SECO 2026: YAG laser capsulotomy standard techniques

Nate Lighthizer’s, OD, FAAO, lecture at SECO 2026 about YAG laser capsulotomy, covering both basic (YAG cap 101) and advanced (YAG cap 201) concepts. He emphasized that YAG capsulotomy is likely the most common laser procedure currently performed by optometrists in the 14 laser-authorized states.

Lighthizer began by explaining the clinical indication for YAG capsulotomy: patients who have undergone cataract surgery and later develop a cloudy posterior capsule (posterior capsular opacification, or PCO). These patients typically present with reduced vision and glare complaints months to years after surgery. The purpose of the YAG procedure is to use the laser to create an opening in the cloudy membrane, restoring a clearer visual axis.

Lighthizer briefly mentioned that there are different patterns for creating the capsulotomy—such as the cruciate pattern, circular pattern, and others—and that proper patient selection, technique, and complication management are key elements of good clinical practice.

The pre- and post-operative protocols are described in detail. Before the procedure, the team performs a dilated fundus exam to confirm that the posterior segment is healthy enough to proceed. They also evaluate pupil size in undilated, dim illumination, because the opening created should be at least as large as the undilated pupil. The clinician looks carefully for retinal pathology (e.g., tears or breaks) that could be worsened by the laser, and screens for inflammation or elevated intraocular pressure (IOP) that might contraindicate treatment. The thickness of the membrane is also evaluated to help determine energy settings: a typical membrane might use around 1.5 mJ, while an extra thick membrane may need approximately 2.5 mJ.

Regarding IOP management, Lighthizer’s team uses an IOP-lowering agent (Brimonidine) both before and immediately after the laser procedure, then measure IOP 30–60 minutes postoperatively to monitor for rare IOP spikes. If the pressure remains within normal limits—as it does in the vast majority of cases (98–99+%)—the patient is scheduled for follow-up in 1–2 weeks, depending on scheduling logistics. At that follow-up, they recheck IOP, evaluate the opening undilated to ensure there are no remaining PCO “flaps” requiring touch-up, and repeat a dilated exam to confirm overall ocular health.

Lighthizer also offered practical advice for clinicians adopting YAG capsulotomy. He notes that many optometrists already possess strong slit lamp and lens skills, forming a solid foundation for learning the procedure. He recommends taking a formal training course, such as the laser and surgical procedures course he teaches at SECO, to gain confidence and hands-on familiarity.

For beginners, Lighthizer strongly advised careful patient selection. Early in one’s experience, clinicians should avoid extremely anxious, “triple type A” patients or highly dense capsules and other advanced-case scenarios. More complex situations—such as anterior capsulotomy, working with premium or multifocal IOLs, the presence of silicone oil, and similar challenges—should be considered advanced techniques (YAG cap 201) and not the first cases undertaken.

Lighthizer described YAG capsulotomy as one of the most rewarding procedures in optometric practice: patients often present with impaired vision and leave, after a brief 1–5 minute laser procedure, with significantly improved sight, frequently expressing that they “haven’t seen this well in months or years.” Finally, Lighthizer encouraged optometrists in states that have recently passed laser legislation to consider adopting YAG capsulotomy to better serve their patients. For those in states without such legislation, he urged them to continue advocating and “keep pushing” for expanded scope of practice.