Laser Techniques in Ophthalmology: A Guide To YAG and Photothermal Laser Treatments in Clinic 1st Edition Anita Prasad
Laser Techniques in Ophthalmology: A Guide To YAG and Photothermal Laser Treatments in Clinic 1st Edition Anita Prasad
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Laser Techniques in
Ophthalmology
Laser Techniques in
Ophthalmology
A Guide to YAG and Photothermal
Laser Treatments in Clinic
Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
0.1 Lasers in Ophthalmology (Diagnostic and Therapeutic). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
vii
Table of Contents
viii
Table of Contents
ix
Table of Contents
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
x
Acknowledgements
Writing this book has been a rewarding and A big thanks to Amy, Tom, and Mike from
fulfilling experience. I hope to bring a trainer’s medical illustration, for their help and advice in
perspective, giving essential laser training collating images for the book.
some structure, based on knowledge and To the trainees who jogged my memory,
clinical experience. and proofread the book in its early stages
The book concentrates on common laser with encouraging feedback. Thank you, Luke,
techniques in the eye clinic, bringing clarity Francis, Alex, James, Connor, Sejal, Shoaib, and
on treatment concepts, techniques, and plans, Ellie. I hope you learnt as much from me as
developing good clinical practice and skill I have from teaching you.
sets, with an easy to understand, user-friendly Thanks to Gwyn and Patrick for their initial
approach, using multiple digitally enhanced input and encouragement, and to Shivangi,
illustrations, for ready reference in the laser Himani, and everyone on the publishing team.
clinic. I could not have done this without your help.
xi
Trainee Feedback
I am not aware of any existing book that The pictures are good, in particular I like the
approaches this subject in this way. I think treatment plan ones with areas you might deliver
ophthalmic trainees nationally and internationally lasers. I would have felt a lot more confident having
would find appeal in a book that provides a read this before doing my own cases. I think the
structured theoretical grounding in the subject format with boxes is good with good snippets of
with a practical approach to using ophthalmic information.
lasers. The use of illustrations is vital for teaching
JP
this subject and the approach used by annotating
these images in this book is ideal for demonstrating
techniques.
LP
xiii
About the Author
Anita Prasad is an ophthalmologist with an enhanced images to highlight learning points
interest in medical retina, with over 25 years and simplify techniques, making it easy for
of experience, and a laser lead and trainer at learners to get started with lasers. Outside of
ABUHB Trust for over 20 years. It has given medical work, Anita is an artist, dabbling in oils
her a unique insight and approach into an and acrylics, and enjoys reading, cooking, and
area that is not well taught, using digitally community work.
xv
Glossary
Absorb: To transform radiant energy into a Hertz (Hz): Measurement of frequency of light
different form, usually with a resultant rise (cycles / second)
in temperature Intensity: Magnitude of radiant energy / light
Amplification: Growth of the radiation field per unit time or area
in the resonator cavity from multiple Joules: Measurement of laser energy in time –
reflections between the cavity mirrors watts / second, for pulsed laser
Amplitude: The maximum value of Lifetime: Time taken for an excited atom to
electromagnetic wave height spontaneously decay back to ground state
Bandwidth: The width of the optical spectrum or a lower energy state
of light, expressed in wavelength units Luminance: The flux / unit area
(m) or frequency units (Hz) Monochromatic: Light consisting of single
Brightness: The luminous power of a light beam wavelength of light
Coherence: Waves that are synchronized, with Nanometre: Unit of length =1 billionth of a
phase difference between their oscillations meter, used to measure wavelength
remaining constant as they propagate. This OHT: ocular hypertension
allows laser light to be concentrated into Optical density: Protection factor of eyewear
small spots, or ultra-small pulses filter used with lasers. Each unit of OD
Collimation: Process by which divergent rays represents ×10 increase in eye protection
(natural light) are converted to parallel rays Optical fibre: Light or laser transmitting optical
CNV: Choridal neovascular membrane material for great distances
CW mode: Continuous emission of Optical pump: Exciting a lasing material using
electromagnetic wave of constant light as the external source
frequency or wavelength and amplitude, at PCO: Posterior capsular opacification
constant power Photon: Smallest packet of light energy. Energy
Depth of field: The working range of the beam, is directly proportional to the frequency
based on wavelength and laser focusing of light
mechanisms Population inversion: State when the atoms
Energy: Measurement of laser light to induce in the excited state exceed atoms in the
change (heating / cutting), measured in ground state; forms the basis for stimulated
watts. Energy is inversely proportional to emission
wavelength. Power: Energy / unit time measured in watts.
