A randomized controlled trial of peeling and aspiration of Elschnig pearls and neodymium: yttrium-aluminiumgarnet laser capsulotomy

AIM: To compare surgical peeling and aspiration and neodymium yttrium garnet laser capsulotomy for pearl form of posterior capsule opacification(PCO).METHODS: A prospective, randomized, double blind,study was done at Rotary Eye Hospital, Maranda,Palampur, India, Santosh Medical College Hospital,Ghaziabad, India and Laser Eye Clinic, Noida India.Consecutive patients with pearl form of PCO following surgery, phacoemulsification, manual small incision cataract surgery and conventional extracapsular cataract extraction(ECCE) for age related cataract, were randomized to have peeling and aspiration or neodymium yttrium garnet laser capsulotomy. Corrected distance visual acuity(CDVA), intra-operative and postoperative complications were compared.RESULTS: A total of 634 patients participated in the study, and 314(49.5%) patients were randomized to surgical peeling and aspiration group and 320(50.5%) to the Nd:YAG laser group. The mean pre-procedural log MAR CDVA in peeling and neodymium: yttrium-aluminium-garnet(Nd:YAG) laser group was 0.80 ±0.25 and 0.86 ±0.22, respectively. The mean final CDVA in peeling group(0.22 ±0.23) was comparable to Nd:YAG group(0.24 ±0.28; t-test, P =0.240). There was a significant improvement in vision after both the procedures(P <0.001). A slightly higher percentage of patients in Nd:YAG laser group(283/88.3%) than in peeling group(262/83.4%) had a CDVA of 0.5(20/63) or better at 9mo(P <0.001). On the contrary, patients havingCDVA worse than 1.00(20/200) was also significantly higher in Nd:YAG laser group as compared to peeling group(25/7.7% vs 15/4.7%, respectively). On application of ANCOVA, there was less than 0.001% risk that PCO thickness and total laser energy had no effect on rate of complications in Nd:YAG laser group and less than 0.001% risk that PCO thickness had no effect on complications in peeling group respectively. Sum of square analysis suggests that in the Nd:YAG laser group,thick PCO had a stronger impact on complications(Fischer test probability, P r <0.0001) than thin PCO and total laser energy(Fischer test probability, P r <0.002),respectively; similarly, in peeling group, thick PCO and preoperative vision had a stronger effect on complications than thin PCO, respectively(Fischer test probability, P r <0.001). The rate of complications like uveitis(P =0.527) and cystoid macular edema(P =0.068),did not differ significantly between both the groups.However, intraocular pressure spikes(P =0.046) and retinal detachment(P<0.001) were significantly higher in Nd:YAG laser group as compared to peeling group.Retinal detachment was more common in patients having degenerative myopia(7/87.5%, P <0.001). Recurrence of pearls was the most common cause of reduction of vision in the peeling group(24/7.6%, P <0.001).CONCLUSION: There is no alternative to Nd:YAG laser capsulotomy for fibrous subtype of PCO. For pearl form of PCO, both techniques are comparable with regard to visual outcomes. Nd:YAG laser capsulotomy has a higher incidence of IOP spikes and retinal detachment whereas recurrence of pearls may occur after successful peeling and aspiration. When posterior capsulotomy is needed in patients with retinal degenerations,retinopathies and pre-existing retinal breaks, the clinician should be cautious about increased risks of possible complications of Nd:YAG laser capsulotomy.