11. YAG Capsulotomy: The Quick Fix Your Eyes Might Need After Cataract Surgery

You had cataract surgery. Your vision was crisp and clear — and then, months or even years later, it started getting hazy again. You're frustrated. You thought cataract surgery was supposed to fix this. Did something go wrong?

Nothing went wrong. What you're experiencing is called posterior capsule opacification — and it's one of the most common things I see in my patients after cataract surgery. The good news? There's a quick, painless, in-office fix called a YAG capsulotomy. And most patients walk out seeing better than when they walked in.

I'm Dr. Parul Khator, a board-certified ophthalmologist and glaucoma specialist in Marietta, Georgia — and in this episode I'm pulling back the curtain on one of the most commonly needed procedures after cataract surgery that nobody ever tells patients about in advance.

In this episode, I'll cover:

• What posterior capsule opacification actually is — and why it happens after cataract surgery
• How to know if your blurry vision after cataract surgery means you need a YAG capsulotomy
• What a YAG capsulotomy actually involves — spoiler: it's faster and easier than you think!
• What the procedure feels like from the patient's perspective
• What to expect afterward — and how quickly your vision improves
• When YAG capsulotomy is and isn't the right solution

If you've had cataract surgery and your vision isn't as sharp as it used to be — this episode is exactly what you need to hear. And if cataract surgery is in your future, consider this your heads up for what might come next. 👁️

📬 Have a question or topic you'd love me to cover? I'd love to hear from you! Email me at demystifytheeye1@gmail.com

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🌐 Learn more about Dr. Parul Khator, MD: https://www.gaeyepartners.com/metro-atlanta-eye-doctors/parul-khator-md/

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Demystify the Eye is for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of your eye doctor or qualified healthcare provider with any questions you may have regarding your eye health.