Excited state: State of higher energy of an atom Power is constant in CW laser or variable
or molecule in a pulsed laser
Flashlamp: Source of powerful light used Power density: Laser power / surface area
to excite stimulated emission in a solid- (spot size) on which it works. Increasing
state laser power or decreasing spot size will increase
Flux: The radiant or luminous power of a power density. Excessive power density
light beam can rupture Bruch’s membrane and
Fluence: All laser irradiance =laser irradiance + cause choroidal neovascularisation.
any backscattered irradiance. POAG: Primary Open angle glaucoma
Frequency: Number of light waves / complete Pulsed mode: Light emitted in short bursts
vibrations in a fixed period of time. or pulses of highly concentrated energy.
Frequency is inversely proportional to the Energy of laser in pulsed mode is much
wavelength of light greater than CW lasers
IOL: Intraocular lens Q-switch: Shutter device that allows laser
Irradiance: Laser power per unit area =watts / energy to be released in small pulses.
cm2. It is a measure of how strongly laser Energy is only released when it reaches a
works on a given tissue higher power
Gain: The increase in energy through Radiance: A measure of how strong a laser is
amplification Raman effect: When a wavelength of light can
Gain medium: The lasing medium that provides be changed by molecular scattering
the atoms / molecules for stimulated Refractive Index: Property of a medium that
emission and coherent amplification determines how light propagates through
Ground state: The state of lowest stable energy it. RI of vacuum is 1 and of water is 1.33
level in an atom or molecule (This means that light travels 1.33 times
Heat sink: Substance or device used to absorb more slowly in water than vacuum). RI
or dissipate unwanted heat determines how light bends when passing
xvii
newgenprepdf
Glossary
through a medium. RI of lens –1.386, inversion; forms the basis of laser light
vitreous –1.336, RI of silicon oil > RI of generation
vitreous Wavelength: The distance an EM wave travels
Resonator: The optical cavity with mirrors on during 1 cycle of oscillation. Property of
each end that amplifies the stimulated light that determines its colour, measured
emission, generating a laser beam in nanometres. Monochromatic light has
Spontaneous emission: Emission of a photon a single wavelength, while polychromatic
of light by spontaneous decay of an light is multi-coloured. Wavelength
excited atom determines how effectively light penetrates
Stimulated emission: External source of ocular media and how well it is absorbed
energy / photon that stimulates atoms by the target tissue
to get excited and achieve population
xviii
Introduction
Introduction
LASER is an acronym for Light Amplification haemorrhages. Surgical lasers can cut,
by Stimulated Emission of Radiation. To lase coagulate, and remove tissues, with minimal,
is to absorb energy in one form and emit a new no-touch techniques, improving outcomes. New
more useful form of energy. concepts and advances have improved laser
Lasers were first conceptualized by safety and delivery including eye-tracking
Albert Einstein (1917). The first prototype feature, subthreshold, shorter pulse and
photothermal laser was built by Theodore multispot lasers.
Maiman (1960), and they have since become Lasers have branched into diagnostic
essential tools in ophthalmic practice. Recent realms, including the laser-based microscopic
technological advances and new concepts have technique for early diagnosis of ocular (ARMD,
renewed interest in the topic. glaucoma) and neurodegenerative conditions
Lasers can be generated in a spectrum like Alzheimer’s disease. Laser technology is
of wavelengths (short UV to long IR) with used in investigative techniques such as laser
a multitude of applications including interferometry, spectroscopy, microperimetry
electronics, information technology, science, mapping of macula, confocal scanning laser
medicine, entertainment, military, industry, ophthalmoscope (CSLO), optical coherence
and law enforcement. Modern fibre-optic tomography (OCT and OCT-A), and laser
communication technology such as the Internet retinal Doppler flowmetry.
uses lasers.
