LASERS IN OPHTHALMOLOGY

MODERATOR: DR. S. KALPANA

PRESENTER: DR. ANJALI

Brief outline
Introduction.
History
Laser

physics.

Classification
Laser
Uses

tissue interactions.

therapeutic.
- diagnostic.

Complications.

INTRODUCTION
LASER is an acronym for:
L : Light
A : Amplification (by)
S : Stimulated
E : Emission (of)
R : Radiation
Term coined by Gordon Gould.

Lase means to absorb energy in one form and to emit a

new form of light energy which is more useful.

HISTORY

1960 :The first laser was built by Theodore

Maiman using a ruby crystal medium.

1963 :

The first clinical ophthalmic use of laser

in humans.

1968 :

L Esperance developed the argon laser.

1971 :Neodymium yttrium aluminum garnet

(Nd.YAG) and Krypton laser develop.

1983 :Trokel developed the eximer laser.

LASER Vs. LIGHT

LASER

Stimulated emission
Monochromatic.
Highly energized
Parallelism
Coherence
Can be sharply focussed.

LIGHT

Spontaneous emission.
Polychromatic.
Poorly energized.
Highly divergence
Not coherent
Can not be sharply
focussed.

PROPERTIES OF LASER LIGHT

Coherency

Monochromatism

Collimated

Constant Phasic Relation

Ability to be concentrated in short time interval

Ability to produce non linear effects

LASER PHYSICS

Light as electromagnetic waves, emitting radiant energy

in tiny package called quanta/photon. Each photon has
a characteristic frequency and its energy is proportional
to its frequency.

Three basic ways for photons and atoms to interact:

Absorption
Spontaneous Emission
Stimulated Emission

HOW LASER WORK ???

HOW LASER WORK ???

Contd.

Continuous and pulsed

lasers

Pulsed energy delivered in brief

bursts, more power
Examples: Nd YAG, Excimer lasers
Continuous Argon, krypton lasers,
diode lasers, and dye lasers

CLASSIFICATION OF LASER

Solid State
Ruby
Nd.Yag
Erbium.YAG
Gas
Ion
Argon
Krypton
He-Neon
CO2
Metal Vapour
Cu
Gold

Dye
Rhodamine
Excimer
Argon Fluoride
Krypton Fluoride
Krypton Chloride
Diode
Gallium-Aluminum
Arsenide (GaAlAs)

THREE TYPE OF OCULAR PIGMENT

Haemoglobin:
Argon Green are absorbed , Krypton yellow. These
laser are found to be useful to coagulate the blood
vessels.

Xanthophyll:
Present in inner and outer plexiform layers of macula.
Maximum absorption is blue. Argon blue is not
recommended to treat macular lesions.

Melanin:
RPE, Choroid
Argon Blue, Krypton
Pan Retinal Photocoagulation, and Destruction of RPE

ABSORBTION SPECTRUM

ELECTROMAGNETIC SPECTRUM

LASER SAFETY

Class-I : Causing no biological damage.

Class-II : Safe on momentary viewing but chronic
exposure may cause damage.
Class-III : Not safe even in momentary view.
Class-IV : Cause more hazardous than Class-III.

LASER SAFETY REGULATION:

Patient safety is ensured by correct positioning.
Danger to the surgeon is avoided by safety filter
system.
Safety of observers and assistants.

LASER TISSUE
INTERACTION

LASER VARIABLE:
Wavelength
Spot Size
Power
Duration

TISSUE VARIABLE:
Transparency
Pigmentation
Water Content

Power density.

This is the amount of power delivered

to a unit area of tissue.

To prevent creating very intense

burn. Decrease in the spot size
should be accompanied by decrease
in power.

LASER TISSUE INTERACTION

LASER

TISSUE

Thermal
Effect

Photochemical

Photocoagulation

Photoradiation

Photodisruption

Photoablation

Photovaporization

Ionizing
Effect

THREE BASIC LIGHT TISSUE

INTERACTIONS
(1) Photocoagulation:
Laser Light

Target Tissue

Generate Heat

Denatures Proteins
(Coagulation)
Rise in temperature of about 10 to 20
coagulation of tissue.

C will cause

THREE BASIC LIGHT TISSUE

INTERACTIONS
Contd.
(2) Photodisruption:

Mechanical Effect:
Laser Light

Optical Breakdown

Miniature Lightening Bolt

Vapor

Quickly Collapses

Thunder Clap

Acoustic Shockwaves

Tissue Damage

THREE BASIC LIGHT TISSUE

INTERACTIONS
Contd.
(3) Photoablation:

Breaks the chemical bonds that hold tissue together

essentially vaporizing the tissue, e.g. Photorefractive
Keratectomy, Argon Fluoride (ArF) Excimer Laser.

