Study Warns of Unnecessary Capsulotomies

Optometrist giving eye exam to senior patient
Investigators used “real world” data to assess the rate of Nd:YAG capsulotomies and expressed concern about the potential for unnecessary risk.

When selecting treatment for posterior capsule opacification (PCO); choose wisely. A study published in Clinical Ophthalmology advocates. The research emphasizes performing Nd:YAG laser capsulotomies for the “correct clinical reason” because unnecessary procedures could cause unneeded adverse events, and are an additional cost burden to the healthcare system, according to researchers. Additionally, they warn, the procedure may not even have a visual benefit for some patients. 

Researchers aimed to assess the rate of posterior capsule opacification (PCO) in what they called “real-life conditions” using Nd:YAG laser intervention rates instead of data from controlled studies where patients have been excluded for conditions that would put them at risk for PCO. In essence, they were seeking “real life numbers” based on  a retrospective, multicenter study in an unselected consecutive cohort of patients undergoing surgery for age-related cataracts. 

They recruited 200 patients at 2 centers (one in the United Kingdom and one in Austria) who were 18 years and older and had been previously implanted with an intraocular lens (IOL). They contacted patients at 12, 18, and 24 months to see if they’d had subsequent Nd:YAG laser treatment. At the Austria center, an additional assessment was performed at 36 months.

Among their findings: At 1 year, laser capsulotomy rates were 4.5%; at 2 years, they were 10%; and at 3 years, they were 12%. A total of 3 Nd:YAG capsulotomies, done at other centers, were performed for astigmatism, epiretinal membrane, and age-related macular degeneration. Excluding those 3 situations, the percentage of Nd:YAG for PCO was 3.5% at 1 year and 8.5% at 2 years.

“Laser treatment with Nd:YAG is an effective, quick and relatively easy outpatient procedure,” according to the investigators. However, patients run the risk of complications such as a transient rise in intraocular pressure (5%), drop in visual acuity (4%), cystoid macular edema (<1.5%) and even retinal detachment (<1.5%). Additionally, a second procedure may be required in approximately a quarter of patients. “Although the rate of adverse events associated with Nd:YAG may be relatively low, due to the large number of patients undergoing the procedure, the absolute number of patients experiencing a post-procedure adverse event is high,” the study shows. The researchers point in particular to a prior study that estimated up to 11,500 adverse events for every 400,000 cataract extractions that could have been avoided if capsulotomy rates were reduced.

“In future PCO studies, it should be a requirement to document the fibrosis grade to confirm that Nd:YAG capsulotomy was correctly indicated,” the study says. “This will help to ensure that reported PCO and Nd:YAG rates more accurately reflect the nature of the IOL under assessment. In our study an IOL with a sharp posterior edge, a rigid optic-haptic junction, and good stability in the eye was associated with low rates for Nd:YAG.”


Ling R, Borkenstein EM, Borkenstein AF. Evaluation of Nd:YAG laser capsulotomy rate in a real-life population. Clinical Ophthalmology. 2020:14(10):3249-3257. doi: 10.2147/OPTH.S276329