0.1 L
ASERS IN OPHTHALMOLOGY
(DIAGNOSTIC AND THERAPEUTIC)
Lasers can reshape corneas to improve focus,
improve IOP in glaucoma and cauterize
DOI: 10.1201/9781003144304-1 1
Laser Techniques in Ophthalmology
2
Basic Principles of Laser
DOI: 10.1201/9781003144304-2 3
Laser Techniques in Ophthalmology
4
Basic Principles of Laser
◾ Energy is directly proportional to ◾ The blue and UV end of the spectrum has
frequency –higher frequency has higher more energy than the red or IR end of the
energy and a shorter wavelength. spectrum.
1.1.3 How Does an Atom in the Ground of light stimulates it, electrons absorb the
State Move to an Excited State? photon energy and move up to an excited,
higher energy state –absorption.
◾ Normally, atoms in a medium are in a stable,
low-energy ground state. When a photon
5
Laser Techniques in Ophthalmology
◾ Electrons do not stay excited forever. They electrons at ground state to get excited or
decay spontaneously by releasing energy already excited atoms to reach higher levels
and move down to a lower level of energy or of energy. Eventually, a point is reached
back to the ground state. where the number of excited electrons is
greater than electrons in ground state –
◾ The decay time is called lifetime.
population inversion.
◾ Decay to a lower orbit releases a photon
◾ Population inversion leads to spontaneous
(energy) – spontaneous emission.
emission of higher energy photons, which
◾ The energy of an emitted photon is the stimulates more electrons –stimulated
difference between the stimulating energy emission.
and end energy (same as the stimulating
◾ If this process is repeated multiple times, it
energy if decay is to ground level or lower if
generates an extremely high level of energy –
decay is to a less excited level).
light amplification.
◾ The emitted photon has the same
◾ The newly emitted photons have the same
phase, direction, and wavelength as the
frequency and direction as the stimulating
stimulating photon.
photons. Stimulated emission is effectively
◾ So, transition of electrons up or down the a process of cloning photons, amplifying
orbit is accompanied by absorption or light, and forms the core principle of laser
emission of a replica photon. action.
6
Basic Principles of Laser
Laser pump –External energy to excite atoms and start process of stimulated emission.
Pumping can be by Variety of laser pumps used
• Continuous discharge lamp for CW laser • Optical pump –flashlamp, arc lamps, light from
another laser (diode).
• Intermittent flashlamp for intermittent pulses. • Chemical reactions
• Explosive devices
• Electric currents in semiconductors.
• Pulse duration varies from CW to femtoseconds.
• A laser can fire a single shot or repetitive bursts
of pulses.
Laser or gain medium –Determines laser properties and emitted wavelength.
Provides atoms, electrons, or ions to be excited by the pump.
Gas lasers –Gas enclosed in a tube and pumped by electrical discharge. Three types:
Atomic lasers Ionic lasers Molecular lasers
Example Helium-neon Argon, krypton CO2 laser
Pump Electric Electric Electric, radio waves
Lasing medium Neon atoms Argon, krypton ion CO2 molecule (10–15% CO2 gas)
Role of other Helium carries Nitrogen is transport gas
molecules electric charge to Helium is heat sink gas
neon atom
Wavelength emitted 633 nm, used in 315–529 nm 10600 nm –thermal IR in cutting,
optical research labs 458, 488, 514 nm welding, used in dermatology
Liquids lasers –Active medium is an organic dye (rhodamine), dissolved in a liquid solvent (ethanol or
ethylene glycol), in a glass chamber, pumped by another laser; emits across entire EM spectrum.
Free Electron Lasers (FEL) –Active medium is an electron beam from a particle accelerator. Generates
tuneable wavelengths in widest frequency range of any laser.
