YAG Laser After Cataract Surgery or RLE: Cloudy Vision Explained

Short answer: If your vision becomes cloudy or glary again months or years after cataract surgery or refractive lens exchange (RLE), the usual cause is posterior capsule opacification (PCO), sometimes called a “secondary cataract”. It is the most common after-effect of lens surgery, and it is treated with a quick, usually painless YAG laser in the clinic (EyeWiki; AAO). PCO is more common the younger you are, so if you had lens surgery before 60, our surgeons expect that you will most likely need a YAG at some point. It’s not a sign anything went wrong. If you had your cataract surgery or RLE at Focus Vision, your YAG laser is done at no cost to you.

What is posterior capsule opacification (PCO)?

During cataract surgery or refractive lens exchange, your natural lens is removed, but the thin, clear bag (capsule) that held it is left in place to support your new lens implant. Over time, lens cells left on the capsule can multiply and spread across its back surface, making it hazy (EyeWiki).

It isn’t the cataract growing back: a cataract can’t return once the lens is removed. The American Academy of Ophthalmology describes PCO as “also called ‘secondary cataract’ or ‘scar tissue’” (AAO).

Signs of PCO develop gradually, often months or years after surgery:

• vision becoming blurry or hazy again, like looking through a smudged window;
• more glare or halos around lights, especially at night or when driving;
• colours looking duller, or reading becoming harder.

How common is it?

PCO is common, and it becomes more likely the longer you have your lens implant:

• In a UK study of more than 20,000 eyes of people aged 65 and over, 5.8% to 19.3% needed a YAG laser within five years, depending on the lens implant (Ursell et al., 2020).
• In the UK national cataract database (about 500,000 operations), PCO had developed in 34% of eyes by five years and 47% by nine years (Donachie et al., 2023).

Why it’s more common in younger people

Younger age is one of the most consistent risk factors for PCO (EyeWiki; Donachie et al., 2023):

• In a ten-year study, 37% of people who were under 65 at the time of cataract surgery had needed a YAG laser, compared with 20% of older patients (Lundqvist & Mönestam, 2010).
• In a study of nearly 10,000 eyes, people over 60 had a lower risk of needing a YAG than those under 60 (Li et al., 2023).
• In children, PCO is almost universal unless the surgeon opens the capsule during the operation (EyeWiki).
• Short-sighted eyes, which are common among RLE patients, also have higher rates: 27% needed a YAG within five years in eyes with low-power lens implants, compared with about 14% in other eyes (Lindholm et al., 2020).

People having refractive lens exchange are usually younger than cataract patients, and they will live with their lens implant for longer. If you have lens surgery before 60, our surgeons expect that you will most likely need a YAG at some point. That’s why we talk about it before surgery: it is an expected, easily treated part of life with a lens implant, not a complication to worry about.

Premium lenses

If you have a multifocal or extended depth of focus (EDOF) lens, you are likely to notice PCO earlier, because these lenses are more sensitive to small amounts of haze. In a large US registry, 21% of eyes with these lenses had a YAG within about a year, compared with 4% with monofocal lenses (Horn et al., 2022).

The YAG laser treatment

YAG laser capsulotomy uses a laser to make a small, clear opening in the cloudy capsule, behind your lens implant (AAO):

• It’s quick. The laser part takes about five minutes, in the clinic. No incision is made.
• It’s usually painless. You sit at a machine like the one used for an eye examination. Drops numb and usually dilate the eye.
• Vision improves quickly, usually within a day or two (AAO).
• It’s usually a one-off. The opening is permanent, and once treated, PCO rarely returns in adults (EyeWiki).

Timing with a premium lens. If you have a multifocal or EDOF lens, your surgeon will check that PCO is really the cause of your symptoms before treating it, because once the capsule has been opened, exchanging the lens implant later becomes much harder (Woodward et al., 2009).

