LASERS in Ophthalmology

Health Care Technology Unit

ORBIS Flying Eye Hospital

Contents
LASER history
Wave theory
Overview of LASER
Application of LASERs in Ophthalmology
LASER Safety

LASER history
1917 - A. Einstein: Laser possible.
1958 - C.H. Townes, A.L. Schawlow: Theoretical basis for
lasers.
1960 - T. Maiman: Built first laser.
1963 - C. Zweng: First medical laser trial (retinal
coagulation).
1965 - W.Z. Yarn: First clinical laser surgery.

Light is electromagnetic radiation

Reproduced from Basic Clinical Science Course,

Foundation of the American Academy of
Ophthalmology. 2003 - 2004.

Let there be light...

And the 4 Maxwells equations
where written...

FIAT LUX

What is LASER?
LASER is an acronym for:
L Light
A amplification by
S stimulated
E emission of
R radiation

Interference and coherence

Reproduced from Basic Clinical Science Course, Foundation of

the American Academy of Ophthalmology. 2003 - 2004.

Interference and coherence

Reproduced from Basic Clinical Science Course, Foundation of

the American Academy of Ophthalmology. 2003 - 2004.

Interference and coherence

Reproduced from Basic Clinical Science Course, Foundation of

the American Academy of Ophthalmology. 2003 - 2004.

LASER Characteristics
Monochromatic

ORDINARY LIGHT

One color
chromatic

Coherent

LASER

In-phase
incoherent

Collimated
Light waves aligned
(less than 0.1 degree of divergence)

non-collimated

How is LASER generated?

Quantum mechanics: Plancks equation
E = n.h. = n.h.c /
Where:
E : energy level
n : an integer (1, 2, 3, )
h : Plancks constant (6.64x10-34 Js)
c : speed of light in vacuum (3x108 m/s)
: wavelength of the emitted photon (m)
: frequency of the emitted photon (Hz)

LASER theory
Quantum Mechanics: Electrons must be excited to
emit light.
Absorption vs. stimulated emission

Energy

excited level

upper laser level

excitation
by electron
or photon

laser transition
(emission of photon)
lower laser level

ground state

Laser theory
Stimulated Emission

Reproduced from Basic Clinical Science Course, Foundation of

the American Academy of Ophthalmology. 2003 - 2004.

Stimulated emission leads to a

chain reaction and laser emission
If a medium has many excited molecules, one photon can become
many.
Excited medium

This is the essence of the laser. The factor by which an input beam is
amplified by a medium is called the gain and is represented by G.

Electromagnetic
energy

Reproduced from Basic Clinical

Science Course, Foundation of the
American Academy of
Ophthalmology. 2003 - 2004.

Wavelengths of
Laser systems

Reproduced from Basic Clinical Science Course, Foundation of

the American Academy of Ophthalmology. 2003 - 2004.

LASER properties
Wavelength:
Ultraviolet
Visible
Infrared

Power Density:
Milliwatts to Kilowatts

Duration of Pulse:
Nanoseconds to Continuous

LASER properties
Beam Divergence:
Less than 0.1 degree

Coherence:
Millimeters to meters

Efficiency, Power Requirements:

0.01% to 20%

Basic Laser Components

Laser Tube (Laser medium + Resonating
element or mirror)
Pump or excitation source
Power supply
Cooling unit (water, air)
laser tube

pumping energy source

(light, electricity)

cooling unit

power
supply

power efficiency: 0.01-20%

Note: Energy efficiency: Argon 0.01% - Excimer 2%

Basic Laser Components

Laser tube and pump

Reproduced from Basic Clinical Science Course, Foundation of

the American Academy of Ophthalmology. 2003 - 2004.

Laser medium and pump

Energy (electrical, optical, or chemical) from an external source - the LASER

PUMP - interacts with a substance within the optical cavity - LASER MEDIUM - of
a laser to cause energy emission.

The substance can be a crystalline solid, a gas, a liquid containing a dissolved

organic dye, or a semiconductor. When these electrons return to their original
state, they emit photons with identical wavelengths characteristic of the particular
substance.

Mirrors at either end of the laser tube selectively reflect photons traveling parallel
to the tube axis, which strike other atoms and cause the spontaneous emission of
more photons of identical wavelength. Photons moving in other directions are
absorbed or reflected by the sides of the tube.