Excimer lasers –excited diatomic molecule (excited dimer) –electrical pumping forms an unstable diatomic
molecule (from union of 2 rare gases or a rare gas with a halogen). UV emission occurs when unstable diatom
dissociates back to the constituent atoms. Examples: argon fluoride –193 nm, krypton chloride –222 nm, krypton
fluoride –248 nm, xenon chloride
7
Laser Techniques in Ophthalmology
Metal-vapor lasers –hybrids lasers (features of atomic and ionic lasers). Examples: helium-cadmium laser,
helium-copper, helium-gold lasers.
Chemical lasers –two highly reactive gases form a molecule which becomes the lasing medium. Emit IR
spectrum (2700 nm–3800 nm). Example: hydrogen fluoride (HF).
Solids state lasers –use cylindrical crystal (YAG, sapphire) or glass rod that has been doped with the active
lasing medium. The crystal is used for its mechanical, thermal, and optical properties.
•
The dopant or lasing medium is a 1% impurity such as chromium, erbium, neodymium, titanium,
holmium, and ytterbium ions added to the crystal.
•
Normally, solid state lasers emit in the infrared spectrum but can be made to emit a wide range of
wavelengths by using a variety of crystals and harmonic generation or frequency doubling.
•
Example: Nd-YAG emits 1064 nm (IR), but can be frequency-doubled 532 nm PASCAL (green, visible), tripled –
355 nm, and quadrupled –266 nm (UV) rays, by using KTP crystal.
•
They are pumped by a flashlamp or light from another laser. A flashlamp is not the most effective as 70% is
wasted as heat in the crystal, requiring cooling.
•
A laser-generating higher frequency-monochromatic light is a better pump (diode laser).
• A CW solid laser causes tissue heating (IR emissions), and is best operated in a pulsed mode, using
Q-switch or mode lock to generate ultra-short pulses.
Dopant Examples of laser Wavelength generated
Neodymium Nd –yttrium aluminium garnet (YAG) Near IR –1064 nm, can be made to emit other
Nd –yttrium orthovandate (Nd-YVO4) wavelengths (tuneable)
Nd –yttrium lithium fluoride (Nd-YLF)
Titanium Ti –sapphire laser IR, highly tuneable
Holmium Ho –YAG laser Far IR –2097 nm
Chromium Cr –sapphire laser (ruby laser) Near IR spectrum
The resonator cavity –optical cavity around the laser medium with highly reflective mirrors at each end, to
reflect photons multiple times, cause amplification, and improve laser efficiency.
•
Amplification and directionality of beam –multiple reflections increase energy exponentially; only
parallel beams get reflected.
•
Use of other optical devices –spinning mirrors, modulators, absorbers, filters, and crystals, placed in the
cavity to alter laser wavelength or pulses’ duration.
•
Provides means of controlling laser usage –output mirror is 95% reflective, allowing controlled release of
laser for tissue effect.
8
Basic Principles of Laser
9
Laser Techniques in Ophthalmology
10
Basic Principles of Laser
11
Laser Techniques in Ophthalmology
12
Basic Principles of Laser
13
Laser Techniques in Ophthalmology
◾ Eyepiece lens –Magnifying lenses (+10/ corneal or lenticular damage, with media
+12D), with refractive adjustments from +7 opacities or poor focus.
to −7 dioptres, housed in converging tubes
◾ Defocused beam delivery (Ellex) –beam
(10–16°), to provide good stereopsis. Eyepiece
has high divergence, which reduces laser
IPD can be adjusted, from 52mm to 78mm.
energy at the cornea and minimizes risk of
The slit lamp has three types of laser delivery inadvertent corneal burns. As the 2 focal
systems: planes are not the same, the spot is less well
defined.
◾ Parfocal system (Zeiss, PASCAL) –Slit
lamp and laser have the same focal plane, ◾ Surespot system (Lumenis) –defocused
with low beam divergence (parallel beam), system with a more controlled spot, to
leading to a sharp spot, uniform energy improve precision, reduce power density at
delivery and well-defined retinal burn. The the cornea, and increase laser efficacy and
size of the beam is the same at the cornea, safety.
lens, and retina, leading to potential risk of
Slit lamp examination and laser treatment is preferably done in a semi-dark room
Adjust eyepieces, for IPD, refractive errors, and focus.