Transcript

SPEAKER_00 0:00

Hello, my name is Parl Kator MD. I'm an ophthalmologist in Atlanta, Georgia, specializing in cataract and glaucoma surgeries. After practicing medicine for over a decade, I have learned that the more a patient knows about their disease, the better they do. Patient education is a passion of mine. But like most doctors, I have a lot of patients and not a lot of time to see them. So I created this podcast where I could spend the time I don't have during the day to give you insights into the eyeball and ocular disease. Let's empower you as a patient or a patient support system. Together, let's demystify the eye. My specialty is brown buttered chocolate chip and toffee cookies. And my favorite type of baking is baking with my daughter. Though this is also the messiest type of baking that requires the most patience as she dumps a cup of flour on the counter instead of into the mixing bowl. If you have baked, you have certainly used parchment paper and saran wrap. You know the parchment paper is not quite opaque and not quite translucent, but somewhere in the middle. The saran wrap has a sort of sheen to it and gets these little folds and crinkles when you wrap it around a bowl. Now imagine what would happen if parchment paper had a baby with saran wrap. What would that substance look like? Foggy, filmy, crinkly, maybe even smoky when held up to the light? That, my friends, is what develops in every single eye that has had cataract surgery. Have you had cataract surgery? Well, this substance is developing in yours. Sound frightful? It's not frightful at all, thanks to a simple procedure called a YAG capsulotomy. Pathophysiology. Hold on a second. Back up just a little bit. You just said something about parchment paper marrying saran wrap and having a baby in my eye? Please explain. Okay, folks, let's begin where I always like to, with the basics of anatomy. This time we are talking about the anatomy of the lens. This beautiful and important structure sits just behind the colored portion of the eye or iris. It is suspended in the middle of the eye by hundreds to thousands of microscopic little strings called zonules that attach to the wall of the eye. The lens itself looks like an onion with layer upon layer of cells coming together. There are three parts to this onion. The bulk of the lens consists of lens fibers. These are rows and rows of elongated epithelial cells that are as transparent as possible. The lens fibers are encased in the lens capsule. This is a membrane or bag that surrounds the lens. Think of it like an elastic glove on a hand. It moves with a lens and protects it. We divide the lens capsule into the anterior capsule, which faces the front of the eye, and posterior capsule, which faces the vitreous jelly, in the back of the eye. Now the final structure I want you to know about lies between the lens fibers and the lens capsule. It is called the lens epithelium. This is a single layer of cube-shaped cells that have an important job. They will travel from behind the anterior capsule to the equator of the eye and turn into new lens fibers. Why do they do this? So old lens fibers that are no longer useful can get compacted in the center, and new ones that help you see can get added to the outside. When do they do this? Throughout your entire life. We call this PCO for short develops. PCO is sometimes referred to as a secondary cataract, but this is a terrible nickname because it just isn't true. Once removed, your cataract can never grow back. I had a patient come in steaming mad at me. She was told she had a secondary cataract. You told me my cataract surgery would be a once-in-a-lifetime procedure. So how in the world did it grow back? Let me reassure you, like I reassured her, barring unforeseen complications, you will only have cataract surgery once in your lifetime. The cataract cannot grow back. However, every human being will develop a posterior capsular opacification after their cataract surgery. Why has this been inappropriately dubbed as a secondary cataract? Because it can give a patient the same symptoms as their original cataract did. So if it's not a cataract coming back to haunt an eye, what is a posterior capsular opacification? Do you remember that third layer of the lens we discussed, the lens epithelium? Well, remember, these cells are microscopic. When we do cataract surgery, even the best of the best surgeons, we cannot remove all of these cells. And you wouldn't want us to try. Why not? Because the lens capsule, the bag that holds the lens in place, is a very important structure we do not want to damage during surgery. This bag, after all, will house your brand new artificial lens. Violation of this capsule means the jelly in the back of the eye, called the vitreous, can come forward to the front of the eye, which can create a whole slew of issues. This important capsule is also quite fragile. How fragile? Well, the anterior capsule, that's the side facing the front of the eye, is only 25 micrometers thick. That is one quarter the thickness of a piece of human hair. And the posterior capsule facing the back of the eye is only four micrometers thick. That is half of one red blood cell. If we were to be too aggressive about removing your cataract, we would surely damage your capsule somewhere. So instead, we remove 99% of your cataract. There are some lens epithelial cells that get left behind. We call these residual lens epithelial cells or LECs for short. Now, imagine if you are a lens epithelial cell and you know your job is to create more lens fibers. One day, 99% of the lens fibers suddenly go away. Poof, they are gone. What is your reflex? To go make more. After all, you think something must have happened. You rush to create more, but since there is no longer a lens, you do this on the posterior capsule instead. Statistics. Every single human being develops that posterior capsular opacification after cataract surgery. Every single one. But how many become visually significant to need treatment? 