Eventually, the remaining photons pass through the partially reflective mirror at
one end of the tube to the laser delivery system in a coherent beam (one in which
all photons are in phase and moving in the same direction) of extremely high
irradiance (power density measured in watts/cm2).

Cooling unit

Ophthalmic lasers are typically equipped with a water or air cooling system
to prevent heat damage to the laser medium and pump.

In most units, the cooling system is self-contained; others require water and
drain connections.

Surgical Laser Terminology

ABLATION Removal of tissue using laser energy, usually by progressive

VAPORIZATION of the tissue cells.

ACTIVE MEDIUM The core material of a laser that emits a specific wavelength
of light; used to designate the laser type.

ARGON LASER Emits a green wavelength of 514 nm and a blue wavelength

of 488 nm that are readily absorbed by pigmented tissue.

AVERAGE POWER The energy per pulse times the pulse rate.

COAGULATION (COAG) The application of laser energy at a density sufficient

to cause thermal DENATURATION of protein without significant loss of tissue
mass. Often used to achieve HEMOSTASIS or tissue NECROSIS.

CONTACT-TIP METHOD Nd:YAG LASER surgery conducted with a shaped

tip that converts some laser energy to heat, causing a tissue effect only when the
tip is in contact with the tissue.

CO2 LASER Carbon dioxide laser. Emits a mid-infrared beam of 10,600 nm

that is absorbed by water.

Surgical Laser Terminology

CUTTING The application of laser energy at a density sufficient to incise or divide

tissue, ideally without creating significant thermal tissue damage on either side of the
cut.

DENATURATION The disruption of organic molecules (e.g., proteins, collagen) by

application of energy (e.g., laser light, heat). Raising tissue temperature above 65C
will cause denaturation.

ENERGY VERSUS POWER Both express the laser emissions capacity to cause
damage to or achieve a therapeutic effect in tissue. Energy, expressed in joules (J),
causes the temperature to rise when applied to a volume of cells; the faster the
energy is delivered, the higher the power, and the faster the temperature rises.
Power, expressed in watts (W), is the rate of energy emitted (i.e., J/sec).

FIBEROPTIC DELIVERY SYSTEM A mechanism used to convey laser energy by

internal reflection in a flexible, small-diameter fiber (usually silica) from the laser
aperture to a treatment site.

FREE-BEAM METHOD Laser surgery conducted with the laser aperture either a
short distance away from or just touching the target tissue.

HEMOSTASIS The stoppage of blood flow from severed vessels.

Energy Concepts
WATTS (Power) Rate of Energy Delivery,
but doesnt say how much energy (Dose).
JOULES (Dose) Amount of Energy
Delivered, but doesnt say how fast (Rate)
Joules = Watts x Time, i.e.;
1 Joule = 1000 watts x .001 seconds

Energy Concepts
POWER DENSITY: Spot Size & Power
Watts per Square Centimeter (W/cm2)
Concentration of the Power within the spot size.
Analogous to a magnifying glass and the sun.
Small spots burn (or ablate) because they are
more intense. Large spots dont burn as quickly
because they are less intense. Spot size will
change the power density faster than a change
in power.

Energy Concepts
ENERGY DENSITY: Spot Size & Dose
Joules per Square Centimeter (J/cm2)
Concentration of the total Dose of light
within the spot size. This considers both
the Power Density and length of time.

Different Types of Lasers

LASERS are referred to by the substance they
use (e.g., argon, krypton); each type of laser
produces light, either a characteristic
wavelength or a set of discrete wavelengths:
Gas Laser
Insulating Crystal Laser
Solid-state PN Junction Laser
Excimer Laser

Gas LASER
Types - Argon, Krypton, HeNe, Excimer
rear mirror

laser rod

gas reservoir

cathode

output mirror

anode

high voltage
power supply

Gas Laser
Laser materials: CO2, He-Ne, Argon, Krypton
Pump: electrical field (electrical pump)
Laser wavelength:

