CHAPTER 1

Practical
Considerations—
Laser Application
 4 LASER IN OPHTHALMOLOGY

Laser (an abbreviation for Light Amplification by Stimulated

Emission of Radiation) is the equipment capable of emitting
a powerful, highly monochromatic and coherent beam of
electromagnetic radiation. Monochromatic electromagnetic
radiation is meant for single frequency or single wavelength
and eliminates chromatic aberration. Coherent beam means
all photons produced are in phase with each other with
limited divergence.

Laser Tissue Interactions

Laser interaction with various tissues of the eye may be
classified into following categories (Fig. 1.1).

Photocoagulation
In photocoagulation temperature of treated tissue is
increased from 37°C to at least 50°C, resulting in dena-
turation of tissue protein and coagulation at the absorbent
tissue site. This results from conversion of light energy to
heat energy.
The monochromatic light from laser is absorbed by
melanin, xanthophyll present in the macula and hemo-
globin.
Melanin pigment universally absorbs light spectrum
between 400 and 700 nm whereas, xanthophyll and
hemoglobin pigments are selective absorber. Melanin
pigment is the principal absorber of light in photo-
coagulation of trabecular meshwork and co-absorber of light
in retinal pigment epithelium (melanosomes) and choroids
(melanocytes). The longer the wavelength, the deeper the
chorioretinal burns. Hence, Argon laser (514.5 nm) and freq-
doubled Nd: YAG (532 nm) laser are absorbed at the level of
the retinal pigment epithelium (RPE) and choriocapillaries
whereas, Krypton red (647 nm) and diode laser (810 nm)
Fig.1.1: Various laser tissue interactions and the type of laser involved
PRACTICAL CONSIDERATIONS—LASER APPLICATION
5
 6 LASER IN OPHTHALMOLOGY

produce deeper lesion in the choroids. The appearance

(ophthalmoscopic) of optimum/threshold retinal burn in
argon laser and freq-doubled Nd: YAG laser (green/KTP)
will be the same and quite different from the krypton red
and diode laser photocoagulation burn. So, similar
appearing krypton red and diode laser retinal photo-
coagulation burn will be markedly of higher threshold and
will cause more extensive choroidal damage and pain as
compared with argon laser and freq-doubled Nd: YAG laser
burn.
Xanthophyll pigment is present in the inner and outer
plexiform layers of retina of the macular area. They absorb
blue light maximally and green light poorly. Hence, in
macular photocoagulation blue light (blue-green argon
laser) will cause unwanted inner retinal damage. Therefore,
argon green laser (514.5 nm) and freq-doubled Nd: YAG
laser (532 nm-green/KTP) are preferred over argon blue-
green laser in macular photocoagulation.
Hemoglobin absorbs blue, green and yellow light
considerably and red light poorly. The shorter wavelength
yellow lights are more easily absorbed. The red and near
infrared wavelength lights are totally unabsorbed by the
hemoglobin.

Lasers Commonly Used in Photocoagulation

CW green Argon laser (514.5 nm)
• It is absorbed selectively at the retinal pigment
epithelium (RPE), hemoglobin pigments, chorio-
capillaries, layer of rods and cones and at the outer and
inner nuclear layers.
• It is readily absorbed by the melanin granules.
• It coagulates from choriocapillaries to inner nuclear layer
of the retina.
 PRACTICAL CONSIDERATIONS—LASER APPLICATION 7

• It is suitable for photocoagulation of retinal pigment

epithelium (RPE), choroids and blood vessels.

Freq-doubled Nd: YAG laser (532 nm)

• It produces a pea-green beam.
• It is often termed as “green Nd: YAG laser” or “KTP
laser”.
• It is more highly absorbed by hemoglobin (Hb) and the
melanin present in retinal pigment epithelium (RPE) and
trabecular meshwork than the argon laser beam. It
coagulates from choriocapillaries to outer nuclear layer
of the retina.
• It is small and portable like diode laser.
• It is a solid state and diode pumped CW laser.
• The aiming beam is usually diode laser (635 nm,
max.1mW)
• It causes photocoagulation with least energy trans-
mission and shows considerable safety in macular
treatment. Hence, it is fast gaining major market share of
posterior segment photocoagulator.