Usually Visible Wavelength

Ultraviolet Yields :

Photoablation

Infrared

Photocoagulation

Photodisruption
Photocoagulation

PHOTOVAPORIZATION

Vaporization of tissue to CO2 and water occurs when its

temperature rise 60100 0C or greater.

Commonly used CO2

Absorbed by water of cells

Visible vapor (vaporization)

Heat
Cell disintegration

Cauterization Incision

PHOTOCHEMICAL EFFECT
PHOTORADIATION (PDT):

Also called Photodynamic Therapy

Photochemical reaction following visible/infrared light

particularly after administration of exogenous chromophore.

Commonly used photosensitizers:

Hematoporphyrin
Benzaporphyrin Derivatives

e.g. Treatment of ocular tumour and CNV

PHOTOCHEMICAL EFFECT
Contd.
Photon + Photosensitizer in ground state (S)

3S (high energy triplet stage)

Energy Transfer

Molecular Oxygen Free Radical

S + O2 (singlet oxygen) Cytotoxic Intermediate

Cell Damage, Vascular Damage , Immunologic

Damage

IONISING EFFECT

Highly energized focal laser beam is delivered on

tissue over a period of nanosecond or picoseconds
and produce plasma in target tissue.
Q Switching Nd.Yag

Ionization (Plasma formation)

Absorption of photon by plasma

Increase in temperature and

expansion of supersonic velocity

Shock wave production Tissue Disruption

iridotom
y

THREE BASIC COMPONENTS

A Laser Medium
e.g. Solid, Liquid or Gas

Exciting Methods
for exciting atoms or molecules in the medium
e.g. Light, Electricity

Optical Cavity (Laser Tube)

around the medium which act as a resonator

MODES OF LASER OPERATION

Continuous Wave (CW) Laser: It deliver their energy in a

continuous stream of photons.
Pulsed Lasers: Produce energy pulses of a few tens of
micro to few mili second.
Q Switches Lasers: Deliver energy pulses of extremely
short duration (nano second).
A Mode-locked Lasers: Emits a train of short duration
pulses (picoseconds).
Fundamental System: Optical condition in which only
one type of wave is oscillating in the laser cavity.
Multimode system: Large number of waves, each in a
slight different direction ,oscillate in laser cavity.

Delivery systems

Transpupillary: - Slit lamp

- Laser Indirect
Ophthalmoscopy

Trans scleral : - Contact

- Non contact

Endophotocoagulation.

Slit lamp biomicroscopic laser

delivery

Most commonly employed mode for

anterior and posterior segment.

ADVANTAGES:

Binocular and stereoscopic view.

Fixed distance.
Standardization of spot size is more
accurate.
Aiming accuracy is good.

Laser indirect ophthalmoscope.

Advantages :
Wider field(ability to reach periphery).
Better visualization and laser application in
hazy medium.
Ability to treat in supine position.(ROP/EUA)
Disadvantage : difficulty in focusing.
Difficulty to standardize spot size.
Expensive.
Un co-operative patient.
Learning curve.

USES

THERAPEUTIC.

DIAGNOSTIC.

LASER IN ANTERIOR SEGMENT

CORNEA:
Laser in Keratorefractive Surgery:
Photo Refractive Keratectomy (PRK).
Laser in situ Keratomileusis (LASIK).
Laser Sub epithelial Keratectomy (LASEK).
Epi Lasik.
Laser Thermal Keratoplasty .
Corneal Neovascularization.
Retrocorneal Pigmented Plaques.

EXCIMER LASER

High energy UV laser.

Excited dimer.
Argon fluoride(193nm) most
commonly applied for corneal
surgeries.
Photoablation.

EXCIMER LASER(contd)

Laser removes approximately

0.25microns of corneal tissue with
each pulse.
Amount of tissue to be ablated
derived from munnerlyn equation
Central ablation depth in
microns=diopters of
myopia*(ablation zone diameter in
mm)2
3

PRK

LASIK

FEMTOSECOND LASER
ADVANTAGES:
Flap are more accurate and uniform in thickness.
Centration of flap is easier.
Better adherence to underlying stroma.
Patient are more comfortable.
DISADVANTAGES:
Suction break
Costly

Contd.

