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3F: Surgery Final > YAG Cap > Flashcards

YAG Cap Flashcards

1
Q

Capsule

A 
Elastic membrane 
Barrier
Permeable 
Reproducing 
-basal membrane of lens epithelium-anterior 
-basal membrane of elongating fiber cells-posteriorly 
Thickness 
-thickest near the equator 
-thinnest at post capsular poles
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2
Q

Lens

A

Surrounded by a capsule

  • anteiror
  • posterior
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3
Q

Surgery on lens

A

Anterior=capsulorhexis
Posterior=remains in tact to hold the IOL implant
-posterior capsular opacification. Growth and proliferation of lens epithelial cells from original cataract migrate on lens capsule

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4
Q

Anterior capsular opacification

A

Anterior capsular opacification

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5
Q

Posterior form of capsular opacification

A

Fibrosis
Proliferation
Linear
mixed

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6
Q

Anterior capsular opacification and anteiror capsule contracture syndrome

A
  • starts by the 1st post op month-6 months
  • occurs at the continuous capsulorhexis (CCC)
  • complications: decenter IOL-multifocal IOL, MUST maintain good centration, lens title induced astigmatism
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7
Q

Incidence of anteiror capsular opacification nand antihero capsule contracture syndrome

A

Lens materials

  • highest with silicone IOL with sharp optic edges and plate haptic silicone design
  • lowest: acrylic IOL
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8
Q

Disease and anteiror capsular opacification and anteiror capsule contracture syndrome

A

RP ad DM

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9
Q

Soemmering’s ring

A

Looks like anteiror capsular opacification but ONLY OCCURS in APHAKIA

Results of anterior capsule edges attachment to the posterior capsule

  • absence of IOL
  • congential aphakia
  • Lowe syndrome and hallerman-Streiff Francois syndrome
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10
Q

Fibrosis form of capsular opacification

A
  • anterior epithelial cells form spindle shaped fibroblasts-migrate to PC
  • appearance: white opacities, fine folds, wrinkles
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11
Q

Proliferation (pearl form) O.D. opacification

A
  • pre-equatorial zone lens epithelial cells form swollen cells called bladder (or Wedl) cells-migrate to PC
  • appearance: circular opacification, pearls (elschnig pearls)
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12
Q

Mixed form opacification

A

Combination of fibrosis and proliferation

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13
Q

Linear form of opacification

A
  • PCO along persistent striae-create a channel allowing epithelial cells to bypass the barrier created by the square edge design of the IOL
  • appearance: linear striae
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14
Q

Most common complication of cataract surgery

A

PCA

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15
Q

When doe PCA occur

A

30-50% within 3-5 years

Occurs within 20-26 months usually

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16
Q

Yougner patients and PCA

A

Highest risk

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17
Q

PCA within 3mm zone affects

A

High contrast sensitivity
Low contrast acuity
Psychophysical test resutls with differing degrees of sensitivity
-forward light scatter>contrast sensitivity>VA

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18
Q

Preventing PCO

A
  • removal of all epithelial cells and cortical remnants
  • lovage the intracapsular space with saline during surgery to denature residual epithelial cells
  • clean the anterior chamber well with an irrigation dynamic pressure-assisted hydrodiessection tool
  • pharmacological drops
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19
Q

Previous treatments for PCO

A
  • surgical cutting or peeling

- polishing posterior capsule

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20
Q

New treatments for PCA

A

Nd:YAG 1064

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21
Q

Nd:YAG 1064

A
  • pigment independent
  • 4ns. Large amount of energy delivered in small spot size for brief time

photodisruptive:
- high light energy causes tissue to reduce to plasma
- disintegrates tissue
- no thermal or coagulation effect
- hydrodynamic waves and acoustics pulses travel back toward surgeon=OFFSET

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22
Q

Nd-YAG laser capsulatomy Sadie’s

A

Dilating drops
Use lenses
Half use steroid

23
Q

Contraindications for yag cap

A

Absolute

  • corneal haze or pathology
  • unable to hold steady/fixate

Relative

  • glass IOL
  • active intraocular inflammation
  • known/suspect CME
  • high risk for RD
24
Q

Most common complications of yag cap

A

IOP spike

Floaters

25
Q

IOP spike in yag cap

A

-reduced faciltiy for aqueous humor outflow
—capsular debris
—acute inflammation cells
—liquefaction of the vitreous
—shock wave damage to TBM
->10mmHg in 15-67% of patients. Peaks at 3-4 hours but decreases after 24 hours
-associated with: glaucoma, capsuolotomy size, lack of IOL, sulcus fixation, energy, myopia, vitreoretinal Disease