Krypton red laser (647 nm)

• The melanin granules also readily absorb it.
• It is not absorbed by the hemoglobin (Hb) and
xanthophylls pigments present in the macular area.
Hence, it is particularly suitable for macular photo-
coagulation and coagulation of subretinal neovascular
membrane
• It coagulates deeper into the retinal pigment epithelium
(RPE) and choroids. It has insignificant photo-
coagulation effect on the vascular system of the retina. It
is less absorbed and more highly transmitted through
retinal pigment epithelium (RPE) . So, it is able to produce
 8 LASER IN OPHTHALMOLOGY

more extensive and deep coagulation of choriocapillaries

and choroids.

Diode laser (810 nm)

• It is the most important semiconductor laser [GaAlAs
(720-890 nm) GaAs (810 nm)]
• Direct photocoagulation of microaneurysm is difficult
because it is poorly absorbed by hemoglobin.
• However, it is as effective as argon, freq-doubled Nd:
YAG laser in reducing macular edema.
• It offers increased patient comfort due to absence of bright
flash of light.
• However, due to deeper penetration in to the choroids, it
may be painful if the intensity of retinal coagulation is
not properly titrated /reduced.
• It is a low cost, portable, small, high powered and
versatile laser.
Lasers with blue wavelength light should not be used
for photocoagulation in following situations;
1. In the macular area – Xanthophyll pigments absorb blue
light maximally and green light poorly. Hence, in
macular photocoagulation blue light (blue-green argon
laser) will cause unwanted inner retinal damage
2. In older patients – The ageing lens absorbs blue light
much more than other light wavelengths. The shorter
wavelength blue lights are also more scattered by aged
crystalline lenses.

Influence of Opacities in the Ocular Media

Upon Laser Parameter (Power)
Any opacity in the ocular media such as corneal edema,
corneal haziness, flare and cells in the anterior chamber,
lental opacity and vitreous opacity reduces energy level of
 PRACTICAL CONSIDERATIONS—LASER APPLICATION 9

Table 1.1: Various chorioretinal coagulations (Grades

1/light to 4/heavy)
Grade 1/Light Barely visible blanching of retinal
pigment epithelium (RPE)
Grade 2/Mild Hazy, faint white retinal coagulation
Grade 3/Moderate Opaque, dirty white retinal coagulation
Grade 4/Heavy Dense white, chalky retinal coagulation

the laser beam striking the retinal surface by reflection,

scattering or absorption of the laser beam. Hence, the
optimum power level should be arrived at by gradually
increasing the power to cause optimum coagulation burn
(Figs 1.2 and 1.3) for that procedure.

Gradation of Photocoagulation Lesions

Visible photocoagulation intensity of chorioretinal tissues
except retinal vessels can be graded from grade1/light to
grade 4/heavy (Table 1.1, Figs 1.2 and 1.3). Similarly visible
photocoagulation of retinal vessels can be graded from
grade I to grade IV (Fig. 1.4).
The grading is clinically very significant to ascertain the
end point /optimum intensity of photocoagulation indicated
for a specific retinal lesion, e.g., Grade1/light chorioretinal
coagulation is optimum intensity of photocoagulation in
focal/grid laser in diabetic maculopathy whereas, Grade 3/
moderate chorioretinal coagulation is optimum intensity of
photocoagulation in scatter/Panretinal photocoagulation
(PRP), retinal breaks and abnormal blood vessels.