FEMTOSECOND LASER

LASER IN GLAUCOMA

Laser Iridotomy.
Laser Trabeculoplasty (LT)
Selective Laser Trabeculoplasty
Trabecular ablation
Gonioplasty (Iridoplasty, Iridoretraction)
Pupilloplasty
Sphincterotomy
Iridolenticular Synechiolysis
Goniophotocoagulation
Goniotomy

Peripheral Iridectomy
Argon
Nd:YAG
Light Irides Dark Irides

Argon
Laser
Iridoplasty

Spot size (m)

50

50

200500

Spot duration
(seconds)

0.2

0.020.05 Fixed
0.20.5
(nanoseconds)

Power (mW)
1000
Number of spots per 1525
quadrant

Wavelength
Contact lens

Pretreatment

1000
25100

Argon green Argon

green
Abraham
Wise

Fixed

38 mJ
200400
15 shots
410
(each burst
consists of 13
pluses)
1064 nm
Argon green

Abraham,
Goldmann
Wise, or Lasag
CGI
Pilocarpine Pilocarpine Pilocarpine and Pilocarpine
and
and
apraclonidine
apraclonidi apraclonid or brimonidine
ne or
ine or

LASER
IRIDOTOMY

PUPILLOPLASTY
2-3 rows of burns
circumferentially 1mm
away from the pupillary
margin.
Innermost
row:8spots, 200micron
size, 200-400mW.
Outer row:1012spots,400micron
size,300-500mW

Stretching the updrawn

pupil
Laser parameters are
same for
photomydriasis.
Burns are placed along
the inferior margin.

ARGON LASER
TRABECULOPLASTY

Mechanism of
action:Mechanical.
Biological.

Argon laser trabeculoplasty

Parameters

Argon laser trabeculoplasty

Spot size (m)

50

Spot duration (seconds) 0.1

Power (mW)

200800

Number of spots per

quadrant

2025

Wavelength

Argon green

Contact lens

Goldmann

Anesthetic

Topical

Pretreatment

Apraclonidine or brimonidine

LASER IN GLAUCOMA
Contd.

Laser Filtration Procedures (sclerostomy):

Ab Externosclerostomy (Holmium)
Ab Internosclerostomy (Nd.YAG)

Contact

Non-contact

Cyclodestructive Procedures (cyclophotocoagulation)

Transscleral Cyclophotocoagulation
Trnaspupillary Cyclophotocoagulation
Diode Laser Endophotocoagulation

SCLEROSTOMY

AB INTERNO SCLEROSTOMY

LASER IN LENS

Posterior capsulotomy

Laser phacoemulsification

Phacoablation.

Laser in Lacrimal Surgery:

Laser DCR.

LASER IN VITREOUS

Vitreous membranes

Vitreous traction bands

LASER TREATMENT OF
FUNDUS DISORDERS

Diabetic Retinopathy

Retinal Vascular Diseases

Choroidal Neovascularization (CNV)

Clinical Significant Macular Edema (CSME)

Central Serous Retinopathy (CSR)

Retinal Break/Detachment

Tumour

LASER TREATMENT OF
FUNDUS DISORDERS
Contd.

ARMD

Retinal Vein Occlusion

Eales Disease

Coats Disease

Peripheral Retinal Lesion

Retinopathy of prematurity.

Informed consent

Patient should be explained about the

possible complications to avoid legal
problems to the treating physician
later.

CLASSIFICATION OF
CHORIORETINAL BURN INTENSITY

Light :

Barely visible retinal blanching

Mild

Faint white retinal burn

Moderate :

Opaque dirty white retinal burn

Heavy

Dense white retinal burn

Pathogenesis of diabetic macular

edema

DIABETIC RETINOPATHY
Contd.
TYPE OF RETINOPATHY

THERAPY

Background

Control of diabetes, regular

review

Maculopathy
CSME

Focal photocoagulation

Diffuse leakage around

macula

Grid laser

Circinate

Focal photocoagulation

Pre-proliferative Retinopathy Frequent review

Proliferative retinopathy

Pan retinal photocoagulation

Advanced diabetic eye

disease

Vitreoretinal surgery with

photocoagulation

Step 1

Step
2

Step
3

Step
4

Retinal hemorrhage

Retinal breaks and tears

Laser settings
Wavelength :argon
green, Nd YAG,dye
yellow red , diode.
Duration :0.10.2seconds.
Retinal spot size:
200-500microns.
Intensity : moderate
retinal whitening

Choroidal melanoma
Indication:
Photocoagulation
technique.
Initial destruction of
the surrounding
choroidal blood supply1-2rows -200-500
microns 0.5-1secintense burn.
Direct tumour
photocoagulation-low
energy burns long
duration5-30sec.

