser capsulotomy increases the risk of RD after (odds ratio, 3.8) 0.4%: 2/526 (6 mos) 0.17%: 5/2808 eyes 2%: 12 eyes 1.6%: 16 of 1000 eyes 0% of 103 patients with IOLs having an A constant of or greater 4.8% of 42 patients with IOLs having an A constant less than (1 y) 3.1% after Nd:YAG capsulotomy and 1.0% after No cases of RD and Nd:YAG capsulotomy and phacoemulsification First 2 months after capsulotomy Increased risk for retinal complications (RD or retinal tear) in axial myopia; preexisting vitreoretinal disease; male; younger age; vitreous prolapse into the anterior chamber; spontaneous extension of capsulotomy Combination of the following factors: male with axial myopia ( mm), a history of lattice degeneration, or a history of RD in the fellow eye 3.9-fold increase in the risk of retinal break or detachment among those who underwent capsulotomy Axial length of 26.1 mm to 28.0 mm Low A constant The increase in the prevalence of RD after Nd:YAG capsulotomy is most likely due to changes in the vitreous which occur when the posterior capsule is no longer intact. Patients undergoing YAG capsulotomy, especially those with axial myopia, should be advised of the risk of retinal complications associated with this procedure and informed of the symptoms of RD or retinal tears. Predisposing risk factors for RD should be taken into account when evaluating a candidate for YAG laser posterior capsulotomy. Patients undergoing Nd:YAG laser capsulotomy require medical observation to detect and treat these serious complications. There is a statistically significant increase in the risk of RD or break in those patients who undergo capsulotomy after cataract extraction. Therefore, capsulotomy should be deferred until the patient s impairment caused by capsular opacification warrants the increased risk of retinal complications associated with performance of capsulotomy. No causal relationship between YAG laser capsulotomy and subsequent RD. Cumulative complication rates in the laser-treated population were very low. Low risk of RD. All patients with disturbance of the anterior vitreous and vitreous prolapse in anterior chamber should be followed closely. No greater risk of RD associated with Nd:YAG laser capsulotomy than with surgical discission. The increase in the incidence of RD within a relatively short time after capsulotomy supports the thesis of an increasing risk of RD after the opening of the posterior capsule. To achieve a 90% confidence level it is necessary to have 450 patients in each group to compare the data. The surgical approach in cataract surgery affects Nd:YAG and RD rates. Continued on next page 2018 Asia-Pacific Academy of Ophthalmology 341

4 Grzybowski and Kanclerz Asia-Pacific Journal of Ophthalmology Volume 7, Number 5, September/October 2018 TABLE 1. (Continued) Preceding Cataract Study Year Procedure RD Rate (Average Follow-Up, If Presented) Risk Factors Conclusions Ranta et al Özyol et al Bhargava et al Wesolosky et al Van Westenbrugge 1992 et al 17 Powell and Olson Jahn et al Min et al or phaco 2% in 341 patients (5 y) 1/277 (1 wk) 11/474 eyes (22.9 ± 4.5 mos) 0.6%: of 92,654 discrete billing records yielding 73,586 ocular procedures (3 mos) 0.96% (6 mos) 1.19% (9 mos) 1.39% (12 mos) 1.0%: 2/198 (24.2 mos) 0.82%: 2/244 (at least 12 mos) 0%: 0/483 (6 mos) 0%: 0/407 (12 mos) 0.5%: 1/213 (24 mos) 0/77 eyes of 76 patients (15.8 mos) The axial length, whether modeled as a continuous variable [hazard ratio (HR) 1.51 for each mm increase] or categorized using 25.0 mm as a cutoff (HR 11.1). Other risk factors predicted RD after Nd:YAG laser posterior capsulotomy. High pulse number, pulse energy, and total energy (for retinal complications, including ME and RD) Higher axial length Higher mean total laser energy Time after Nd:YAG capsulotomy Preexisting retinal tear Close follow-up and prophylactic photocoagulation of preexisting retinal breaks are worth considering, especially in high-risk eyes. Anterior hyaloid face integrity should be considered for YAG laser-related retinal complications. Type of PCO significantly influenced laser energy levels required for capsulotomy, whereas IOL biomaterial and fixation did not. An increased risk for RD in the first 5 months after Nd:YAG. Rates of RD were very low among YAG cases and controls, not significantly different. The rate of RD after uncomplicated phacoemulsification was not statistically different from the rate after phacoemulsification and Nd:YAG laser capsulotomy. RD after Nd:YAG capsulotomy for PCO was rare in eyes that had previous uneventful phacoemulsification and IOL implantation. The exact relationship between the 2 events remains to be established. ME indicates macular edema; phaco, phacoemulsification Asia-Pacific Academy of Ophthalmology