Focusing of Laser Beam

All the lasers except xenon-arc emit monochromatic rays.
So, energy of these lasers except xenon-arc can be focused to
a fine point without significant chromatic aberration.
 10 LASER IN OPHTHALMOLOGY

Fig. 1.2: Schematic drawing of various chorioretinal coagulations

(Grades 1/light to 4/heavy)
1 = Grade 1/Light,2= Grade 2/Mild, 3 = Grade 3/Moderate and
4 = Grade 4/Heavy

Fig. 1.3: Schematic drawing of various vascular coagulations

(Grades I to IV)
I = Minimal visible constriction of the vessel,
II = Total constriction and spasm of the vessel,
III = Total constriction of the vessel along with coagulations of the
surrounding tissue and
IV = Total constriction, charring of the vessel, coagulations of the
surrounding tissue

The properly focused laser beam in an eye without any

opacity in the refracting mediums should be circular with
clearcut margin (Fig. 1.4A). An oval beam with a blurred
outline indicates incorrect focusing (Fig. 1.4B).
 PRACTICAL CONSIDERATIONS—LASER APPLICATION 11

Fig. 1.4: Focusing of laser beam

A = Properly focused laser beam without any opacity in the refracting
mediums,
B = Oval beam with a blurred outline -incorrect focusing,
C = Large wedge shaped deficit-cortical cataracts,
D = Elongated and irregular outline-astigmatism,
E = Large irregular deficit-vitreous opacity and
F = Round hazy focus and irregular outline –diffuse haziness of ocular
media.

However, opacities in the ocular refracting mediums will

not only block a certain percentage of laser beam energy to
reach retina but also superimpose a shadow on the round
laser focus. The round focused beam may take the shape of
following distorted images (Figs 1.4C to F):
• Small or large wedge shaped deficit-cortical cataracts
(Fig. 1.4C)
• Elongated and irregular outline-astigmatism (Fig. 1.4D)
• Large irregular deficit-vitreous opacity (Fig. 1.4E)
• Round hazy focus and irregular outline – diffuse
haziness of ocular media (Fig.1.4F)
So, the circular target beam should be critically exa-
mined before proceeding to laser procedure.
 12 LASER IN OPHTHALMOLOGY

Nd: YAG laser (1064 nm) emission rays are invisible since
1064 nm is at infrared end of the light spectrum. Single or
multiple Helium-Neon/He-Ne (632.8 nm) visible red beams
are usually employed for aiming of Nd: YAG laser (1064
nm). Diode red (670 nm) may be also employed as aiming
beam in Nd: YAG lasers (1064 nm).

Laser Parameters
• Power = Number of”photons”emitted each second and
is expressed in watts (W).
• Exposure time = The duration in second (sec.) the
“photons” are emitted in each burn from the laser.
• Spot size = The diameter of the focused laser beam and
is expressed in micron (µm). Spot size is usually fixed
for treatment of a particular lesion. However, the energy
(Power × Exposure time) parameters must be decreased
or increased, with the decrease or increase in the spot
size parameter. The spot size when focused on the retina
depends on; 1) Laser Spot Magnification Factor (LSMF)
of the laser lens, 2) Spot size selected in the Slit-lamp
and 3) Refraction of the eye under treatment.
• Energy = Number of”photons”emitted during an
exposure of any duration and is expressed in joules (J).
So, Energy (Joules) = Power (Watt) × Exposure time
(Second).

Energy calculation
1. 1 watt is equal to 1 Joule of energy derived in 1 sec.
exposure.
2. 0.5 sec exposure with 2 watt power parameter = 1 joule
coagulative energy.
3. 0.5 sec exposure with 1 watt power parameter = 0.5 joule
coagulative energy.
 PRACTICAL CONSIDERATIONS—LASER APPLICATION 13

Post Photocoagulation Advice

The following restrictions are advisable to continue for a
period of 3 weeks postlaser. The aim is to reduce/ control
the venous pressure rise in the eyes, head and neck region.
• Avoid sneezing, cough and constipation and control
with medication.
• Do not lift heavy objects.
• Avoid heavy exercise and yoga.
• Avoid sudden jerky movements of the head.
• Only paracetamol can be taken orally as pain killer.
• During sleep level of head should be above the level of
heart.
• Avoid medications containing ephedrine and epine-
phrine.
It is ideal to supply post photocoagulation advice in a
printed format.

Photovaporization
In photovaporization, laser irradiation higher than
photocoagulation threshold is applied to the target tissue.
As a result, the tissue temperature can reach the boiling
point of water and sudden fast expansion of water vapor
will cause tissue disruption, i.e. photovaporization.
Photovaporization, i.e. cutting is usually accompanied by
photocoagulation, i.e. cautery (or hemostasis).