10600 nm for CO2

633 nm for He-Ne
488 and 515 nm for Argon
568 nm for Krypton

Gas LASER specifications

Argon:
expensive, high power
excitation: first 10 - 70 A, then 90 - 400 V
emission: 488, 514 nm, - 20 W, continuous
cooling: air (< a few Watts), water (higher)
lifetime: 1,000 - 10,000 hrs (factory refill)
cost: US$1,000s - 10,000s
Excimer:
expensive, very high power
emission: UV (~200 nm), < 100 W
pulsed (~100 ns, 10 - 1000 Hz)
lifetime: 100 - 1000 shots (user refill)
cost: US$35,000 - 50,000
HeNe:
inexpensive, low power
excitation: first 10 mA, then 2000 V
emission: 633 nm, 0.1 - 10 mW, continuous
lifetime: >10,000 hrs
cost: US$20 - 100

Solid state LASER

Nd: YAG (neodymium in yttrium-aluminum-garnet)
rear mirror

laser crystal

output mirror

arc or flash lamp

high voltage
power supply

The photons emitted from the crystal when it is excited by light energy
from the flash lamp are transmitted through the partially reflecting mirror
to the delivery system.

Insulation Solid Laser

Laser materials: ruby (Al2O3), neodymium (Nd3+) in
yttrium-aluminum-garnet (YAG)
Pumps: Xenon flash tube, Krypton arc lamp or tungsteniodine lamp (optical pump)
Laser wavelength:
693 nm for ruby
1060 nm for Nd: YAG

Semiconductor LASER
Diode Laser
electron donor
junction
power
supply

10

electron acceptor

~ 0.5 mm

Solid-state PN Junction Laser

(Diode Laser)
Laser materials: semiconductor PN junction
Pump: electrical field (electrical pump)
Laser wavelength:
760-905 nm for AlGaAs
1200-1550 nm for InGaAsP

Excimer Laser
Laser materials: Rare gases ( Argon, Krypton or
Xenon) combined with chlorine, fluorine, iodine
or bromine.
Pump: electrical field (electrical pump)
Laser wavelength:

New technology
Frequency doubled YAG lasers
Also known as the KTP/532 LASER. Emits a green
wavelength of 532 nm that is readily absorbed by
pigmented tissue.

Frequency doubled diode lasers

Pure green light

Dual fibre lasers

Both infrared and visible

Uses a frequency doubling crystal

Best crystals are made in China

LASER energy absorption by water

Wavelengths which are readily

absorbed by water (e.g., CO2) are
able to cut precisely (by vaporizing
cellular water) without causing
significant thermal injury to adjacent
tissue;

However, this also precludes their

use in liquid environments because
the energy is absorbed before it
reaches the target tissue.

Reproduced from Health Devices, ECRI. March 1995Vol. 24, No. 3

Tissue effects

Laser energy typically produces three zones of damage when

applied to tissue:

(1) a crater from which vaporized tissue is ejected;

(2) a zone of NECROSIS caused by boiling tissue;
(3) a zone of coagulation caused by thermal DENATURATION of
collagen.

Laser wavelengths produce depths of damage ranging from 50 m

for CO2 to 4,000 m for Nd:YAG energy using the FREE-BEAM
METHOD.

The depth of tissue effects for electrosurgery, by contrast, can range

from 1,000 to 5,000 m.

Vaporization versus Coagulation

Reproduced from Health Devices, ECRI. March 1995Vol. 24, No. 3

How do Lasers affect

the tissue?
Photo effects on mammal tissues:
Photochemical damage:
Light of high intrinsic energy breaks the chemical bonds in a
molecule and changes its conformation and causes dysfunction.

Photothermal damage:
Light causes a rise in temperature within the tissue by energy
absorption. The hydrogen bonds in molecules are relatively
weak and readily destroyed by heating.

Photodisruption damage:
Lights of short duration and high energy cause tissue to be
ionized (plasma formed), which literally tears molecules apart.

Photo Effects on Mammal

Tissue Versus Time

Photo Effects on Mammal

Tissue Versus Wavelength

Laser Effects on
Mammal Tissue

Example 1
Burning on mammal cornea

Example 2
Cutting on mammal cornea

Example 3
Cutting on mammal cornea

Lasers Application in
Ophthalmology
Photocoagulation
Photodisruption
Photorefraction

Photocoagulation

The photocoagulation effects on eyes depend on the properties of

both laser and target (tissue).