5 Asia-Pacific Journal of Ophthalmology Volume 7, Number 5, September/October 2018 Nd:YAG Capsulotomy Increases Risk of RD? DISCUSSION It is generally believed that Nd:YAG capsulotomy is related to an increased risk of RD. 20 It was speculated that specific damage caused by the Nd:YAG laser in an eye with an underlying predisposition (eg, myopia or aphakic state) might result in RD development. 33 The possible mechanisms by which plasmas are believed to produce damage are ionization, vaporization, cavitation, mechanical stress waves, impelled particles, electromagnetic field stress, and light emission. It was also argued that the loss of the physical barrier provided by the posterior capsule might result in retinal breaks and subsequent RD weeks or even months after the procedure. 11 Chemical changes in the vitreous itself, particularly the loss of hyaluronic acid, liquefaction, or chemical inducement of a vitreous detachment may contribute to alterations of the vitreous base. It is unlikely that any single mechanism alone can induce vitreous changes sufficient to initiate the development of retinal breaks or RD. The current analysis presented no convincing evidence supporting the association between Nd:YAG capsulotomy and increased risk for developing RD. The existing discrepancy between some studies might be associated with inadequate group sizes, short observation period, and coexisting disorders. We also reviewed the possible risk factors for RD after Nd:YAG capsulotomy and found no association with preceding surgical approach, existing PVD, and IOL design. On the other hand, higher energy levels and anterior hyaloid damage might be associated with an increased risk of developing RD after Nd:YAG capsulotomy, particularly in eyes with long axial length. CONCLUSIONS The risk of developing RD after Nd:YAG capsulotomy is low, and based on the current evidence it is unlikely that Nd:YAG capsulotomy increases RD incidence. Myopic patients with longer ocular axial length should be treated with caution, as it cannot be concluded that Nd:YAG capsulotomy does not increase RD rates in this cohort. Treatment energy should be as low as possible, as high energy levels and anterior hyaloid damage might increase the chance for RD development. Cataract surgery itself is a potential risk factor for RD, particularly after intraoperative capsule complications. REFERENCES 1. Colin J, Robinet A, Cochener B. Retinal detachment after clear lens extraction for high myopia: seven-year follow-up. Ophthalmology. 1999; 106: ; discussion Fernández-Vega L, Alfonso JF, Villacampa T. Clear lens extraction for the correction of high myopia. Ophthalmology. 2003;110: Awasthi N, Guo S, Wagner BJ. Posterior capsular opacification: a problem reduced but not yet eradicated. Arch Ophthalmol. 2009;127: Werner L. Biocompatibility of intraocular lens materials. Curr Opin Ophthalmol. 2008;19: Olsen G, Olson RJ. 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6 Grzybowski and Kanclerz Asia-Pacific Journal of Ophthalmology Volume 7, Number 5, September/October 2018 complications after neodymium-yag laser posterior capsulotomy. Arch Ophthalmol. 1989;107: 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: Sheard RM, Goodburn SF, Comer MB, et al. Posterior vitreous detachment after neodymium:yag laser posterior capsulotomy. J Cataract Refract Surg. 2003;29: Smith SG, Gregory Smith S, Aleman CT. Reduced incidence of retinal detachment post-yag capsulotomy with high A-constant IOLs. Eur J Implant Refract Surg. 1995;7: Fechner PU. Retinal detachment after neodymium:yag laser posterior capsulotomy. Am J Ophthalmol. 1989;108: Ficker LA, Vickers S, Capon MR, et al. Retinal detachment following Nd:YAG posterior capsulotomy. Eye (Lond). 1987;1(Pt 1): Javitt JC, Tielsch JM, Canner JK, et al. National outcomes of cataract extraction. Increased risk of retinal complications associated with Nd:YAG laser capsulotomy. The Cataract Patient Outcomes Research Team. Ophthalmology. 1992;99: ; discussion Keates RH, Steinert RF, Puliafito CA, et al. Long-term follow-up of Nd:YAG laser posterior capsulotomy. J Am Intraocul Implant Soc. 1984;10: Asia-Pacific Academy of Ophthalmology