Don't Get Burned by Lasers

As an OD with considerable experience comanaging cataract surgery patients, I would like to offer my thoughts on what is a manufactured case against one optometrist concerning one patient that was then used to castigate the entire profession:

(1) Cheaper IOLs without laser ridges might require IOL pitting to get the capsule to open regardless of the operator (whether optometrist or ophthalmologist). 

(2) IOL pitting on one YAG capsulotomy patient by an ophthalmologist or optometrist does not indicate either poor technique or poor equipment. Pitting IOLs on all YAG capsulotomies obviously does represent a problem, which I have seen with certain ophthalmologists.

(3) Even when I have seen consistent, extensive pitting of the IOL from an ophthalmologist in my area, I haven’t had patients complain about their vision. I do question the symptoms the patient reported as caused by a pitted IOL. Thus, I have not seen a cause and effect between IOL pitting and reduced vision in any patient that I can remember in 35 years of post-op cataract surgery patient care.

(4) Though I have not done even one YAG capsulotomy, I have extensive experience with patients who have had the procedure. Equipment company technicians used to train ophthalmologists on how to perform the procedure, but I believe most YAG laser instruments have so many automatic features that this is no longer necessary. Initially, the lasers had problems with alignment and the instruments were hard to use correctly, but that was 30 years ago.

(5) In California, a lobbyist for organized ophthalmology testified falsely that he was in his ophthalmology residency program being trained how to use the YAG capsulotomy laser when he inadvertently pressed a wrong button, causing an IOL to dislodge into the back of the eye. Only after emergency surgery with a gifted university chorioretinal specialist was the eye saved. 

IOLs don’t fall back into the eye with YAG capsulotomies. If the patient had an iris-fixated IOL from the late 1970s, there would be the possibility of this, but this would also require a totally incompetent ophthalmology resident with a totally incompetent ophthalmology university professor. 

Basically, this statement killed an old California optometry bill that included the ability to do YAG capsulotomies. The thought of IOLs ‘falling back into eyes’ and multiple patients going blind was too much for the legislative committee. So great was the lie by the lobbyist that the California optometrists who were testifying did not know what to say and did not know if this had ever happened. The bill was later substantially amended to exclude YAG capsulotomy privileges for California optometrists.

(6) Why would optometrists want to do YAG capsulotomies in the first place? If the result is anything but stellar, the patient could then return to the original ophthalmologist and give the MD ammunition. The ophthalmologist could blame the optometrist for almost anything, including floaters (which are common anyway), halos if the capsulotomy is not big enough and, of course, IOL pitting, which doesn’t bother the patient but can be photographed and shown to stoke fears and resentment.

 (7) The issue of the cost of using a laser must also be considered. Can an optometrist afford to do this procedure? Probably not. Refractive lasers might be something for optometry to consider; keeping that out of our hands is what this is all about. Sometimes there is no reality to the politics of medical procedures and patient care, and monetary factors influence what we do and why.


—Don Stover, OD, Porterville, CA