• Set IPD slightly less than normal to account Setting slit lamp eyepiece focus.
for proximal convergence of slit lamp. •
Use focusing rod (in slit lamp drawer). Mount it in front of
• Set a fraction more minus than user microscope, by removing the flat groove alloy plate. Set slit
refractive error to overcome proximal beam 1–2mm wide and direct it at the centre of the rod.
accommodation and convergence of the •
Set one eyepiece at a time, by moving from the +side of
eyepieces. scale, until the image first appears sharply focused (to avoid
• Set focus of eyepiece when first using slit stimulating accommodation)
lamp or laser. •
Make a note of the readings on the eyepiece and use this in the
future. You do not need to use the focusing rod after this first
occasion.
• Adjust table height and chin rest for comfort.
• Ensure slit beam is evenly illuminated with sharply demarcated edges.
• Pull joystick back and move slit lamp in to focus on area of interest. The final focus is sharpened by
small movements of the joystick.
Set Slit Parameters
•
Slit brightness –Just visible level. Excessive brightness causes glare, adversely affecting procedure and
safety.
•
Slit height –Tallest position (remains unchanged during treatment).
•
Slit width –moderate wide (5–6mm), keeping disc and fovea in view.
•
Narrow slit –reduces FOV (smaller area of illumination) but increases depth of focus, useful to identify
subtle details, treat mA, and sharpen focus.
•
Wide slit –allows larger FOV, good for faster treatment in PRP.
•
Do not make the slit so narrow that you lose your bearings on the retina.
Set slit lamp magnification
Low ×6 for initial examination and PRP
High magnification ×10 or ×16 for details and FLT
1.3.2 Binocular Indirect Ophthalmoscopy ◾ Fundal view and spot size are influenced by
(BIO); Laser Indirect Ophthalmoscopy (LIO) lens used, working distance, and patient’s
BIO offers good illumination, stereopsis, refractive error.
and FOV but lower magnification and can be Indirect ophthalmoscope-delivered laser (LIO) –
difficult to learn. Movements affect size and For retinal vasculopathies and peripheral retinal
clarity of the fundal image. diseases, in patients where slit lamp delivery
◾ Fundal image is inverted and laterally is difficult (anxious, physically or mentally
transversed. handicapped patients, paediatric patients,
presence of media opacities, perioperative laser
◾ Power of condensing lens determines treatment after surgery). Patients lie supine –a lid
retinal magnification and field of view. speculum is used to keep the eye open and saline
◾ The 20D lens with working distance drops to keep the cornea moist.
of 47mm provides a reasonable FOV, LIO is a less controlled method of laser
stereopsis, and magnification, and is the delivery, with no standardization of spot size
most common lens used. and inability to treat the posterior pole safely.
14
Basic Principles of Laser
Laser variables:
Laser wavelength (affects energy)
Spot size (affects irradiance=
power/area)
Laser power (watts=energy/time)
Pulse duration –affects power
Tissue variables:
Tissue transparency
Tissue pigmentation
Tissue water content
16
Basic Principles of Laser
17
Laser Techniques in Ophthalmology
1.4.3 Starling’s Law and Macular Oedema and proteins leak out, tissue oncotic pressure
Starling’s law explains water exchange between increases, attracting more fluid out and increasing
vascular and extracellular tissue compartments the oedema. The process is controlled by VEGF,
in formation of vasogenic oedema, stating that which in turn is influenced by oxygen levels.
◾ If hydrostatic pressure =oncotic 1.4.4 How Does Focal Laser Treatment
pressure –there is no movement between 2 Reduce Macular Oedema?
compartments.
The exact mechanism is unclear and likely
◾ If oncotic pressure > hydrostatic pressure, to be multifactorial. It is established that
fluid will leak out, causing oedema. retinal blood flow and vessel diameters
are inversely related to oxygen tension.
◾ If hydrostatic pressure > oncotic pressure, it
FLT increases retinal oxygenation, causing
will drive fluid out, causing oedema.
vasoconstriction, reducing blood flow,
Retinal arterioles are resistance vessels that hydrostatic pressure, and oedema.
control hydrostatic pressure downstream.