20 to 50 percent within five years after cataract surgery. So about half of people will develop this clouding over their vision five years after cataract surgery. And that number is going up. Risk factors. Well, the most important risk factors here are one, being a human, and two, having had cataract surgery. But what else increases the risk of developing a visually significant PCO? Well, the Royal College of Ophthalmologists in London looked at over 500,000 cataract surgeries and came up with some pretty important risk factors. We will divide these into patient risk factors and surgery risk factors. First, patient risk factors, and age is a big one. The younger you are when you have cataract surgery, the greater the chances you will develop a posterior capsular opacification requiring treatment. Children who have had cataract surgery develop a PCO 100% of the time. Ladies, unfortunately, we have a higher rate of PCO development. One study found women had twice the risk of developing a visually significant PCO than men. High myopia or nearsightedness. Nearsighted eyes are like eyes from Texas. Everything is bigger. The length of the eye, the space inside the eye, and the size of the bag that holds the lens. Bigger bag means more of those lens epithelium cells left behind to proliferate. If you have had prior retinal surgery, especially if you have had the jelly in the back of the eye removed, called a vitrectomy. If you have had a history of uveitis or eye inflammation, if you have other systemic diseases like diabetes. The second category of risk factors has to do with the surgery itself. The first is what kind of lens you get in your eye. If you get a premium lens, you will develop a visually significant PCO faster. Premium lenses are the fancy schmancy lenses you pay extra out of pocket for because they get you out of glasses, distance, and up close. These lenses have a complex design and need a crystal clear view in order to work properly. So patients with these lenses will definitely notice a PCO a lot earlier than someone with a standard lens covered by insurance. The second is whether your surgeon left a little more than a few lens epithelium cells behind. But before you get mad at her, remember, we as surgeons will only remove as much of the cataract as is safely possible. I have operated on patients with cataracts that are very sticky. They are stuck to the bag with gorilla glue instead of my daughter's Elmer's glue. In these cases, I leave them behind knowing I will remove them with a YAD capsulotomy later. A thoughtful and sometimes staged approach to surgery always leads to better outcomes. Symptoms. The symptoms of a posterior capsular opacification are the same as the initial cataract. Blurry vision, hard time seeing road signs in the distance, hard time reading comfortably, and glare in dim lighting conditions. Imagine you are looking through a crystal clear and clean window, and then I come by and throw a pail full of goop on the window. Now, in reality, I would never come to your house and goop your windows. That would be rude. The more dense the PCO, the worse the symptoms. Diagnosis. Posterior capsular opacification is easily diagnosed in the office at our slit lamp or upright microscope. I can see your crystal clear artificial lens, and then I can see the parchment paper saran wrap film just behind the lens. We grade your PCO on a scale of zero to four. Most people begin to notice a PCO when it is a one or greater. But what I see doesn't always match what you see. The other day I saw a patient with a two plus PCO, a pretty cloudy membrane. And yet she was happy as a clam, so we left it alone. Then I went into the next room and saw a one-plus PCO. The patient was devastated. She said she felt like all the good work I had done with her cataract surgery was undone. I had to reassure her she was going to be able to get that beautiful crystal clear view back. Treatment. Okay, now we get to the good stuff. How do we get rid of this film that is taking away the vision you so rightly earned when you underwent cataract surgery? Thanks to advancements in laser technology, the removal of a PCO is a quick in-office procedure. How quick? About 30 seconds quick. The laser is called a YAG capsulotomy. YAG stands for the type of laser energy used, yttrium aluminum garnet. This is a man-made crystal that is highly durable and creates powerful concentrated bursts of light. Think about how a pressure water can take simple and harmless water and mold it into a concentrated burst of water energy. What is the wavelength of the light? 