Photoablation
In photoablation, temperature rise does not take place in
the shorter wavelengths of the ultraviolet spectrum. At the
site of impact, the tissue simply disappears without any
charring and temperature rise. Surface of the target tissue
can be precisely removed, layer-by-layer, in photoablation.
Photoablation with 193 nm argon fluoride (ArF) excimer
 14 LASER IN OPHTHALMOLOGY

laser produces superior predictable tissue ablation than

longer wavelength (248 nm) krypton fluoride (KrF) excimer
laser in lasik /lasek.

Photoradiation
Hematoporphyrin derivative is selectively taken up and
retained by metabolically active tumor tissue. In photo-
radiation, this photosensitized tissue is exposed to 630 nm
red lights from a dye laser, producing cytotoxic singlet
oxygen and tissue destruction. Similarly, Verteporfin
preferentially accumulates in choroidal neovascular
membrane (CNV). In photodynamic therapy the choroidal
neovascular membrane is subjected to laser emission from
diode (689 nm) with resultant occlusion and thrombosis of
the neovascular tissue.

Photodisruption
In photodisruption, temperature of treated localized
microscopic area of tissue is increased from 37°C to 15000°C.
On optical breakdown at the desired site, electrons are
stripped from the atoms of target tissue resulting in
development of plasma field and bubble. This leads to
hydrodynamic and acoustic shock wave, which mechani-
cally tears the tissue microscopically.

Laser delivery
Laser can be delivered through 3 types of approach;
1. Slit-lamp Biomicroscope:
• The most common and popular delivery system.
• Laser parameters viz.; power, exposure time and spot
size can be changed.
2. Laser Indirect Ophthalmoscope (LIO):
• Argon green and diode lasers are delivered through
a fiberoptic cable.
 PRACTICAL CONSIDERATIONS—LASER APPLICATION 15

• Ideal for photocoagulation of peripheral retinal

breaks and degenerations.
• Ideal for PRP/scatter photocoagulation of extreme
retinal periphery in eyes with rubeosis iridis, PDR,
post-CRVO, retinopathy of prematurity (ROP) etc.
• Ideal for photocoagulation in children under general
anesthesia.
• Ideal for photocoagulation in eyes with small pupil,
intraocular gas and lental opacities.
• Unsuitable for focal and or grid laser of macula.
• Spot size is altered by the dioptric strength of the
hand held condensing lens and moving a lever on
the headset.
• Spot size is also altered by the refractive status of the
eye. The spot size in a hypermetropic eye is smaller
than in an emmetropic eye whereas, the spot size in
a myopic eye is larger than in an emmetropic eye.
• In LIO,
Power of condensing aspheric
lens × Image plane spot size
Retinal spot size =
60
3. Intraoperative Laser Endoscope:
• Argon green and diode lasers are delivered through
Laser Endoscope during vitrectomy.
• Ideal for photocoagulation of retinal surface
neovascularization (NVE), peripheral retinal breaks
and degenerations after retina is attached by internal
fluid-air exchange after vitrectomy.
• Since, detached retina cannot be treated, prior sub-
retinal fluid (SRF) removal is essential before
application of laser.
• Ideal for photocoagulation of giant retinal tear.
 16 LASER IN OPHTHALMOLOGY

Indications for infiltration anesthesia

1. Uncooperative patient
2. Presence of significant ocular movement, e.g. nystagmus
3. Presence of significant ocular pain
4. Photocoagulation near the macular center
Pascal (Pattern Scan Laser) photocoagulator is recently
developed by OptiMedica corporation, USA, which is a
significant improvement in laser delivery systems. Pascal
photocoagulator incorporates semi-automated, multiple
pattern, short pulse, multiple shot, painless and precise laser
burns in a very short duration in a predetermined sequence
with Freq. doubled YAG (532 nm) laser.
Pascal photocoagulator can be used in all the retinal
diseases (Proliferative and nonproliferative diabetic
retinopathy, diabetic maculopathy, branch and central
retinal vein occlusion, retinal tears and peripheral retinal
degenerations, choroidal neovascular membrane, retinal
telangiectasia, retinopathy of prematurity, etc.) treated with
conventional single spot lasers (Argon, Freq. doubled YAG,
Krypton, etc.).