Diameter of retinal arterioles is controlled ◾ Direct coagulation of leaky capillaries
by oxygen levels. In hypoxia, arterioles dilate, reduces vascular permeability and oncotic
reducing resistance and increasing blood flow pressure.
downstream, increasing the hydrostatic pressure, ◾ Reduced hydrostatic pressure (improved
causing capillary dilatation and leakage. As fluid oxygenation causing vasoconstriction).
18
Basic Principles of Laser
19
Laser Techniques in Ophthalmology
1.5 L
ASER HAZARD AND LASER dangerous, as they do not stimulate the
SAFETY PROTOCOLS protective blink reflex. Skin injury is more
Lasers are associated with potential hazards likely with prolonged exposure. UV rays cause
for patients and clinicians, and laser safety is sunburn type injury, while visible and IR rays
paramount to avoid laser related accidents. cause thermal damage.
The hazards relate to phototoxicity from The extent of injury depends on laser
high radiance (brightness) and high irradiance wavelength, energy, exposure time, spot size,
(ability to be focused into a small spot of and target tissue factors (reflectivity, absorption,
concentrated energy), making lasers extremely dispersion, and thermal properties). Short
dangerous to work with. wavelengths and short pulses equate to higher
Visible and near IR light (400–1400 nm energy with higher risk of injuries.
wavelength) can penetrate ocular media,
1.5.1 Laser Classification and
causing retinal damage. UV and IR wavelengths
Safety (ANSI Standards)
(<400 nm and >1400 nm) are absorbed by the
cornea and lens, causing corneal burns and Lasers’ safety is classified by their wavelengths
cataracts. IR wavelengths are particularly and their maximum output power.
Classification of lasers –based on accessible emission limits (AEL) –maximum power (watts) or energy (joules)
that can be emitted in a specified wavelength range and exposure time.
Class 1 lasers Safe under all conditions, due to low output or enclosed laser –no risk of exposure.
Example: CD player, laser printer
Class 2 lasers Associated with exposure to very bright light. Output power is up to 1 mw. Relatively safe
because blink reflex reduces exposure to <0.25 sec. If blink reflex was supressed or patient
stared into laser light, eye injury can occur. Example: supermarket scanner, laser light toys.
Class 3 lasers 3A lasers –output power is up to 2.5 mw, dangerous if used with optical instruments that
focus light and increase power density. Examples:Laser pointers, laser sight on firearms.
3B lasers –output is 5–500 mw. Dangerous if enters the eye, protective eyewear
recommended, risk of skin burns, fire hazard. Diffuse reflection is safe, but specular
reflection is dangerous.
Class 4 lasers Power output >500 mw, high risk of ocular and skin injury, dangerous with both specular
and diffuse reflections. Includes all industrial, scientific, military, and medical lasers.
Protective eyewear recommended.
MPE –maximum permissible exposure –highest irradiance (power density w/cm2), or fluence (energy
density – J/cm2) of light that is considered safe, measured at the cornea at a given wavelength and exposure
time. It is usually 10% of the dose causing damage 50% of the time. MPE for UV and IR rays > visible rays,
with a higher risk of injury.
Laser hazards are classified as non-beam and Skin injuries –photochemical effects of mid/
beam related hazards. far UV rays cause sunburns, reddening, blisters,
Ocular injury can be reversible or permanent. premature ageing, and skin cancers (UV –290–
Inadvertent exposure causes headache, 320 nm). Thermal burns are rare –they occur
lacrimation, gritty sensation, floaters, sudden with high energy and prolonged exposure (CO2
visual loss with macular burn, or gradual loss and some IR lasers). There is a higher risk of
from cataract, reduced retinal sensitivity, and burns in photosensitive patients (idiopathic or
colour vision. drug related).
20
Basic Principles of Laser
Beam-related hazards
Wavelength ranges Pathological effects
180–315 nm (UV-B, UV-C) Photokeratitis, corneal inflammation, erythema, increased skin
pigmentation, accelerated skin aging, skin cancer
315–400 nm (UV-A) Photochemical cataract, skin pigmentation, skin burns
400–780 nm (visible light) Photothermal retinal injury, skin pigmentation, light photosensitivity,
cataract, skin burn
780–1400 nm (near IR) Cataract, retinal burn, skin burn
1400–3000 nm (IR) Aqueous flare, cataract, corneal burn, skin burn
>3000 nm (far IR)
Type of beam exposure
Direct exposure or indirect exposure (reflections from grade 4 lasers).