Risks

YAG laser is a very common and generally safe procedure, but like any treatment it has risks (EyeWiki):

• a temporary rise in eye pressure, which is checked after treatment;
• new floaters for a while;
• inflammation, or swelling at the back of the eye (macular oedema), which is uncommon;
• a small mark on the lens implant, which rarely affects vision;
• retinal detachment, which is rare. A meta-analysis of 11 studies found a small increase in risk overall, but no significant increase after modern cataract surgery (Liu et al., 2022).

After treatment, contact us urgently if you notice a sudden shower of new floaters, flashes of light, or a shadow or curtain across your vision, as these can be signs of a retinal tear (AAO).

Cost: free if we did your lens surgery

If you had your cataract surgery or refractive lens exchange at Focus Vision, your YAG laser is done at no cost to you. It is part of your care after lens surgery with us, whenever you need it.

If your lens surgery was done elsewhere, Medicare item 42788 covers laser capsulotomy (MBS item 42788). We can assess you and explain any out-of-pocket cost first.

For what’s included in our lens surgery prices, see our costs page, refractive lens exchange cost and cataract surgery cost. If a small prescription remains after lens surgery, laser fine-tuning is also free for two years under our enhancement policy.

If your vision has become cloudy again after lens surgery, book an appointment or call (07) 3239 5005.

References

1. American Academy of Ophthalmology. Posterior capsule opacification. EyeWiki. eyewiki.org/Posterior_Capsule_Opacification
2. American Academy of Ophthalmology. What is a posterior capsulotomy? EyeSmart. aao.org/eye-health/treatments/what-is-posterior-capsulotomy
3. Ursell PG, Dhariwal M, et al. 5 year incidence of YAG capsulotomy and PCO after cataract surgery with single-piece monofocal intraocular lenses: a real-world evidence study of 20,763 eyes. Eye (Lond). 2020;34(5):960-968. pubmed.ncbi.nlm.nih.gov/31616057
4. Donachie PHJ, Barnes BL, Olaitan M, et al. The Royal College of Ophthalmologists’ National Ophthalmology Database study of cataract surgery: Report 9, risk factors for posterior capsule opacification. Eye (Lond). 2023;37(8):1633-1639. doi:10.1038/s41433-022-02204-1. doi.org/10.1038/s41433-022-02204-1
5. Lundqvist B, Mönestam E. Ten-year longitudinal visual function and Nd:YAG laser capsulotomy rates in patients less than 65 years at cataract surgery. Am J Ophthalmol. 2010;149(2):238-244. doi:10.1016/j.ajo.2009.08.029. doi.org/10.1016/j.ajo.2009.08.029
6. Li X, Li J, Sun D, et al. Development and validation of a prediction model for Nd:YAG laser capsulotomy: a retrospective cohort study of 9768 eyes. Ophthalmol Ther. 2023;12(4):1893-1912. pubmed.ncbi.nlm.nih.gov/37133707
7. Lindholm JM, Laine I, Tuuminen R. Intraocular lens power, myopia, and the risk of Nd:YAG capsulotomy after 15,375 cataract surgeries. J Clin Med. 2020;9(10):3071. pmc.ncbi.nlm.nih.gov/articles/PMC7598659
8. Horn JD, Fisher BL, Terveen D, et al. Clin Ophthalmol. 2022;16:1721-1730 (IRIS Registry study of Nd:YAG capsulotomy rates by lens type). pubmed.ncbi.nlm.nih.gov/35673348
9. Woodward MA, Randleman JB, Stulting RD. Dissatisfaction after multifocal intraocular lens implantation. J Cataract Refract Surg. 2009;35(6):992-997. pubmed.ncbi.nlm.nih.gov/19465282
10. Liu H, Liu X, Chen Y, et al. Effect of Nd:YAG laser capsulotomy on the risk for retinal detachment after cataract surgery: systematic review and meta-analysis. J Cataract Refract Surg. 2022;48(2):238-244. pubmed.ncbi.nlm.nih.gov/34538778
11. Australian Government Department of Health. Medicare Benefits Schedule, Item 42788: laser capsulotomy. MBS Online. www9.health.gov.au