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EFFECTIVE STRATEGIES FOR PREVENTION OF COMPLICATIONS
AFTER ND: YAG-LASER CAPSULOTOMY OF SECONDARY
CATARACT (LITERATURE REVIEW)
Nigmatjonova Nozima
Doctor of ophthalmology in the private clinic "Nazar"
Oralov Behruz Abdukarimovich
PhD, Assistant of the Department of Ophthalmology,
Tashkent Medical Academy
https://doi.org/10.5281/zenodo.15575140
Annotation.
The aim of the review was to systematize the current data on the medical
management of patients after Nd:YAG laser capsulotomy for secondary cataract
and to identify optimal strategies for the prevention of complications. A
literature search was conducted in PubMed, Scopus, and CyberLeninka
databases for 2014-2024 using the keywords "Nd:YAG capsulotomy,"
"secondary cataract," "intraocular pressure spike," "cystoid macular edema," and
"anti-inflammatory therapy." Thirty- four studies meeting the selection criteria
were included in the analysis. The results indicate that the combined use of
hypotensive agents (β-blockers, carboanhydrase inhibitors, rock inhibitors) and
prolonged anti-inflammatory therapy (topical GCS ± NSAIDs) reduces the
incidence of intraocular pressure spike by more than 70% and reduces the risk
of cystoid macular edema development to 1-2%. Low-energy laser mode (≤35 μJ,
≤25 pulses) additionally reduces the probability of damage to IOL and
vitreomacular structures. Individualization of treatment taking into account
biometric parameters of the eye, total laser energy and risk factors (myopia,
pseudoexfoliation, early macular changes) provides the best functional
outcomes and forms the prerequisites for standardization of clinical
recommendations.
Keywords:
secondary cataract, Nd:YAG capsulotomy, intraocular pressure,
anti-inflammatory therapy, cystic macular edema, rock inhibitors.
Relevance.
The relevance of the study is determined by the increasing prevalence of
secondary cataract, which forms in a significant proportion of patients within
the first five years after cataract surgery.
Nd:YAG-laser capsulotomy has long been recognized as the optimal method
for the elimination of posterior capsular opacification, but even with perfect
equipment, the procedure is associated with the risk of a whole range of
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complications: short-term or persistent increase in intraocular pressure,
development of iridocyclitis, cystic macular edema, rupture of the posterior
hyaloid membrane, intraocular lens movement and, rarely, retinal detachment.
In the conditions of increasing requirements to the quality of visual
rehabilitation and to the safety of outpatient procedures, optimization of
medication support after Nd:YAG capsulotomy, which allows minimizing
inflammatory and ophthalmotonal fluctuations, preventing late retinal
complications and ensuring maximum visual acuity in the shortest possible time,
is of particular importance.
At the same time, clinical practice still lacks unified schemes of patient
management, and the prescription of topical glucocorticosteroids, nonsteroidal
anti- inflammatory drugs and hypotensive drugs is often empirical, which
determines the variability of outcomes.
In addition, the heterogeneity of the results of randomized and
observational studies creates the need for a systematic rethinking of the
available data on the prevention of the discussed complications in order to
develop evidence-based clinical recommendations. Together, these factors
determine the scientific and practical significance of the study aimed at
improving the postoperative management of patients undergoing laser
capsulotomy.
The aim of the study is to summarize and analyze the current scientific data
on the methods of medical management of patients after Nd:YAG-laser
capsulotomy in order to increase the effectiveness of inflammatory processes
prevention and improve the functional results of secondary cataract treatment.
Materials and methods of the study.
To prepare the review article, we conducted a targeted search of scientific
literature in PubMed, Scopus, CyberLeninka and other authoritative sources for
the period 2014-2024. Original studies, clinical reviews, and guidelines on the
management of patients after Nd:YAG capsulotomy were examined. The
selection was based on keywords in Russian and English, with a focus on
inflammatory and ophthalmotonal complications, as well as methods of their
prevention. The selected publications were analyzed, systematized, and critically
reviewed to identify effective treatment regimens and modern approaches to
postprocedural therapy.Keywords and their combinations in English and
Russian included "Nd:YAG capsulotomy", "secondary cataract", "intraocular
pressure spike", "cystoid macular edema", "anti-inflammatory therapy", "post-
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laser management", "laser capsulotomy", "secondary cataract", "inflammation",
"hypotensive prophylaxis".
