Ophthalmology Volume 100, Number 5, May 1993

Risk of Retinal Detachment after YAG Capsulotomy

Dear Editor: The authors of the article entitled, "National Outcomes of Cataract Extraction: Increased Risk of Retinal Com­plications Associated with Nd: Y AG Laser Capsulotomy" (Ophthalmology 1992;99:1487-97), should be com­mended on pointing out conclusively and showing the data to support the fact that Y AG laser capsulotomy is associated with an increased risk of retinal detachment or retinal tear. Unfortunately, additional assumptions are made leading to a recommendation that Y AG capsulo­tomy be deferred until the patient's visual complaints and impairment due to capsular opacification warrant the in­creased risk of retinal complications associated with cap­sulotomy.

I suggest that there is a strong possibility that the in­creased incidence of retinal complications may be due to total Y AG energy delivered during capsulotomy, and therefore their recommendation to wait could in itself cause a higher incidence of retinal detachment. It is clear clinically that the greater the opacification and thickness of the posterior capsule, the more laser energy is needed to be delivered to perform an adequate capsulotomy.

My clinical judgment tells me that the fewest shots with the least amount of energy delivered would pose the least amount of retinal risk. If this is so, then I certainly think early intervention should be recommended rather than what the authors propose.

Authors' reply

STEPHEN M. WEINSTOCK, MD Largo, Florida

Although Dr. Weinstock agrees with our conclusion that performance ofYAG laser capsulotomy is associated with an increased risk of retinal detachment or tear, he disagrees with our recommendation that posterior capsulotomy be deferred until the patient's visual impairment due to cap­sular opacification warrants performance of a procedure that has some risks associated with it. His recommenda­tion that capsulotomy be performed "early" (which we infer to mean before posterior capsule opacification be­comes symptomatic) is based on the assumption that the risk of retinal detachment associated with laser capsulot­omy increases with the degree of opacification present at the time capsulotomy is performed.

We are not aware of any data that support such an association. In the absence of such data, we believe it is inappropriate to subject patients who may never develop a clinically significant decrease in visual functioning as a result of capsular opacification to the risk and cost of cap­sulotomy. Instead, we believe the indications for perfor­mance of capsulotomy are the same as those for perfor­mance of cataract surgery, namely that (1) the patient's lifestyle is compromised by visual impairment; (2) per­formance of the procedure is likely to improve the pa-

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tient's visual function; and (3) the expected benefit of the procedure exceeds the risk associated with the procedure.

Dear Editor:

JONATHAN C. JAVITT, MD, MPH JAMES DELSCH, PhD MARGARET KOLB, DRPH ALFRED SOMMER, MD, MHS EARL P. STEINBERG, MD, MPP Washington, DC

Recent news media attention to the study by Javitt and associates regarding their conclusion that YAG laser pos­terior capsulotomy increases the risk of retinal detachment has created an unnecessary concern for our patients. Careful analysis of the rates of retinal detachment after intracapsular cataract extraction versus that after a com­bination of extracapsular cataract extraction and subse­quent Y AG capsulotomy will show that our patients are far better off with the latter approach. It would be nice if this could be stressed by the press as well.

What is most shocking and potentially embarrassing for our profession are the data depicted in Figure 3. It shows that approximately 15% of the Y AG capsulotomies performed were done less than 3 months after the cataract surgery and 29% were done less than 6 months postop­eratively. It is hard to believe that this many eyes cloud their capsule this early after surgery. Fifty-five percent had their capsulotomy before 1 year had elapsed.

Before the development of the Y AG laser, we all be­came quite well aware that if we delayed surgical discus­sion to at least 1 year after surgery, the risk of retinal detachment and cystoid macular edema were extremely low compared with performing it earlier than 1 year. I have persisted with this surgical plan after the introduction of the Y AG laser and for the past decade have only had to perform a total of four capsulotomies earlier than 1 year after surgery. Could my patients be so radically dif­ferent from those of the rest of the nation or am I somehow missing these 55% of my patients that "need" their capsule opened or ignoring their cries for help to avoid the surgical renumeration? My ultimate long-term rates for capsular opening are the same as those in Javitt's report but the timing is definitely different. Our experience with post­Y AG laser retinal detachment is anecdotal, but negligible.

For the past decade, I have exclusively implanted laser ridge or meniscus implants within the capsular bag. Might this be a cause for delaying the necessity for capsulotomy within the first year? Evidence certainly indicates that de­laying the capsulotomy beyond 1 year is beneficial to the patient's retina.

I fear those not friendly to ophthalmology may inter­pret these data as an example of unnecessary or earlier than necessary surgery and I urge my colleagues to re­evaluate their timing of Y AG capsulotomy to drastically decrease the already low rate of retinal detachment after this procedure.

KENNETH J. HOFFER, MD Santa Monica, California