1,064 nanometers. That is in the infrared frequency, which means an observer watching the laser from the side could not see the beams of light being produced. The YAG laser is known as a disruptive laser, meaning it disrupts or destroys tissue. The other type of laser we use is called an argon laser, which is a thermal laser that heats up tissue. What does this YAG laser disrupt? The now cloudy bag that holds your artificial lens in place. Hold on, you might be thinking, how do you disrupt or destroy this capsule without hurting my beautiful, shiny, crystal clear artificial lens? I do not want that destroyed. Neither does your surgeon. It's an important question because the average space between the artificial lens and the posterior capsule is 120 micrometers. That's the thickness of a sheet of paper in a printer. Well, the YAG laser is able to do this because the spot size it creates is only 8 to 50 micrometers, so about a quarter the thickness of a piece of printer paper. The YAG laser consists of two beams of light that the surgeon brings together into one single beam of light. Wherever that single beam of light hits is where the 50 micrometer light energy will be focused. So if we aim for the artificial lens, we will hit the artificial lens. If we aim for the posterior capsule, we will hit that. If we aim behind the posterior capsule, we will hit the vitreous jelly in the back of the eye. So yes, folks, you have to trust your surgeon. How can we tell what we are focusing on? The laser is connected to a slit lamp. That is our very powerful upright microscope. The slit lamp allows us to magnify your eye by six to forty times its normal size. The optics in the microscope allow us to magnify without losing detail. Pretty key if we are lasering your eye. Prior to meeting me in the laser room, my technicians will have given you drops to dilate your pupil so I can see the full extent of your posterior capsule. How large of an opening do I make with a laser? Large enough so that even when your pupil is fully dilated in natural dim lighting conditions, think watching a movie in a movie theater, you will not catch the edges of your filmy membrane. So about four millimeters in diameter. So what does a patient experience during a typical YAG laser procedure? What are the common questions patients have for me about this laser? Well, let's listen in to one of mine so you can get a good understanding of how things are done. Hi, sir. How are you? Nice to see you. All right. So let's get this done for you. We're gonna do this laser to your left eye to clear up the scar tissue that was formed behind your artificial lens. Before we get started, let's do a timeout where you give me your date of birth. Patients laugh when they have surgeries and lasers done because we will confirm their name, date of birth, eye, and procedure a zillion times before we actually do it. This is called a timeout and it's a non-negotiable. But wouldn't you rather us make you say your name and date of birth six times than do the wrong thing on the wrong eye? Let's get you comfortable in the machine. Chin goes down, forehead goes forward. Yep. You can put your hands there if you want to. Let's have you look up. Is that comfortable, by the way, for your neck and back? Good. Look up for me. Here comes the lens with a goopy goopy jelly. This part is very strange. With your right eye, I want you to look right here at this green light. That is my guiding light. Perfect. Look at that green light. If I move that light, you will just find it again. This is not going to hurt. You may just see some funky red lights. Let's get started. Do I lie down or sit up for the procedure? You sit up in our microscope. You do not get any intravenous sedation, so yes, you can generally drive yourself that day. You just need to feel comfortable driving while being dilated. How in the world will I keep my eye open during the laser? Not to worry. We will keep your eye open with a lens. This lens is coupled to your eye with a clear viscous gel that allows us to control your eye's movement. What if I look in the wrong place? Can I go blind? No, not at all. We help you know where to look by putting a fixation light, that's the green light, in front of your other eye to get your eye in the proper position. And no, you cannot go blind from this procedure. The important portions of your eye that control vision are in the back of your eye. These are your optic nerve and retina. The YAG laser energy simply does not reach that far back. What if I move? Things happen. Sometimes you have to sneeze. If you have to move, simply back away from the laser. Remember, the laser energy can only go so far. Is this going to hurt? Some lasers are painful, but not this one. There are no sensory nerve endings in the posterior capsule, so no pain. What is that red light? The fixation light for most lasers is a green light. The aiming beam for the laser is always a red light. You will see that red light scatter as we work, but you will not look directly at the red light. Green go, red stop. But what will happen if I do look at the red light? We surgeons do not push a button that then makes a laser fire for a minute straight. No. We decide when every single shot is fired. If you look in the wrong place, we will not fire the laser until you get back into the proper position.

