Comment on: Influence of Nd:YAG laser capsulotomy on toric intraocular lens rotation and change in cylinder power

We commend Cinar et al. on their unique and interesting study regarding Nd:YAG laser capsulotomy on toric intraocular lens (TIOL) rotation.1 Cinar et al. performed a retrospective study from January 2017 to September 2022 involving uneventful cataract surgery with implantation of a TIOL (AcrySof IQ SN6ATX); TIOL orientation, tilt, and decentration were measured 1 month before and after capsulotomy using an iTrace aberrometer and Scheimpflug imaging. Statistically significant TIOL rotation was found 1 month after Nd:YAG capsulotomy along with a significant decrease in IOL tilt coupled with a significant decentration of the TIOL (P < .05).1 Although we agree with the authors that the degree of TIOL rotation was not clinically significant as the spherical equivalence (SE) before and after Nd:YAG capsulotomy was similar (P = .352), we have several concerns with the study. For one, the study has unclear inclusion criteria. A total of 1274 patients were analyzed, of which 353 underwent a Nd:YAG laser capsulotomy. However, only 41 eyes of 20 female and 21 male patients were included. It is unclear why such a small percentage of the total number of Nd:YAG patients were included or why only 1 eye per patient was involved. Second, the posterior capsule opacity (PCO) was not graded in the study but can be assumed to be very significant as pretreatment corrected distance visual acuity was 0.4 ± 0.22 logMAR (mean of 20/60), which corrected to 0.023 ± 0.06 logMAR (approximately 20/20) after treatment. Combined with a time interval for Nd:YAG capsulotomy of 33.02 ± 12.9 months, we can infer that a majority of the PCO was likely greater than 2+ on the Cogon grading scale.2 As the authors suggest, a dense PCO can adversely affect the internal wavefront map and refraction measurements made by the iTracer and Scheimpflug imaging, making it difficult to determine residual cylinder or decentration before Nd:YAG capsulotomy.3 Finally, inference regarding the effect of early (3 months or less) Nd:YAG capsulotomy on TIOL cannot be made based on the authors' data as the mean laser capsulotomy was approximately 3 years after cataract extraction. Data from Coleman et al. on symptomatic trifocal TIOL and non-TIOL patients with almost no residual refractive error (sphere −0.07 ± 0.37, cylinder 0.48 ± 0.22, SE 0.09 ± 0.39) underwent a Nd:YAG capsulotomy 55 ± 26 days after cataract surgery.4 The cohort was found to have a significant improvement in objective visual acuity and contrast sensitivity with a decrease in the amount and severity of dysphotopsias. Although decentration, tilt, or TIOL rotation was not directly measured, clinically significant tilt or decentration was unlikely as trifocal IOL performance is very sensitive to residual refractive error and positioning over the visual axis. In our experience with over 10 000 Nd:YAG capsulotomies performed on TIOL, we have never experienced a clinically significant TIOL rotation or refractive change. Thus, we do not believe a Nd:YAG capsulotomy should be withheld in any PCO for fear of IOL rotation or decentration as the literature does not support a clinically significant risk of refractive shifts after capsulotomy.5