No ring approach technique for Nd:YAG capsulotomy in pinhole intraocular lenses: mask-sparing strategy to prevent occluder ring damage

Posterior capsule opacification (PCO) is the most common late complication after cataract surgery, with incidence rates influenced by intraocular lens (IOL) material and design. Small-aperture IOLs such as the IC-8 Apthera incorporate a central carbon-black mask that provides extended depth of focus but is highly susceptible to Nd:YAG laser energy. Bench experiments demonstrate that identical pulse settings cause catastrophic mask fragmentation with volumetric material loss, whereas the hydrophobic acrylic periphery shows only microscopic pits. Clinical cases confirm that inadvertent mask hits may induce dysphotopsia and necessitate IOL exchange. The “no ring approach” (NORA) strategy is introduced to prevent such outcomes by confining laser application either within the 1.36 mm central aperture or in the clear peripheral optic while strictly avoiding the 3.23 mm carbon-black mask. Practical recommendations include wide dilation, low initial energy, posterior offset, and careful alignment. Adoption of the NORA technique preserves the optical benefits of pinhole IOLs while enabling safe restoration of vision after PCO.