26
Q

Stromal haze/edema/decreased endothelial cell count in yag cap

A
  • occurs in 2.3-7% of patients

- this can lead to Fuchs dystrophy depending on extend of damage

27
Q

CSME and yag cap

A
  • occurs in 0.55-2.5% of patients
  • within 3 weeks-11 months
  • decrease risk by increasing time between ECCE and capsulotomy
28
Q

IOL damage/pitting and yag cap

A

Significant glare and image degradation

Minimal VA impact

29
Q

Material complications and yag cap

A

Glass=fractures
PMMA=sustain cracks and central defects with radiating fractures
Silicone=blistered lesions and localized pits
Acrylic=white haze (highest risk of pitting)

30
Q

RD and yag cap

A
  • lifetime risk of RD after cat sx=1%
  • lifetime risk of RD after capsuolotomy=additional 0.8-1.9%
  • incidence: immediately to 1+ years
31
Q

Retinal breaks and yag cap

A

Asymptatomic breaks found in 2.1% of patients within 1 month

32
Q

Endophthlamitis and yag cap

A
  • propionibacterium acnes endophthalmits reported following capsuolotomy
  • presumed opportunity for organisms within capsule=vitreous
33
Q

Nd:YAG energy levels for PCO 2015

A

474 consecutive eyes studied on several factors VERSUS total energy used

  • complication rates
  • type of PCA
  • IOL material
  • fixation of IOL

Analyzed for factors that led to complication

34
Q

Incidence of IOP spike

A

12.9%

35
Q

Uveitis incidence

A

9.9%

36
Q

IOL pitting incidence

A

7.8%

37
Q

CME incidence

A

2.9%

38
Q

RD incidence

A

2.3%

39
Q

Energy going in to the eye and complications

A

Less energy into the eye equal less complications

  • the more energy and higher myopia=RD more likely
  • pearl vs fibrosis: pearl were easier to clean off and fibrosis required more energy to get completely off. Using a lens will help concentrate the energy and decrease energy needed
  • IOL material and fixation had no influence on issues with total energy use
40
Q

Candidate for YAG cap

A
  • Vision 20/30 or worse
  • Symptomatic: glare, blur, vision, contrast
  • > 3 months post op cataract surgery
41
Q

Pre op yag cap

A

Psychophysical

  • VA
  • glare testing
  • PAM
SLE
IOP
DFE/posterior segment evaluation (or B scan if unable to visualize fundus)
Signed inform consent
Vitals (BP, pulse)
42
Q

posterior capsulotomy setting

A
  • 1.3-1.8mJ
  • spot size: fixed (8-11 microns)
  • duration: fixed (4ns)
  • pulses-1
  • amount of burns: 10-40
  • pattern: cruciate/horseshoe/Christmas tress/Can-opener (circular)
  • Offset: +150 to +500 microns posteriorly
43
Q

Cruciate

A

Top to bottom

44
Q

Horseshoe

A

An upside down U from 7 clockwise to 5 o clock

45
Q

Christmas tree

A

12 o’clock-4:30 and 12 o’clock to 7:30 without shots in central optical zone

46
Q

Can opening )circular)

A
  • creates large fragments that dont necessarily sink

- large floater within vision

47
Q

Procedure for posterior capsuolotomy

A
  • comfortable placement
  • optional marker shot
  • 1 drop tropicamide
  • 1 drop alphagan 15-30m before
  • 1 drop proparacaine OU
  • focus on post cap (post offset)
  • adjust energy PRN. Little/no tissue interaction=increase
  • treat about 4mm in cruciate pattern (larger than undulated pupil). 10-40 total shots
48
Q

Anterior capsulotomy setting

A
  • 1.3-1.8mJ
  • spot size fixed (8-11)
  • duration: fixed (4ns)
  • pulses: 1
  • amount of burns: 10-40
  • pattern: radial burns @ the clock hours
  • offset: -150 to -500 microns ANTERIORLY
49
Q

When would you make the treatemtn size smaller than the pupil in post yag cap

A

If they have a thick membrane. Creates a pinhole for them

50
Q

Procedure for anteiror capsuolotomy

A
  • comfortable placement
  • 1 drop tropicamide
  • 1 drop alphagan 15-30m prior
  • 1 drop proparacaine OU
  • focus on anterior phimosis (anterior offset)
  • adult energy PRN
  • treat in radial pattern @ clock hours to release phimosis. 10-40 total shots
51
Q

Post op yag cap

A
  • 1 drop alphagan
  • recheck IOP 15-30m in office
  • Rx PF QID x 7 days
52
Q

FU for yag cap

A

1 day
-high risk patient

1-2 weeks

  • check IOP
  • check AC reaction
  • dilation (r/o holes/tears/RD)
53
Q

RTC 2m decreased vision and yag cap

A

Assess for

  • refractive error shifty
  • CME
  • RD
  • glaucoma
  • vitreous hemorrhage

3F: Surgery Final (5 decks)

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