Advantages of pascal photocoagulator over conventional

single spot lasers
• Pulse duration is very short (10-20 msec) compared to
conventional single spot lasers (100-200 msec). Hence,
Pascal causes less collateral damage to the eye with
similar effective regression of new vessels.
• The size of the retinal burn remains relatively stable after
Pascal photocoagulation due to low intensity. In
conventional single spot photocoagulation the laser spot
burn enlarges with time. Hence, Pascal laser burns are
less destructive than conventional single spot laser spot
burns.
 PRACTICAL CONSIDERATIONS—LASER APPLICATION 17

• Pascal is as efficient as conventional single spot

photocoagulators.
• The gradation of retinal burns are the same but can be
titrated more easily.
• Pascal allows the laser surgeon to apply different
patterns of treatment with variable retinal grades of
coagulation. Since the eyeball is spherical in shape
semicircular pattern is better suited for photocoagulation
of retinal periphery and standard square pattern is ideal
for retinal midperiphery. Circular pattern is suitable for
treating retinal holes/breaks.
• Pascal allows the laser surgeon to adjust the individual
spot size, adjust the distance between the spots perfectly
and the pattern of the spots with much more precision
than is possible with a conventional single spot
photocoagulator.
• Pascal allows the laser surgeon to place multiple spots
in one depression of the foot pedal.
• Pascal allows the laser surgeon to complete PRP in a
regular pattern, more quickly and usually in one day.
Short treatment duration leads to improved patient
cooperation and fixation.
• Pascal allows the laser surgeon to place burns in
distant retinal periphery in a regular pattern in PRP,
peripheral retinal degenerations and retinopathy of
prematurity.
• Pascal allows the laser surgeon to place burns in macular
grid laser more accurately in a regular pattern compared
to conventional single spot lasers.
• Increase in macular edema following confluence of
retinal burns is extremely low compared to conventional
single spot photocoagulator.
• Since the distance between the spots is perfectly spaced,
accidental confluence/overlapping of laser spots is not
 18 LASER IN OPHTHALMOLOGY

possible. Hence, patient’s field of vision is much better

after Pascal photocoagulation than conventional single
spot photocoagulation.
• Single-spot mode for conventional photocoagulation is
also available.
• Using the Pascal Method, physicians can deliver up to
56 spots in approximately 0.6 seconds.
• Patients experience less pain than with traditional,
single-spot laser photocoagulation.
• Reduced treatment duration.

Disadvantages of Pascal photocoagulator

• The spot size available is restricted (only 100, 200 and
400 µm ). Spot sizes of 150,300 and more than 400 µm
are not possible.
• Inability to design the laser patterns at the surgeon’s
convenience.
• Pascal photocoagulator produces some noise when
activated.
• Pascal photocoagulator emits green wavelength, which
is difficult to penetrate through media opacities, e.g.
cataract, retinal and vitreous hemorrhages.
• Pattern burn with Pascal photocoagulator in retinal
periphery is often difficult and always use lower
intensity by titration in retinal periphery to avoid intense
burn.

Precise, pre-determined settings

• Square arrays (2 × 2, 3 × 3, 4 × 4, 5 × 5) for proliferative
diabetic retinopathy
• Triple arcs for retinal tears, lattice degeneration and
proliferative diabetic retinopathy
• Modified macular grid for diffuse diabetic macular
edema
 PRACTICAL CONSIDERATIONS—LASER APPLICATION 19

• Single-spot mode for conventional photocoagulation

OptiMedica holds the exclusive license to the Pascal
Photocoagulator technology, which was originally deve-
loped at Stanford University. Since its worldwide market
introduction in 2006, Pascal photocoagulation procedures
have been performed on tens of thousands of patients
worldwide.

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