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| CASE REPORT |
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| Year : 2021 | Volume
: 59
| Issue : 1 | Page : 85-87 |
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An uncommon complication from a common procedure
Rithulaa Raja, M Nivean, Sangeetha Rajagopal, Pratheeba Devi Nivean
Department of Ophthalmology, M. N. Eye Hospital Pvt. Ltd, Chennai, Tamil Nadu, India
| Date of Submission | 16-Oct-2020 |
| Date of Acceptance | 18-Jan-2020 |
| Date of Web Publication | 27-Mar-2021 |
Correspondence Address:
Dr. Rithulaa Raja
15/2, Agathiar Street, Teachers Colony, Erode - 638 011, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/tjosr.tjosr_157_20
The study aims to highlight the importance of appropriate sizing of yttrium-aluminum-garnet (YAG)–capsulotomy. We report a case of a patient who developed sudden loss of vision, due to an unprecedented posterior dislocation of the posterior chamber intraocular lens, following an apparently uncomplicated YAG laser capsulotomy for a posterior capsular opacification (PCO), which was restored to complete visual recovery. We also stress the importance of appropriate size of the YAG openings. Although neodymium: YAG laser posterior capsulotomy is a safe procedure for treating PCO, it is not free from complications. Limiting the size of the YAG opening to meet the basic requirements is necessary.
Keywords: Cataract surgery, iris–claw intraocular lens, posterior capsular opacification, yttrium-aluminum-garnet–capsulotomy
How to cite this article:
Raja R, Nivean M, Rajagopal S, Nivean PD. An uncommon complication from a common procedure. TNOA J Ophthalmic Sci Res 2021;59:85-7 |
| Introduction | |  |
The neodymium: yttrium-aluminum-garnet (Nd: YAG) laser is a solid-state laser with a wavelength of 1064 nm that can disrupt ocular tissues by achieving optical breakdown with a short, high-power pulse. Nd: YAG laser posterior capsulotomy introduced a technique for closed-eye, effective, and relatively safe opening of the opacified posterior capsule.[1] Posterior dislocation of an intraocular lens (IOL) is an uncommon complication of the Nd: YAG posterior capsulotomy.[2]
| Case Report | | |
A 64-year-old female presented to us with sudden diminution of vision in the right eye of 2 days duration, associated with some discomfort. She gave a history of YAG–capsulotomy, done in her right eye, 3 weeks ago at another hospital. She had undergone cataract surgery, in both eyes in 2008.
On examination, her best-corrected visual acuity was 2/60 and 6/6 in the right eye and left eye, respectively. Slit-lamp examination of the right eye revealed a clear cornea with a quiet anterior chamber; pupil was round and reactive. However, the patient was found to be aphakic. Dilated examination showed the intact circular anterior capsular rim with a large YAG opening of the posterior capsule [Figure 1]. On downgaze, the rim of a posteriorly dislocated IOL could be seen in the anterior vitreous phase [Figure 2]. Fundus examination revealed normal disc and vessels, foveal reflex was seen, and peripheral retina was intact. The left eye was pseudophakic and within normal limits. Intraocular pressure (IOP) was 14 and 18 mmHg in the right and left eye, respectively. | Figure 1: The intact circular anterior capsular rim with large yttrium-aluminum-garnet opening
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 | Figure 2: Downgaze showing the rim of the posteriorly dislocated intraocular lens into the AVF
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After appropriate investigations, the IOL power was calculated. We planned for an anterior vitrectomy with IOL explantation, followed by a secondary IOL implantation, in the same sitting. The procedure was carried out under local anesthesia. Triamcinolone acetonide was injected and anterior vitrectomy was done. A single-piece, foldable, hydrophilic IOL was explanted, and subsequently, a retropupillary posterior chamber iris–claw lens was enclavated into position. Postoperatively, the patient was put on a short course of topical antibiotics and steroids, tapered over a period of 4 weeks.
