YAG Laser Capsulotomy: The Solution for Posterior Capsular Opacification

Written by Dr Osama Bahsas Zaky
Updated on October 26, 2021

Cataract Surgery.

What Is Posterior Capsular Opacification (PCO)?

Signs and Symptoms of Posterior Capsular Opacity.

Risk Factors for Developing Posterior Capsular Opacification.

YAG Laser Capsulotomy.

The Procedure.

Side Effects and Recovery.

Complications from Laser Capsulotomy.

How much does YAG Laser Capsulotomy Cost?

Posterior capsular opacification (PCO), better known as “secondary cataract,” is a complication that can occur after cataract surgery.

With posterior capsule opacity, you may feel like your cataract has returned. Although it’s essential to make clear that a genuine cataract cannot actually reappear after surgery.

Posterior subcapsular cataract is a cloudy membrane that forms just behind the intraocular lens implant.

However, you can have your vision clear again with a quick, effective, and painless procedure called YAG laser capsulotomy.

Cataract Surgery

A cataract is when the natural lens in your eye gets cloudy. This normally occurs as part of the aging process. However, there are types of cataracts that may develop earlier in life, including congenital cataracts.

During cataract surgery, your eye’s natural lens, which has become cloudy, is replaced by a clear artificial lens known as an intraocular lens (IOL). This new artificial lens is placed inside your lens capsule, the thin membrane “bag” that originally supported your natural lens.

In theory, your lens capsule is clear and should remain as such following your cataract surgery.

What Is Posterior Capsular Opacification (PCO)?

Posterior capsule opacification (PCO) is the most common complication of cataract surgery.

During the phacoemulsification, the surgeon opens a portion of the anterior capsule (capsulorhexis) to remove the cloudy lens inside your eye. Then, he places a synthetic lens into the intact capsular bag.

PCO occurs when residual lens epithelial cells (LECs) on the residual anterior capsule migrate and grow over the back (posterior capsule), causing it to thicken gradually.

The membrane also becomes hazy and cloudy. This means that light is less able to travel through to the retina (at the back of your eye), causing adverse effects on your vision.

Sight can become blurred and cloudy.

Posterior capsular opacity presents in two forms, fibrous and pearl (also called proliferative).

Fibrous PCO presents as wrinkles and folds on the posterior capsule. It is located at the site of fusion of the anterior and posterior capsules.
Pearl PCO accounts for the majority of vision loss PCO cases. It is composed of normal LECs that occupy the equatorial (middle) lens region. Microscopic examination shows clusters of swollen and opacified LECs called bladder or Wedl cells.

If you had cataract surgery in both eyes, posterior capsular opacification could affect both of them. But each eye may be affected at different times.

A better understanding of the pathophysiology of PCO has led to modifications in surgical techniques and intraocular lens designs to decrease its development.

Certain lenses used in cataract surgery may lower this risk and the need for laser capsulotomy later.

Signs and Symptoms of Posterior Capsular Opacity

Posterior capsular opacification can cause significant visual symptoms, especially when it involves the central visual axis.

The onset of blurry vision or visual problems after cataract surgery should prompt your eye doctor to look for signs of PCO.

The diagnosis of posterior subcapsular cataract is based on history and slit-lamp examination of the eye. Most patients can present it a few months up to several years after uneventful cataract surgery.

You may experience gradual blurred or decreased vision, glare, halos, light sensitivity, impaired contrast sensitivity, or difficulty reading.

Slit-lamp examination reveals a semi-opaque membrane on the posterior capsule.

Your doctor may also see notable signs, including:

Elschnig’s pearls (pearl-type PCO): clusters of residual LECs that look like perfectly round, clear “pearls” shinning on retro-illumination.
Soemmering rings: LEC rings that form between the posterior capsule and the edges of the residual anterior capsule. These are often too peripheral to cause visual disturbances, but they could cause glare and visual loss.

Risk Factors for Developing Posterior Capsular Opacification

Posterior capsular opacification develops in 20-50% of patients within 2 to 5 years of cataract surgery.

Although PCO is quite common, there are some reasons why you may be more likely to develop it. The pathophysiology of posterior capsular opacity is multifactorial.

Children have a significantly higher incidence and earlier onset of PCO, with the added potential for associated lazy eye (amblyopia).

So, the younger you are when you have cataract surgery, the more likely you will develop posterior subcapsular cataract.

This complication is also more common when there is inflammation (swelling) in your eye, called uveitis.

Other risk factors are medical conditions, such as diabetes, myotonic dystrophy, retinitis pigmentosa, and traumatic cataract. However, it’s not unusual to develop posterior capsular opacity even if you don’t have any of these conditions.

