YAG laser

The YAG laser is a solid-state laser which uses a crystal and emits radiation with a wavelength of approximately 1064 um (infrared range), which leads to photodisruption. This can be used to alter or tear tissue in the eye.

YAG capsulotomy

Indication: post-cataract, capsulophimosis, before refractive post-treatment for ametropia following cataract surgery (e.g. Touch UP)

Inform the patient, have a declaration of consent signed

Maximum pupil dilate with Tropicamide eye drops (Mydriaticum dispersa®) 3x every 10 minutes

The capsulotomy must be at least as large as the pupil in miosis.

Laser settings

Energy: 1-3 mJ (start low and slowly increase until capsule is torn)
Pulse: 1
Mode: fm
Focus:

• Without contact glass: posterior defocus (Ellex® 500um),
• With contact gas: defocus 300um (Volk YAG Capsulotomy®)
  • Okybuprocaine eye drops 1x
  • Hydroxypropyl methyl cellulose 2-3% (HPMC, Methocel 2%®)

Pattern: cross/star with magnification shots (no circle -> optically annoying)

Post-operative treatment:

• Total applied energy < 100mJ: NSAID eye drops (e.g. Yellox) 2x/day for 1 week
• Total applied energy > 100 mJ: prednisolone eye drops 4x/day for 4 days, 2x for 3 days, 2x for 2 days, 1x for 1 day

YAG-PLI (Peripheral Laser Iridotomy)

Indication: primary narrow-angle glaucoma and partner eye prophylaxis, secondary narrow-angle glaucoma (pupillary block), plateau iris syndrome, malignant glaucoma

Inform the patient, have a declaration of consent signed

Narrow the pupil: 1x apraclonidine 1% eye drops (Iopidine 0.5-1%®) and 1x pilocarpine (Spersacarpine 2%®) within 10 minutes

Superotemporal iridotomy (fewer apertures and fewer ghost image as covered by the upper eyelid)

Laser settings

Energy: 4-7mJ (start low and slowly increase until iris tissue)
Pulse: 3
Mode: fm
Focus: 0 (no defocus) on iris crypts (fewer vessels)
Contact gas: (Volk Irid YAG® /Abraham YAG Iridotomy Lens®)

• Okybuprocaine 0.4% eye drops 1x (Oxybuprocaine®)
• Hydroxypropyl methyl cellulose 2-3% (HPMC, Methocel 2%®)

If blood escapes from the iris tissue, reapply contact gas and apply low pressure for 60 seconds or until bleeding stops

Eye pressure monitoring after 1 hour and gonioscopy to evaluate the angle of the chamber

Post-operative treatment: prednisolone eye drops 4x/day for 4 days, 2x for 3 days, 2x for 2 days, 1x for 1 day

YAG-SLT (Selective Laser Trabeculoplasty)

Indication: Existing glaucoma and malcompliance when applying eye drops (possible as a first-line treatment)
Lowers eye pressure by approximately 20-30% (corresponds to an active ingredient in eye pressure lowering eye drops)

Confluent laser spots in the area of the pigmented trabecular meshwork over 180°-360°

Laser settings

Energy: 0.6-0.9 mJ (deep until bubbles become visible)
Fixed (Ellex®): size 400 um, 3 ns)

Focus: 0 (no defocus) on iris crypts (fewer vessels)
Contact gas: (Volk Irid YAG/Abraham YAG Iridotomy Lens)

• Okybuprocaine 0.4% eye drops 1x (Oxybuprocaine®)
• Hydroxypropyl methyl cellulose 2-3% (HPMC, Methocel 2%®)
  

Eye pressure check after 1 hour (pressure spikes possible)

The SLT can be repeated after 6 months

Post-operative treatment: alpha agonist eye drops 1x, prednisolone eye drops 4x/day for 4 days, 2x for 3 days, 2x for 2 days, 1x for 1 day
Continue to reduce existing glaucoma eyedrops up to 6 weeks after

Sources: Will's Eye Manual

YAG vitreolysis

Laser device: Ellex laser (Ultra Q Reflex, Ultra Q Reflex Neo, Tango Reflex, Tango Reflex Neo)
Contact glass: Volk Singh Mid-Vitreous, Ocular Karickhoff Off-Axis Vitreous
Energy: Titrate 3-4 mJ up to max. 10 mJ (the farther posterior the more energy)

Indication (patient selection)

vitreous opacities

• clinically significant (e.g. visible on ultrasound or during fundus copy)
• symptomatic (annoying e.g. when driving, reading, etc.) for > 6 months
• consistent for at least three months
• dense, sharply limited opacities (e.g. white ring) are easier to treat than diffuse opacities

Relative contraindication (treatment with caution)

• Myopia magna -> increased risk of retinal rupture or detachment
• Advanced glaucoma -> increased eye pressure

Absolute contraindications

• Current symptomatic posterior vitreous lift (positive dysphotopsia) -> increased risk of retinal rupture or detachment
• Simultaneous laser treatment (e.g. capsulotomy)
• Turbidity is outside the safety zone (3 mm in front of retina or behind lens)

preparation

Tropicamide eye drops 3x and phenylephrine eye drops 2x oxybuprocaine AT 2x (alternating every 3-5 minutes)

implementation

1. Use on-axis (coaxial) and off-axis lighting to identify and localize turbidity and adjust the intensity of the red reflex

2. Decide whether the turbidity is in the safety zone

3. Start with low energy 3mJ then slowly increase to 10 mJ if necessary until opic decomposition and evaporation of the vitreous collagen occurs. Initially, the number of pulses should not exceed 300-400 (300-2000 mJ). Visibility may be impaired due to the resulting gas bubbles.
4. Order: from anterior to posterior, from superior to inferior
5. Move the eye to move opacities to areas that are easier and safer to treat
6. lookout
   
   1. Do not fire when the retina is also in focus (i.e. appears sharp)
   2. Particular care should be taken when treating near the retina or lens (at least 3 mm safety distance), especially at higher energies

Post-operative procedure

Recommendations: no restrictions necessary, black spots, especially in the lower field of vision, correspond to air bubbles that dissolve within a few days.
Post-operative treatment: Yellox AT 2x/day/Nevanac 3mg AT 1x/ day/Nevanac 1mg AT 3x/day for 1 week
Eye pressure measurement 30 minutes after treatment
Follow-up after 3-7 days, repeat treatment if necessary (several treatments are usually necessary)

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