Specular reflection –from flat reflectors (mirror) –risk of harm is high.
Diffuse reflection –from irregular reflectors (jewellery, metal tools) –lower risk of harm.
A surface may be a diffuse reflector for one, but specular for another wavelength.
Factors that affect laser hazards
Laser parameters
Wavelength (determines UV rays (180–390 nm), mid-far IR (1400 nm–1 mm) –corneal and lens injury.
energy and absorption) Visible and near IR (400–1400 nm) penetrates ocular media, absorbed by the
retina and macula. Maximum retinal absorption is at 400–570 nm, making
Argon and PASCAL lasers hazardous for eye injuries.
Energy Higher energy –higher risk of injury.
Shorter wavelength (UV) has higher energy than longer (IR) wavelengths.
Spot size Smaller spot (focused laser) has higher energy density with higher risk of
injury, especially if used with high energy. (Reduce power with small spots.)
Pulse duration A short pulse is associated with a risk of photomechanical injury, while a
long pulse is associated with photothermal injury (longer exposure).
Pulse Repetition Faster rate – associated with less heat dissipation and phototoxicity.
Eye factors –the biconvex lens acts as a magnifier and focuses laser light on the retina. Even a low-powered
laser or diffuse laser reflection can cause retinal injury.
Self-defence mechanisms –blink reflex, light aversion, and head turn protect against visible light. UV and IR
lasers do not stimulate the blink reflex and can be harmful. Sustained exposure with laser pointer directed at
an eye can cause injury.
Size of pupil –small pupil is associated with lesser exposure.
Degree of pigmentation in target tissue –dark fundi have a higher risk of injury.
Aphakia and Pseudophakia –aphakes have a clear media and pseudophakic IOL focuses laser light,
increasing the risk of injury.
Laser Room
21
Laser Techniques in Ophthalmology
22
Basic Principles of Laser
Safety eyewear needed is based on Maximum Permissible Exposure (MPE), Nominal Ocular
Hazard Area (NOHA), and Nominal Ocular Hazard Distance (NOHD) for each delivery device and
configuration of treatment room. For additional information, refer to the laser device’s user manual
and international laser standards and guidelines.
23
Laser Techniques in Ophthalmology
Unfocused spot is large with smaller cone angle. This means Focused spot is small and cone angle is large. Laser
that the laser energy is still concentrated around the spot, with beam diverges quickly before and after the focused
a higher risk of damage to surrounding tissues (purple dot). spot, reducing risk of damage to surrounding tissues
• Cone angle is related to laser safety. A CL focuses the spot sharply, increasing the cone angle, with
sharp divergence of laser beam before and after, reducing laser concentration around the spot.
• A large cone angle means a small, focused spot with more intense tissue effects. This:
• Reduces laser energy requirement.
• Reduces risk of collateral damage, and increases laser safety.
•
Phakic eye –air in cavity (RI of 1.00) –Increases posterior lens convexity, increasing lens power
significantly (myopic shift).
•
Aphakic eye with air –posterior corneal surface changes from a weak concave to a strong concave lens,
neutralizing the power of the anterior cornea, allowing a fundal view without any optical aides/lenses.
•
Phakic eye with silicone oil –RI of silicone oil > normal lens, so silicone oil acts as a concave lens on the
posterior lens surface (normally a weak convex lens), making it into a weak concave (negative) lens –
hypermetropic shift.
•
Aphakic eye with silicone oil –the posterior corneal surface is normally a low-power concave lens.
Silicone oil in the cavity acts as a convex lens at the posterior corneal surface causing a slight myopic shift.
•
Pseudophakia with a flat posterior surface IOL –no change, as flat surfaces do not have any refractive
power.
24
Basic Principles of Laser
25
Laser Techniques in Ophthalmology
26
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