On the 3rd postoperative day, her vision improved to 6/12 with a pin hole. On day 20, it improved to 6/6 with −0.50 D sph/−2.0 Dcyl at 90 and near vision to N6 with + 2.50 D sph. Slit lamp examination revealed a quiet eye with a stable iris–claw lens [Figure 3]. | Figure 3: A quiet eye on postoperative day 3 with good enclavation of the iris–claw lens on both sides
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| Discussion | | |
Cataract surgery is the most commonly performed ocular surgery worldwide.[1],[2] The most frequent postoperative complication of cataract surgery is posterior capsule opacification (PCO), with a reported incidence of 20.7% at 2 years and 28.5% at 5 years after the procedure. PCO develops as remaining lens epithelial cells proliferate and migrate into the space between the posterior surface of the IOL and the posterior capsule.[3],[4] YAG laser capsulotomy is the treatment of choice for PCO. The complications of YAG laser capsulotomy include damage to the IOL, increased IOP, retinal hemorrhage, iritis, vitreous prolapse, corneal injury, vitritis, pupil blockage, hyphema, cystoid macular edema, retinal detachment, IOL dislocation, and exacerbation of endophthalmitis.[5] Although NdYAG laser capsulotomy is a non invasive and safe treatment,it carries risk of some complications.[6]
Different mechanisms such as radial tearing of the large capsular defect with IOL loosening, zonulysis, and IOL dislocation within the intact capsular bag have been reported in literature.[7] Klein et al. suggested in their study that the combination of hydrophilic lens material and a thin lens design may result in early spontaneous IOL dislocation and YAG laser capsulotomy may induce IOL dislocation if the lens design cannot withstand capsular fibrosis.[8] Some studies found that the larger the capsulotomy size, the more pronounced the IOL movement[9],[10]
Clearing the visual axis to the diameter of the undilated pupil is usually sufficient to give a satisfactory visual outcome. In our case, we believe the larger size of the YAG opening to be the culprit. However, the early and effective management aided in complete visual recovery.
| Conclusion | | |
Nd: YAG laser posterior capsulotomy is a safe procedure for treating PCO although it is not free from complications. Limiting the size of the YAG opening to meet the basic requirement is necessary to avoid further hassle.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Steinert RF, Puliafito CA: The Nd:YAG laser in ophthalmology: principles and clinical applications of photodisruption, American Academy Of Ophthalmology, Philadelphia: WB Saunders; 1985. p. 74.  |
| 2. | Congdon N, Vingerling JR, Klein BE, West S, Friedman DS, Kempen J, et al. Prevalence of cataract and pseudophakia/aphakia among adults in the United States. Arch Ophthalmol 2004;122:487-94. |
| 3. | Billotte C, Berdeaux G. Adverse clinical consequences of neodymium: YAG laser treatment of posterior capsule opacification. J Cataract Refract Surg 2004;30:2064-71. |
| 4. | Powe NR, Schein OD, Gieser SC, Tielsch JM, Luthra R, Javitt J, et al. Synthesis of the literature on visual acuity and complications following cataract extraction with intraocular lens implantation. Cataract Patient Outcome Research Team. Arch Ophthalmol 1994;112:239-52. |
| 5. | Nakazawa M, Ohtsuki K. Apparent accommodation in pseudophakic eyes after implantation of posterior chamber intraocular lenses. Am J Ophthalmol 1983;96:435-8. |
| 6. | Karahan E, Er D, Kaynak S. An overview of Nd: YAG laser capsulotomy. Med Hypothesis Discov Innov Ophthalmol 2014;3:45-50. |
| 7. | Framme C, Hoerauf H, Roider J, Laqua H. Delayed intraocular lens dislocation after neodymium: YAG capsulotomy. J Cataract Refract Surg 1998;24:1541-3. |
| 8. | Klein JP, Torun N, Berndt S, Rieck P, Bertelmann E. Ophthalmology 2012;109:54-8. |
| 9. | Findl O, Drexler W, Menapace R, Georgopoulos M, Rainer G, Hitzenberger CK, et al. Changes in intraocular lens position after neodymium: YAG capsulotomy. J Cataract Refract Surg 1999;25:659-62. |
| 10. | Hu CY, Woung LC, Wang MC. Change in the area of laser posterior capsulotomy: 3 month follow-up. J Cataract Refract Surg 2001;27:537-42. |
[Figure 1], [Figure 2], [Figure 3]
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