Study Finds Increased Risk of DR Progression, Complications After YAG Capsulotomy

This graph from the study shows hazard ratios of various ophthalmic outcomes among individuals with NPDR who underwent YAG capsulotomy compared with those who did not. Photo: Alshaikhsalama AM, et al. J Cat Refr Surg. October 13, 2025. Click image to enlarge. While YAG capsulotomy is generally very safe, diabetic patients with nonproliferative diabetic retinopathy (NPDR) are at risk for disease progression, especially when ocular stressors such as laser energy are introduced. In a recent study, researchers evaluated the risk of diabetic retinopathy (DR) progression and associated ophthalmic complications after capsulotomy in NPDR patients. They found an increased risk of DR progression and vision-threatening complications. The findings were reported in Journal of Cataract & Refractive Surgery.Patients aged 18 years or older with Type 1 or Type 2 diabetes and NPDR who underwent cataract surgery with or without subsequent YAG capsulotomy were identified from 69 US healthcare organizations across outpatient and academic ophthalmology settings. A total of 10,750 patients were included after matching (5,375 YAG-treated and 5,375 control eyes) and followed for one-year post cataract surgery.YAG-treated patients with NPDR demonstrated significantly increased risks. Hazard ratios (HRs) at one year were as follows:proliferative diabetic retinopathy: HR 1.91vitreous hemorrhage: HR 1.40tractional retinal detachment: HR 2.04need for panretinal photocoagulation: HR 1.48A secondary analysis of patients with five or more years of NPDR showed similar elevated risks, the researchers noted in their paper.Several potential mechanisms may account for this, the researchers propose. For one, capsulotomy could drive NPDR progression by inducing inflammation throughout the retina. “The laser’s photodestructive effect can trigger an inflammatory response through thermal and mechanical trauma during the procedure, especially when high laser energy settings are used,” the authors explained in their paper. “Although inflammation has been observed after YAG treatment, it is typically transient, and its role in exacerbating underlying DR remains unclear.”Furthermore, laser-induced damage to the vasculature can stimulate release of inflammatory mediators such as interleukin-1b, which promote angiogenic factors involved in PDR development such as VEGF and hepatocyte growth factor. These may be differentially elevated in patients with underlying DR and further exacerbated by YAG capsulotomy due to additional damage to the blood-retinal barrier, enabling additional leakage and inflammation, the researchers wrote.The clinical context in which YAG is performed may also contribute to the larger effect size that was observed. Capsulotomy is usually undertaken months to years after cataract surgery, when posterior capsular opacification has significantly advanced. “At this stage, some patients may already have progression of DR or worsening retinal ischemia,” the authors wrote. “Since cataract surgery always predates YAG laser in this study, the higher risk relative to cataract surgery may reflect the natural course of the disease process rather than a higher pathogenic effect of the YAG laser itself.”Finally, patients with diabetes have a higher risk of early development of posterior capsular opacification, which may reduce the likelihood of timely recognition of retinopathy. “This higher baseline risk profile could enrich the post-YAG cohort with eyes predisposed to developing PDR, which in turn may help explain the stronger association observed in our analysis,” the authors explained in their paper.Patients undergoing a YAG also had a significantly higher risk of needing panretinal photocoagulation. The risks of pars plana vitrectomy and tractional retinal detachment were also elevated, although not statistically significant. “Given this study’s findings, more intensive risk stratification and follow-up are recommended for patients with NPDR undergoing YAG laser, including scheduled dilated fundus examinations during the first postoperative year,” the researchers wrote. “Similar attention should be given to diabetic patients receiving YAG laser because DR progression or unmasking of preexisting PDR may occur with improved retinal visualization.”For high-risk NPDR, the research team recommends prophylactic interventions such as panretinal photocoagulation, anti-VEGF therapy and HbA1c monitoring to reduce neovascularization and stabilize the retina before laser procedures, the authors concluded in their paper. Postoperatively, they say, topical steroids may limit inflammation, although further studies are needed to confirm their effectiveness.Click here for the journal source. Alshaikhsalama AM, Mansoor BS, Zaidi Z, et al. Risk of diabetic retinopathy progression after YAG laser capsulotomy. J Cat Refr Surg. October 13, 2025. This article was developed by the editorial staff in conjunction with experts in the field. In the process, AI may have been among the editorial tools used to meet the goals of human editors, who approved all content.