Neodymium-Doped Yttrium Aluminum Garnet (Nd:YAG) Laser-Induced Damage to Intraocular Lenses: A Systematic Review of Mechanisms, Clinical Consequences, and Preventive Strategies.

Abstract

Neodymium-doped:yttrium-aluminum-garnet (Nd:YAG) laser capsulotomy is considered the gold standard treatment for visually significant posterior capsule opacification (PCO), which remains the most common long-term complication following cataract surgery. However, Nd:YAG laser treatment carries the risk of inducing intraocular lens (IOL) damage, including pits, cracks, and optical degradation, particularly affecting the quality of premium hydrophobic acrylic and small-aperture IOLs. To systematically review the morphology, material dependence, optical, and clinical consequences, as well as preventive strategies associated with Nd:YAG laser-induced IOL damage. A comprehensive literature search was conducted in PubMed and Medical Literature Analysis and Retrieval System Online (MEDLINE) databases, including publications from January 1995 to April 2025. Keywords and MeSH terms included "Nd:YAG capsulotomy," "intraocular lens damage," "IOL pits," "posterior capsule opacification," "device-related injuries," and "Yttrium Aluminum Garnet." Peer-reviewed experimental studies, clinical series, case reports, reviews, and guidelines published in English or German were included. Non-peer-reviewed articles, editorials, and conference abstracts were excluded. A total of 53 relevant publications were included following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Morphological alterations ranged from superficial micro-pits to extensive crater formation and delamination, particularly prominent in hydrophobic acrylic and pinhole (small-aperture) IOLs. Experimental studies consistently demonstrated measurable degradation in optical quality, including reduced contrast sensitivity, increased glare, and higher-order aberrations after central pit formation. Clinically, symptomatic IOL damage requiring lens explantation was identified in up to 9.3% of cases analyzed retrospectively. Laboratory analyses, including micro-computed tomography (µCT) and Raman spectroscopy, revealed structural and chemical alterations within damaged areas. Preventive measures proven effective include peripheral laser patterns, posterior offset focusing, minimal effective energy usage (<1.8 mJ), and structured laser alignment techniques. Nd:YAG laser-induced IOL damage significantly depends on material properties, lens design, and laser parameters. Effective preventive strategies, including optimized laser protocols and targeted surgical training, can substantially mitigate these risks. However, robust clinical data linking experimental findings to patient outcomes remain scarce, highlighting the need for large prospective studies in the future, especially focusing on modern premium IOLs. Careful attention seems essential to minimize IOL damage, particularly in premium lens designs, thereby ensuring optimal visual outcomes and patient satisfaction.