unknown 20:42

Perfect.

SPEAKER_00 20:49

Great job. Perfect. What in the world are we listening to here? What are those beeps? Each beep is a burst of energy fired from the laser. Each shot is 8 to 50 micrometers, and we use these teeny tiny spots to control how we open the posterior capsule. If you wanted to cut a circle out of the center of a cake, you wouldn't hit it with a giant hammer one time. No, you would make tiny and careful cuts in the cake with an itty bitty knife. Controlled destruction. You are done. You can relax back. Great job. How are you feeling?

SPEAKER_01 21:31

Feeling good.

SPEAKER_00 21:32

We will wash that goopy jelly there out of your eyes so you can see again. You are going to get a little steroid drop that you'll take four times a day for a week. And you can stop it. Do not be alarmed or surprised if you see some floater. That is just the debris from the laser floating down out of your line of vision. Flashes of light, like a strobe light, flash, flash, flash, not normal. I want you to let me know about that right away. And then the beautiful thing is. This never grows back. Great. Bye, sir. Good to see you. Where does the scar tissue that you lasered go? It falls to the back of the eye where the vitreous jelly is. Gravity pushes it to the bottom, and then your eye clears that debris by breaking it down over time. Can this debris create a little inflammation? Yes, it can. Does this inflammation create any problems? Not for most patients. So most patients do not need to take any drops after a YAG capsulotomy. But some patients are more sensitive to this inflammation and can develop swelling in the back of the eye as a result. These high-risk folks have a history of diabetes, previous eye inflammation, have a sheet of scar tissue already growing on the back of their eyes called an epiretinal membrane, or their eye has had blood flow issues. For these folks, we will prescribe a mild topical steroid drop. The one I prefer is PregnanClone Acetate. This is generally used four times a day for a week. Complication. Complications from a YAG capsulotomy are low, but not zero. We are, after all, doing something significant to your eye, so there will always be some risk involved. Let's talk about the most common ones. We already talked about the risk of developing swelling in the back of the eye. This is quite low at around 1.5%, based on most studies. This swelling is called CME, standing for cystoid macular edema. You may have some irritation to the front of your eye from the goopy jelly we use to couple the lens and from washing this jelly out. The best way to prevent issues is to make sure you optimize the surface of your eye prior to the laser with dry eye drops. You can also use these to lubricate the front of the eye afterwards. Inflammation in the front of the eye. This is called uveitis and happens less than 1% of the time. This would be treated with a short course of steroid eye drops. Pressure spikes. This is especially important if you have glaucoma. All my patients receive a pressure lowering drop prior to the laser to prevent a pressure spike. The risk of having a spike is highest in the first few hours after the procedure. Having a pressure lowering drop on board prior to keeps that pressure spike from happening. If you have glaucoma, it is very important to resume your normal glaucoma drops right away. Retinal tear or detachment. This is where the tissue in the back of the eye gets a tear, which can then cause it to peel off the back wall of the eye. The risk of this is somewhere between 0.5 to 1.5%, and it is very important to know the symptoms to look out for. These include flashes of light like a strobe light in the periphery, a sudden gush of new small black floating spots, or a black curtain or shade coming across the vision from any direction. It is normal to see some floaters after the laser. That is just the debris from the laser floating out of the line of vision. These should settle down after a few days to a week. Efficacy. It removes the scaffold for those pesky leftover lens epithelium cells. Without a scaffold, they cannot grow back over the visual axis. I have had to take a patient to the laser a second time a handful of times in my 16 years of practice. Sometimes this is because a previous surgeon has performed the laser and the opening is too small. Most of the time, it is because the laser debris gets stuck in the jelly in the back of the eye. It doesn't fall to the bottom as it should, so patients have constant floaters after the procedure. An additional laser fixes this as I can ablate those leftover pieces and force them to fall out of the visual axis. Conclusion. Yes, healing is very important so you don't get leaks or infections. But surgery at its core is trauma to the body. Your body cannot tell the difference between controlled surgical trauma for a good cause and you tripping and falling down a manhole. Thanks to YAG laser capsulotomy, if your body does try to heal in a misguided way, we can fix it quickly and painlessly. And that is like spending one hour baking with my daughter, two hours cleaning the chaos, but at the end getting to pull out a delicious batch of fresh chocolate chip cookies. Until next time, see well and be well. And when you get your glasses, what color are you gonna choose?

SPEAKER_01 28:18

Probably like blue, if it's still my favorite color.

SPEAKER_00 28:23

How many favorite colors have you had?

SPEAKER_01 28:27

Let's see. I had lavender, pink, blue, green, yellow. So I think I had five.

unknown 28:43

Wow.

SPEAKER_00 28:44

That's a lot of favorite colors. All right, let's see which one you like if you ever need glasses in the future. Thanks, baby girl.