Nd:YAG capsulotomy: an update

Posterior capsule opacification (PCO) remains one of the most common late complications following cataract surgery and may lead to decreased visual acuity, glare, contrast sensitivity loss, and impaired visual quality. Nd:YAG laser posterior capsulotomy is currently accepted as the gold standard treatment for symptomatic PCO because of its non-invasive nature and rapid visual rehabilitation. However, despite its widespread use and generally favorable safety profile, concerns remain about procedural variability, postoperative management, and complications such as intraocular pressure elevation, cystoid macular edema, retinal complications, and intraocular lens damage. This updated narrative review aimed to summarize and expand the current evidence on the mechanisms, indications, techniques, outcomes, and complications of Nd:YAG laser posterior capsulotomy.

A narrative literature review was conducted using PubMed/MEDLINE, Scopus, and Web of Science databases, supplemented by Google Scholar screening. The review primarily focused on studies published between 2010 and 2026, although landmark earlier studies were also included when relevant. Primarily English-language publications were included. The search strategy included combinations of the keywords "Nd:YAG capsulotomy", "posterior capsule opacification", "photodisruption", "intraocular pressure", "retinal detachment", "cystoid macular edema", "capsulotomy size", and "intraocular lens". Original articles, clinical studies, systematic reviews, meta-analyses, guideline-based publications, and selected case reports were included. Duplicate publications, conference abstracts without accessible full text, and studies with insufficient methodological or clinical information were excluded.

Current evidence demonstrates that Nd:YAG laser capsulotomy provides effective visual rehabilitation in symptomatic PCO and remains a generally safe procedure. Studies evaluating procedural techniques indicate that both cruciate and circular capsulotomy patterns produce comparable visual outcomes, though differences may exist in energy usage, floaters, light scattering, and macular effects. Significant variability persists in clinical practice regarding timing, postoperative medication use, and follow-up protocols. Although most complications are uncommon, clinically important adverse events including retinal detachment, cystoid macular edema, intraocular pressure elevation, inflammation, and intraocular lens pitting have been reported. The risk of certain complications appears to be influenced by patient characteristics, laser energy levels, capsulotomy size, ocular comorbidities, and the interval between cataract surgery and capsulotomy.

Nd:YAG laser posterior capsulotomy remains an effective and reliable treatment for symptomatic PCO; however, important heterogeneity persists regarding procedural approaches and postoperative management. Current evidence suggests that individualized treatment planning, careful patient selection, and conservative energy settings may help minimize complications. Future prospective and standardized studies focusing on visual quality outcomes, patient-reported measures, optimal timing, and complication risk stratification are needed to improve standardization and clinical decision-making in Nd:YAG laser capsulotomy practice.