What is PDT ?
Visudyne (Verteporfin)
Selective Damage
of SRNVM.
Costly.

Standard Clinical Treatment

Parameters for Visudyne PDT

1. Dye dose = 6 mg/m2 body surface

area
2. Intravenous infusion over 10 min
3. Treatment at 15 min after start of
dye infusion
4. Laser light wavelength of at 689
nm, irradiance of 600 mW/cm2
and fluence of 100 J/cm2

Transpupillary thermotherapy

Thermotherapy can involve using

ultrasound, microwave, or infrared
radiation to deliver heat to the eye.
Retinoblastoma -application of diode
(infrared) laser to the tumor surface in
regions of disease activity.
Goal- cause tumor cell death by raising
the temperature of tumor cells to above
45C for ~1 min, thus reducing blood
supply and producing apoptosis.

Retinoblstoma
before treatment

Retinoblastoma after
thermotherapy

Lens

Uses

Image

Spot
Magnificati
on

Goldmann

Macula
Equator
Periphery

Virtual
Erect

1.08

360

Volk
Supermac
ula 2.0

Macula

Real
Inverted

2.15

700

Mainster
High
Magnificat
ion

Macula

Real
Inverted

1.34

750

Volk Area
Centralis

Macula
Equator

Real
Inverted

1.13

820

Field of
view

Lens

Uses

Image

Spot
Magnificat
ion

Mainster
Standard

Macula
Equator

Real
Inverted

1.03

900

Panfundu
scopic

Equator
Periphery

Real
Inverted

0.76

1200

Volk
Transequa
tor

Equator
Periphery

Real
Inverted

0.75

1220

Mainster
Wide Field

Equator
Periphery

Real
Inverted

0.73

1250

Field of
view

Lens

Uses

Image

Spot
Magnificat
ion

Volk
QuadrAsp
heric

Equator
Periphery

Real
Inverted

0.56

1300

Mainster
Ultra Field
PRP

Equator
Periphery

Real
Inverted

0.57

1400

Volk
SuperQua
rd 160

Equator
Periphery

Real
Inverted

0.56

1600

Field of
view

PAttern SCAn
Laser(PASCAL)

The PASCAL Photocoagulator is an integrated semiautomatic pattern scan laser photocoagulation system
designed to treat ocular diseases using a single shot or
predetermined pattern array.
Laser source:Nd:YAG laser.

Delivery device:slit lampor laser indirect

ophthalmoscope (LIO)

Control system for selecting power and duration

Method for selecting spot size

DIAGNOSTIC USE OF
LASERS

Scanning Laser Ophthalmoscopy

allows for high-resolution, real-time motion

images of the macula without patient
discomfort.

SLO angiography: to study retinal and

choroidal blood flow.

May be used to perform microperimetry, an

extremely accurate mapping of the maculas
visual field.

Optical Coherence Tomography

Uses diode laser light in the nearinfrared spectrum (810 nm) to

produce high-resolution crosssectional images of the retina using
coherence interferometry.

Complications

General complications:
Pain
Seizures.

Anterior segment complications:

Elevated

IOP.
Corneal damage.
Iris burns.
Crystalline lens burns.
IOL and PC damage.
Internal opthalmoplegia.

Complications(contd)

Choroidal detachment and exudative RD.

Choroidal ,subretinal and vitreous

hemorrhage.

Thermal induced retinal vascular

damage.

Preretinal membranes.

Complications(contd..)

Ischaemic papillitis.

Paracentral visual field loss and

scotoma.

Photocoagulation scar enlargement.

Subretinal fibrosis.

Iatrogenic choroidal
neovascularisation.

Lasers can.

Save a childs eye as in Retinoblastoma.

Change a personality as in LASIK.

Cure a middle aged person with Glaucoma.

Restore Vn. in a person with After-Cataract.

Preserve & Retain Vn. in pts. with DR & ARMD

The possibilities are endless...

References
YANOFF

AND DUKER
OPHTHALMOLOGY- 3rd edition.

LASERS

IN OPTHALMOLOGY
A practical guide-AIIMS.

LASER

SURGERY OF THE POSTERIOR

SEGMENT- Steven M. Bloom

Thank you