Common photocoagulation Lasers:

Note: Nd:YAG laser for photocoagulation is of continuous wave.

Photocoagulation

Extinction coefficient versus wavelength for hemoglobin

Hb

Photodisruption
Short-pulsed YAG Laser
Wavelength: 1064 nm
With He-Ne laser as aiming beam

Delivery Systems
Most ophthalmic laser systems consist of a laser module
a laser medium, laser pump, and cooling system that
is typically coupled to a slit-lamp biomicroscope by a
flexible fiberoptic cable.
Other laser-energy delivery systems include indirect
ophthalmoscopes, intraocular probes, and interfaces for
operating microscopes.
The ophthalmologist views the structures within the
patients eye and aims and focuses the laser through the
optics of the slit lamp; when the laser is fired, the energy
is delivered through these optics or through coaxial
optics.

Examples of Laser Devices:

Diode Laser with Slit Lamp

Diode Laser with Endoprobe

Diode Laser with Indirect

Ophthalmoscope

LASER Safety

Reproduced from Health Devices, ECRI. April 1993 Vol. 22 No. 4

LASER Safety

Reproduced from Health Devices, ECRI. April 1993 Vol. 22 No. 4

LASER SAFETY
Warning sign

Light signal
Door contact

LASER

Accessories

Protection curtain
Ventilation
and air filtering

Laser Safety Laser Classifications

ANSI (American National Standard Institute)
Class I: Very low power, safe to view.
Class II: Low power, safe to see for short time.
Class III: Medium power, not safe for brief viewing, but
no diffuse reflection hazard.
Class IV: High power, not safe for brief viewing;
reflection hazard.

Laser Safety Safety Measures

Safety goggles: Correct optical density for
laser wavelength
Safety signs
Training
Proper maintenance

Laser Safety Safety Goggles

Reproduced from Health Devices, ECRI. April 1993 Vol. 22 No. 4

DANGER
LASER SURGERY IN PROCESS - EYE PROTECTION REQUIRED

ARGON LASER (800 mW for 1 Seconds maximum)

Class IV

DANGER
LASER SURGERY IN PROCESS - EYE PROTECTION REQUIRED

Nd:YAG LASER (10mJ of Energy for 3nanosecond maximum)

Class IV

DANGER
LASER SURGERY IN PROCESS - EYE PROTECTION REQUIRED

ARGON LASER (2.5 Watt for 5 Seconds maximum)

Class IV

DANGER
LASER SURGERY IN PROCESS - EYE PROTECTION REQUIRED

DIODE LASER (2 Watt for 9 Seconds maximum)

Class IV

LASER REPAIR IN PROGRESS

Do Not Enter Unless Emergency

EYE PROTECTION REQUIRED

Laser safety summary

The power output of some ophthalmic lasers places them in the highest category
of risk (American National Standards Institute [ANSI] Class IV); stringent safety
precautions are necessary to protect staff, patients, and service personnel.

Protective shutters built into the equipment, filters incorporated into the slit-lamp
biomicroscope, and divergence of the beam at the exit optics help reduce the risk
of injury to clinicians during photocoagulation and/or photodisruption procedures
carried out through a biomicroscope.

Accessory lenses placed on the patients eye during treatment should have an
antireflective coating (ARC) because reflected laser light may exceed
occupational exposure limits for momentary viewing if bystanders are within the
lasers nominal hazard zone (the area in which direct, reflected, or scattered
radiation exceeds safe exposure levels).

When a handpiece is used in place of biomicroscopy, precautions must be taken

to minimize the chance of specular reflection from instruments, which could injure
observers eyes. Protective goggles should be used, and warning signs listing the
lasers type and class should be posted at all entrances to the laser suite.

Maintenance of Laser Devices

Typical problems *:
Symptom:

Possible cause:

no laser output

power supply
fiber optics
cooling system

burn point is off

aiming beam is not aligned with laser beam

incorrect output power output power need calibration

fiber optics is partially broken
* manufacturer authorized maintenance is recommended

Power Calibration
of Laser Devices
Tools required:
laser power meter;
service manual;

Setup power

Basic principle:
select testing point;
compare the setup power with meter reading;
adjust the output level until it meets the reading on the laser meter.

Measured power

Acknowledgements
ALCON Laboratories