Results of the study
.
The results of the review analysis of scientific literature showed that the
most frequent complications after Nd:YAG-laser capsulotomy are short-term
increase in intraocular pressure (IOP), inflammatory reaction in the anterior
segment of the eye and, in some cases, development of cystic macular edema.
According to Ji-Ping Cai et al. data, prophylactic injection of 0.5% timolol 1 hour
before the procedure and within 3 days after it allowed to significantly reduce
the frequency of IOP elevation in patients with normotension [7 ]. In a
randomized study O. Artunay et al. found that bimatoprost 0.03% was more
effective than brimonidine 0.2% in preventing ophthalmotonus surges in
patients with a history of glaucoma [4 ].
According to C. Sharma and colleagues, the use of a fixed combination of
bimatoprost and timolol decreased IOP more stable and prolonged compared to
monotherapy [16 ]. Regarding inflammatory complications such as iridocyclitis
and cystic macular edema, regimens including combinations of topical
glucocorticosteroids and nonsteroidal anti-inflammatory drugs were most
effective. A study published in the Korean Journal of Ophthalmology compared
the severity of inflammation in patients receiving betamethasone 0.1%,
nepafenac 0.1%, and a control group; on days 7-14 after capsulotomy, the
minimum level of inflammation was observed in the combination therapy group
[ ].6
The data of a large retrospective study including more than 1200
procedures showed that the risk of retinal detachment is about 0.16% and the
incidence of CMR is less than 0.1%, with higher rates in patients with high
degree myopia and pseudoexfoliative syndrome. In the Russian literature,
similar data were confirmed in a paper published in the journal Vestnik
Ophthalmologii, where optical coherence tomography data showed no clinically
significant increase in central macular thickness after Nd:YAG capsulotomy [ ].2
According to cumulative data, the use of hypotensive drugs before and after
laser intervention reduces the risk of acute IOP elevation in more than 70% of
cases, and the use of topical NSAIDs and GCS reduces the severity of
inflammation and the risk of macular complications. Introduction of fixed
combinations of drugs and prolonged therapy (up to 2-4 weeks) increases
patient adherence to treatment and improves functional outcomes.
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Additional analysis of scientific publications allowed us to expand the
understanding of therapeutic approaches after Nd:YAG capsulotomy and
confirm the clinical significance of early medical intervention. In a study by
Keates C.M. et al. it was found that even in the absence of a history of glaucoma,
about 6.6% of patients demonstrated an intraocular pressure rise of 5 mm Hg or
higher within 4 hours after the procedure, which justifies prophylactic
administration of hypotensive agents in the "before-and-after" regimen [8 ].
A meta-review published in the Journal of Current Ophthalmology analyzed
the data on late complications of Nd:YAG capsulotomy: the most frequent of
them were cystic macular edema (up to 2.2%) and posterior IOL dislocation (up
to 0.55%) in patients with loose fixation of the lens in the capsular bag, which
requires dynamic follow-up for at least 1 month [ ].15
In a clinical trial by Patel C.K. et al. the use of nonsteroidal anti-
inflammatory drugs alone (0.1% bromfenac twice daily) for 3 weeks after
capsulotomy reduced the risk of macular edema in at-risk patients without the
need to prescribe corticosteroids, especially in those with contraindications to
steroids [ ].13
In addition, the study by Lim J.M. and colleagues noted that patients who
received combined therapy with NSAIDs and GCS demonstrated faster recovery
of visual functions and stability of visual axis against the background of reduced
inflammatory cellular reaction in the anterior chamber as early as 3-5 days after
the intervention [ ].10
A Russian study conducted on the basis of the ophthalmologic center in
Kazan demonstrated that the inclusion of the hypotensive drug dorzolamide in
the therapy reduces the incidence of IOP elevation in the early postoperative
period from 12.7% to 4.1%, especially in patients with borderline tone [ ].1
The accumulated data confirm that multicomponent therapy (antiglaucoma
drugs, GCS and NSAIDs) prescribed for 5-14 days after Nd:YAG capsulotomy
provides reliable prevention of ophthalmotonal and inflammatory
complications, especially in patients with an aggravated history or structural
features of the eyeball. Such a tactic contributes to rapid recovery of visual
functions, reduces the number of repeated visits and improves the quality of life
of patients.
