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Taking your YAG laser to the next level
Second in a three-part series focused on newer technologies for the ASC.
In the March/April 2011 issue, we discussed the importance of establishing and owning a surgery center in today’s ever-changing economy. We also introduced some of the newest technologies in surgical microscopes. In this issue, our focus turns to new-generation YAG lasers — specifically, why they are integral in achieving good patient outcomes and what is new on the market.
Importance of upgrading
Surgeons often take their YAG laser for granted as a piece of equipment that will last forever. In fact, that is not the case, because the consistency of energy delivery drops off with time. This drop-off occurs because the solid-state crystal that generates the laser pulse no longer works as well.
Similar to our phacoemulsification equipment, the YAG laser is something we rely on frequently, and therefore, it needs to be replaced every few years, as newer-generation lasers unquestionably perform better than the previous models. The newest lasers allow us to deliver lower levels of energy that can be more selectively focused to the capsule and not anteriorly to the IOL. This translates to less damage to the lens, which is critical because even minor damage to a lens causes a visual impact. To implant premium lenses, surgeons must pay attention to all of the minor details, and this is clearly one of them.
Visual impact
So often in our medical literature, even with regard to premium lens implants, patients’ visual acuity is discussed in terms of Snellen lines, which we know is a crude measurement of what patients actually experience in the real world.
Premium lens patients are much more sensitive to certain factors pertaining to low-contrast vision than the “average” cataract surgery patient. For instance, light scatter must be minimized because of the already reduced contrast produced by the multifocal lenses. Additionally, patients who have reduced contrast before surgery from pre-existing conditions, such as prior refractive surgery, glaucoma or mild maculopathy, do poorly when implanted with multifocal lenses.
In light of these factors, we have found that performing a YAG procedure on the posterior capsule at an early stage makes sense because even mild opacity of the capsule reduces contrast vision for patients with these lenses. Similarly, patients implanted with aspheric or accommodating lenses are going to be sensitive to glare because of the posterior position of the optic. Thus, no matter how well we fragment the lens with a femtosecond laser, and despite use of even the most advanced phacoemulsification machine, we are going to need to perform YAGs.
Current models
Some of the newest YAG lasers currently available on the market are the YC-1800 (Nidek) and the Ultra Q and Super Q (Ellex).
The YC-1800 features a slim design and a front-facing control display, allowing the surgeon to perform YAG procedures while limiting his or her movements and remaining in the area of focus longer. Although previous models were limited in their range of focus shift, the YC-1800 offers a range from 500 µm posterior to 500 µm anterior and is adjustable at 25 µm steps. This model also features a 360° capable aiming beam for accurate focusing on the target, which helps reduce corneal astigmatism because of the rotation of the beam, a 3 Hz firing rate, and a “smart switch” that allows the surgeon to adjust power on the fly as opposed to having to stop the procedure to readjust. This model can be used as a standalone YAG laser or can be paired with the Nidek GYC/Green photocoagulator.
The Super Q by Ellex features a solid-state Q-switch that has been tested to deliver 400,000 shots without degradation. This model also has a tolerance range of ±8 µm and a fine two-point focusing system to ensure the system remains in focus. Just as with the Super Q laser, the Ultra Q features a proprietary cavity design with a passive Q-switched system and the same two-point focusing system. The Ultra Q also utilizes an ultra Gaussian beam mode, which allows for lower energy treatments, as well as a 3 Hz firing rate.
Although my practice currently uses the YC-1800 YAG laser, we trialed one of the Ellex models and were quite pleased with its performance, as well. Taking into account the high demands of our premium lens patients and the fine-tuning necessary to achieve the best possible results, as well as the fact that most high-use machines last only approximately 5 years, upgrading to one of these new low-energy lasers may certainly be worth your while.
John A. Hovanesian, MD, FACS, can be reached at Harvard Eye Associates, 24401 Calle De La Louisa, Suite 300, Laguna Hills, CA 92653; 949-951-2020; fax: 949-380-7856; e-mail: drhovanesian@harvardeye.com.
Disclosure: Dr. Hovanesian has no relevant financial disclosures.