Case Reports

Corneal decompensation following neodymium-doped yttrium aluminium garnet (Nd:YAG) capsulotomy in a pseudophakic patient

Case Report Details

First Author: S.Kaur UK

Co Author(s):    P. Xanthopoulou   N. Kopsachilis                 

Abstract Details

Purpose:

To report a case of corneal decompensation as a side effect of Nd:YAG capsulotomy in a pseudophakic eye.

Setting:

A 75 year old patient was referred for reduced vision from bilateral posterior capsule opacifications (PCO). Routine Nd:YAG capsulotomy was performed in both eyes and the patient was discharged to his optometrist. Two weeks later he was diagnosed with pseudophakic corneal oedema and referred to the cornea service for treatment.

Report of Case:

A 75 year old male patient was referred by his optometrist with gradual onset bilateral blurred vision. His best corrected visual acuity (BCVA) was 0.10 and 0.80 LogMAR in the right and left eye respectively with evidence of bilateral PCO. His cataract surgeries were performed 10 years ago. Fundus examination and macula optical coherence tomography (OCT) was normal. Bilateral Nd:YAG capsulotomies were performed with the Litechnica Lpulsa Q-switch mode YAG laser device using an Abraham capsulotomy lens and coupling agent. He received a total of 44 pulses of 1.4 milijoule (mJ) per pulse to his right eye and 48 pulses of 1.5mJ per pulse to his left eye then discharged. Two weeks later he was re-referred by his optometrist with reduced vision in his left eye. On examination, his BCVA in the left was unchanged at 0.80 LogMAR with mild epithelial corneal oedema and an otherwise normal eye examination. Four weeks later, his vision had deteriorated to 1.00 LogMAR and Descemets membrane folds were seen. He was commenced on topical Dexamethasone 0.1% 1 drop 2 hourly for 3 days then 8 times a day for a week as well as Sodium chloride 5% drops 4 times a day. A week later, his vision improved slightly to 0.60 LogMAR however a month later his BCVA deteriorated to 0.94 LogMAR with on going endothelial oedema. There were no signs of guttata or corneal dystrophy in either eye at any point and his intraocular pressures were within normal limits. He was consented for and underwent left Descement Stripping Endothelial Keratoplasty (DSEK) uneventfully. Two months later the graft remains clear, with central corneal thickness (CCT) of 760 microns and his vision has improved to 0.30 LogMAR. He remains on Dexamethasone 0.1% 3 times a day and continues to be monitored in the cornea clinic.

Conclusion/Take Home Message:

This is the first reported case of Nd:YAG capsulotomy induced corneal endothelial failure in an otherwise healthy pseudophakic eye with no underlying pathology treated successfully with a DSEK graft that remains clear at 2 month post-operative visit. The cause of endothelial damage is likely due to mechanical shock waves dispersion of post plasma particulate causing shear stress on the endothelium combined with thermal and direct focal damage of the laser radiation in an eye with some presumed endothelial cell loss from previous cataract surgery. This complication is rare and has only been reported in rabbit studies where anterior capsulotomy was undertaken as well as in YAG laser iridotomies. There is a need for long term evaluation of the corneal endothelium in YAG capsulotomies.

Financial Disclosure:

None