In addition to the previously reviewed data, modern studies emphasize the
importance of individualization of therapy depending on the initial state of the
eye, features of the intraocular lens and the time elapsed after primary cataract
surgery. Thus, in the study of Mehdizadeh M. et al. the role of the thickness and
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density of the posterior lens capsule before capsulotomy was analyzed - in
patients with dense fibrous capsule the probability of a marked inflammatory
reaction after Nd:YAG intervention was higher, especially when using energies
above 60 μJ [ ].11
Of particular interest are the works devoted to the use of prolonged-acting
drugs. Alió J.L. and colleagues discuss the use of subconjunctival injections of
triamcinolone as an alternative to long-term topical application of
glucocorticosteroids. This approach achieved comparable control of
inflammation with fewer instillations and better adherence in elderly patients [
].3
Interesting data are presented by Singh R. et al. who compared the efficacy
of a single dose of fixation antiglaucoma drug (brinzolamide+timolol) 1 hour
before the procedure and a traditional 3-day hypotensive regimen. It turned out
that in patients with baseline normal IOP the single dose was equally effective in
preventing ophthalmotonal peak, which makes such a strategy preferable in low
compliance [
].17
In addition, the study by Cheema S.S. et al. draws attention to the
importance of macular profile assessment before and after the intervention
using spectral OCT. In patients with the presence of subtle subclinical macular
edema before capsulotomy, the frequency of development of clinically
significant CMR increased
2.4 times, which requires differentiated prescription of anti-inflammatory
drugs before laser treatment [ ].5
Thus, modern approaches to treatment after Nd:YAG capsulotomy include
not only the standard use of hypotensive and anti-inflammatory therapy, but
also the assessment of anatomo-functional features of each patient, which allows
us to move from universal schemes to personalized prevention of complications.
This is especially important for risk groups - patients with high myopic status,
pseudoexfoliative syndrome, early signs of maculopathy or unstable IOL fixation.
An additional literature search revealed new data expanding the
understanding of ways to minimize complications after Nd:YAG capsulotomy. In
a prospective comparative study, B. Takkar et al. showed that the use of low-
energy mode (≤35 μJ per pulse) while maintaining the total number of pulses
≤25 statistically significantly reduces the incidence of damage to the optical zone
of intraocular lens (0.9% vs. 6.4% at standard energy) without increasing the
residual turbidity of the capsule [ ].18
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Prevention of cystic macular edema remains a subject of intense scrutiny. In
a randomized controlled trial M. Reibaldi et al. topical nepafenac 0.1% three
times a day for four weeks after the procedure reduced the incidence of CME to
1.2%, while in the dexamethasone 0.1% group this figure was 4.8% [ ].14
A large registry-based swept-source OCT analysis of 18,642 procedures
demonstrated that late retinal detachment occurred in 0.21% of cases and was
significantly more common in patients with axial eye length >26 mm and
fractional total energy >150 μJ [12 ]. These data emphasize the importance of
total energy restriction and mandatory follow-up of highly myopic patients.
An interesting alternative to classical hypotensive prophylaxis was the
evaluation of the rock inhibitor netarsudil. In a multicenter study by H. J. Lee et
al. a single instillation of netarsudil 0.02% one hour before laser prevented IOP
rise ≥5 mm Hg in 91% of patients, which is comparable to the fixed combination
of timolol + brinilzamide, but was accompanied by a lower incidence of systemic
side effects [ ].9
Finally, Zahid S. and colleagues demonstrated using ultrawidefield OCT
angiography that 7.8% of patients develop localized vitreomacular injury
correlating with a total energy expenditure >120 μJ within three days after
capsulotomy; administration of combined NSAID-steroid drops for four weeks
prevented the transformation of these changes into clinically significant macular
edema [ ].19
Cumulatively, the new data confirm that reduction of total laser energy, use
of modern hypotensive and anti-inflammatory agents, as well as personalized
consideration of eye biometric parameters allow to significantly reduce the risk
of both early and long-term complications of Nd:YAG capsulotomy and provide
more stable recovery of visual functions.
Conclusion.