There are also special considerations during surgery.

With certain cataracts, such as significant posterior subcapsular (affecting the back of the lens), there can be a residual plaque of cells on the posterior capsule after the lens material is removed.

The surgeon can gently polish this plaque to a certain degree without the risk of rupturing the capsule. However, if not possible, you most likely will present with posterior capsular opacification sooner or later.

Hence, patients with subcapsular cataracts will definitely require YAG laser capsulotomy for removal.

YAG Laser Capsulotomy

Laser treatment for PCO is performed using a very low-energy laser called neodymium: YAG “Nd: YAG,” sometimes referred to as just “YAG.”

The YAG laser can delicately make a hole on the thickened lens capsule without damaging other parts of your eye. Because the laser can travel through the cornea without cutting it, there is no risk of infection from this treatment.

The procedure is a quick, painless, and effective treatment for posterior subcapsular cataract.

Delaying laser capsulotomy is unlikely to cause long-term effects to your eye or make the procedure more difficult. However, you should consider this procedure if PCO seriously affects your vision and quality of life.

You will generally only need laser treatment for PCO once.

Very rarely, patients may develop re-opacification of the posterior capsule. Also, the opening in the capsule made by the first laser treatment could shrink, causing PCO to come back.

If this happens, it is possible to safely have further laser treatment if needed. Also, if you have PCO in both eyes, it is possible to have laser capsulotomy for both on the same day.

Laser capsulotomy is the preferred treatment for posterior capsular opacification in older children and adults. Rarely, it is treated with surgical capsulotomy.

The Procedure

On the day of the procedure, your eye doctor will put some eye drops to dilate (widen) your pupil. These will make your vision blurrier and sensitive to light.

Sometimes, the ophthalmologist may use a contact lens to help keep your eye in the right position.

If this is needed, you will also be given anaesthetic eye drops to numb the front of your eye. So, the procedure will be painless and without discomfort.

Once your pupil is dilated (about 10-20 minutes), you will be asked to sit and put your chin on the bar/frame of the machine. This will keep your head and eye still while the ophthalmologist uses the laser.

The eye doctor focuses the laser exactly onto the back of the lens capsule to cut a small circle-shaped area.

This leaves some of the capsule to hold your artificial lens in place (like a cuff around the lens). But, enough tissue is removed in the middle section to allow the light to pass freely to the retina.

The laser uses a wavelength of light that cannot be seen. However, you may notice a red light, which helps the eye doctor focus the laser beam.

Each laser pulse is over in a fraction of a second. You may see flashing lights or hear a clicking sound as the laser works. Most patients say that they feel a slight “pop” in the eye.

Yag laser posterior capsulotomy is an outpatient procedure performed in the consulting room. It lasts about ten minutes. Quick and easy!

How are the Side Effects and Recovery from a YAG Laser Capsulotomy?

If a contact lens was used to steady your eye during the procedure, you might feel a little discomfort afterward, but this should wear off in no time.

You may need to use special eye drops for one week after the surgery. Your ophthalmologist will let you know if this medication is necessary.

Since this treatment does not require any cuts or stitches, you will be able to return to your normal activities straight away.

However, immediately after the laser treatment, your pupils will still be dilated and have blurry vision for a few hours afterward. So, you will need someone to drive you home.

You should avoid:

touching or rubbing your eyes
putting any bath products in your eyes
swimming for at least two weeks
Contact sports for a month

Most patients see an improvement in their vision within 24 hours. But it may take a few days for your sight to become clear again. Also, you may notice “floaters” after the procedure.

Floaters are a harmless cluster of cells that move freely inside the vitreous humor (a jelly-like substance inside the eye).

They can seem like black spots, dots, cobwebs, or lines that move around in your field of vision. These are due to the membrane breaking up following the laser capsulotomy and usually improve with time, becoming less noticeable.

After YAG laser treatment, your sight should go back to the way it was before PCO developed, provided no other complications arise.

What are the Possible Complications from YAG Laser Capsulotomy?

For some patients, laser treatment for posterior capsular opacification can cause short-term increased eye pressure. This can be an issue if you already have glaucoma, as your eye pressure may already be higher than normal.

If your ophthalmologist is concerned about this, he will check your eye pressure soon after the treatment. And if your eye pressure has increased, you will receive eye drops or tablets to lower it down.

The treatment can rarely cause retinal detachment, where the nerve layer (retina) lifts from the back of your eye. This can happen days, weeks, or months after capsulotomy. It is more likely if you are very short-sighted.

Remember that these risks are extremely rare complications of the YAG laser treatment. The majority of patients get excellent outcomes without experiencing any issues.

How much does YAG Laser Capsulotomy cost?

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