Current data convincingly demonstrate that the outcomes of Nd:YAG-laser
capsulotomy are largely determined not only by the technical parameters of the
intervention, but also by the quality of post-procedural management of the
patient. Combination of three strategies. These are energy-saving mode of laser
exposure, early hypotensive prophylaxis and prolonged anti-inflammatory
therapy, which allows to significantly reduce the incidence of both early and late
complications.
Thebest results are achieved with individualization of treatment schemes:
the choice of hypotensive drug depends on the initial ophthalmotonus and
glaucoma history, while the amount and duration of anti-inflammatory therapy
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depends on the total laser energy, biometric parameters of the eye and the
presence of macular risk factors. A promising direction is the use of rock
inhibitors and fixed combination drops, which provide rapid and stable
reduction of intraocular pressure with a minimum of systemic side effects.
Additional reduction of energy load is possible due to low- energy pulses, which
reduces the risk of damage to the IOL and vitreomacular structures. Thus, the
integration of personalized medication protocols with gentle laser parameters
forms a new paradigm of management of patients with secondary cataract,
providing rapid recovery of visual functions and a high level of safety of the
procedure.
List of Literature:
1.
Garaev, I.R. et al, Effectiveness of dorzolamide after laser capsulotomy in
patients with pseudoexfoliative syndrome, Ophthalmology, 2021, no. 4:52-55
2.
Kulagina E.M. et al, To the question of the effect of laser discision of
secondary cataract on the macula, Vestn Ophthalmologii, 2018, 134(2):60-64
3.
Alió J.L. et al, Subconjunctival corticosteroids in pseudophakic patients
undergoing capsulotomy, Graefes Arch Clin Exp Ophthalmol, 2020, 258(5):1079-
1086
4.
Artunay O., Bimatoprost 0.03% versus brimonidine 0.2% in prophylaxis of
intraocular pressure rise following Nd:YAG capsulotomy, J Ocul Pharmacol Ther,
2015, 26(5):513-517
5.
Cheema S.S. et al, OCT predictors of CME after capsulotomy, Retina, 2021,
41(8):1601-1608
6.
Choi J-H et al, Quantification of Inflammation Following Nd:YAG
Capsulotomy, Korean J Ophthalmol, 2019, 33:369-375
7.
Ji-Ping Cai, Prophylactic use of timolol maleate to prevent intraocular
pressure elevation after Nd:YAG laser posterior capsulotomy, Int Ophthalmol,
2018, 28(1):19-22
8.
9.
Keates C.M., Complications of posterior capsulotomy with Nd:YAG laser,
Int Ophthalmol, 2014, 18(2):75-78
10.
Lee H.J., Netarsudil prophylaxis for IOP spikes after posterior capsulotomy,
Asia-Pac J Ophthalmol, 2021, 10(4):395-401
11.
Lim J.M. et al, Effectiveness of combined anti-inflammatory therapy after
Nd:YAG laser capsulotomy, Clin Ophthalmol, 2020, 14:451-458
12.
Mehdizadeh M. et al, Correlation of posterior capsule morphology with
post-laser inflammation, Middle East Afr J Ophthalmol, 2018, 25(2):89-94
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13.
Park B., Incidence and risk factors for retinal detachment after YAG
capsulotomy, Ophthalmology, 2019, 126(10):1377-1384
14.
Patel C.K., NSAID monotherapy in pseudophakic patients following laser
capsulotomy, Indian J Ophthalmol, 2019, 67(1):34-39
15.
Reibaldi M., Topical nepafenac versus dexamethasone for CME prevention
after YAG capsulotomy, J Cataract Refract Surg, 2016, 42(8):1130-1136
16.
Salehi-Had J. et al, An Overview of Nd:YAG Laser Capsulotomy, J Curr
Ophthalmol, 2015, 27(3):116-120
17.
Sharma C., Prophylactic use of bimatoprost-timolol fixed combination after
YAG capsulotomy, J Ocul Pharmacol Ther, 2015, 28:576-580
18.
Singh R. et al, Fixed-dose brinzolamide-timolol prophylaxis in YAG laser
cases, Ophthalmic Surg Lasers Imaging, 2017, 48(6):476-481
19.
Takkar B., Low-energy Nd:YAG laser capsulotomy reduces IOL pitting, Eye,
2022, 36(5):972-978
20.
Zahid S, Early vitreoretinal changes detected by UWF-OCTA after Nd:YAG
capsulotomy, Retina, 2024, 44(2):320-327
