PHYSICS

Basic principles of lasers

Gary Thomas Richard Isaacs

Learning objectives
After reading this article you should be able to: C describe the structural components of a laser C understand how a laser beam is produced C list the three principal properties of a laser beam C outline the safety measures employed when a laser is used during a surgical procedure

Abstract
The word laser is an acronym of Light Amplication by Stimulated Emission of Radiation. A laser emits a beam of electromagnetic radiation that is always monochromatic, collimated and coherent in nature. Lasers consist of three main components: a lasing medium (solid, liquid or gas), a stimulating energy source (pump) and an optical resonator; and have a wide variety of uses in clinical medicine. Lasers cause tissue damage by various mechanisms and these are mainly determined by power density (irradiance) of the beam and exposure time. It is imperative to be aware of the risks associated with laser use in terms of tissue damage (burns and eye injuries) and re hazards. Strict controls should be implemented governing the safe use of lasers in hospital practice, and all staff must be familiar with all safety measures to prevent injury and res.

produce or amplify a beam of narrow, convergent light with a well-dened wavelength within the electromagnetic spectrum. Wavelengths in the infrared, visible and ultraviolet regions of the spectrum are most commonly used for commercial applications.

Laser design
A laser consists of three main components (Figure 1): Lasing medium: which may be solid (crystals or semiconductors), liquid (organic dyes) or a gas (or gas mixture). Excitation system or pump: this creates the conditions for light amplication by supplying the necessary energy to the lasing medium. There are different kinds of pumping systems: optical (ash lamps, continuous arc lamps, tungsten-lament lamps or even other lasers), electrical (gas discharge tubes, electric current in semiconductors), or chemical pumps. Optical resonator: which in its simplest form consists of two mirrors arranged such that the photons pass back and forth along the length of the lasing medium. Typically, one mirror is partially transparent to allow the beam to exit (output coupler).

Keywords Damage; re; lasers; physics; properties; safety

Introduction
Suddenly a light from hell appeared in the middle of the ruby. Then, from the end of a cylinder, a hundred thousand times brighter than the sun, burst forth a thin red light, a perfectly parallel monochromatic beam. Maiman and his assistants were silent for some time, enthralled by the beauty of this spectacle. Einstein was right he murmured, light can be concentrated and coherent. This newspaper extract describes the public demonstration of the rst working laser constructed by Theodore Maiman in 1960.1 It consisted of a ruby crystal shaped into a rod 4 cm long and 0.5 cm diameter. The ends were polished, at and parallel, with one fully silvered and the other partially silvered. An electronic ash tube was coiled around the ruby. Ruby is a crystalline form of aluminium oxide in which chromium atoms have replaced some of the aluminium atoms to give the crystal its red colour. The ashlight excites electrons in the chromium atoms to higher energy levels. Upon returning to their normal state, the electrons emit their characteristic ruby-red light. The mirrors reect this light back and forth inside the crystal, stimulating other excited chromium atoms to produce more light until the crystals stored energy is eventually dissipated. The word laser is an acronym of Light Amplication by Stimulated Emission of Radiation and aptly describes the theory behind the mechanics of laser generation. Lasers are devices that

Laser physics
A lasing medium can be considered as consisting of atoms with a central nucleus of protons and neutrons surrounded by electrons in discrete orbital shells. These electrons move between different energy levels as the atom absorbs or releases external energy. Three different mechanisms exist which highlight the interaction between electrons and photons of energy (Figure 2).  Absorption: an electron in its ground-state energy level (E1) absorbs a photon of energy hv and moves to an upper level (E2). h is Plancks constant (6.63 1024J/s) and v is frequency.  Spontaneous emission: an electron in an upper level (E2) can decay spontaneously to the lower level (E1). In so doing, a photon of energy hv that has a random direction and phase is emitted.  Stimulated emission: an incident photon causes an upperlevel electron to decay, emitting a stimulated photon whose properties (direction, wavelength and phase) are identical to those of the incident photon. Hence, duplication of the photon. These three mechanisms are always present concurrently. An incident photon has an equal chance of being absorbed by a ground-state electron as being duplicated by interacting with an

Gary Thomas MB BCh (Wales) FRCA is a Consultant Anaesthetist at The Princess of Wales Hospital, Bridgend, Wales. Conicts of interest: none declared. Richard Isaacs MB BChir (Cantab) BSc (St And) FRCA is a Specialist Trainee 6 in Anaesthesia on the Wessex rotation, England. Conicts of interest: none declared.

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PHYSICS

Structural components of a laser

Fully reflective mirror Fully reflective mirror

Emitted laser beam via output coupler

Laser medium Partially reflective mirror Fully reflective mirror

Pumping source

Figure 1

excited-state electron, that is, absorption and stimulated emission are two reciprocal processes subject to the same probability. For a laser to function, conditions have to favour stimulated emission over absorption and spontaneous emission, so that there are more excited-state electrons than those in the ground-state (population inversion). This is achieved by the input of energy from the pump; which may be supplied continuously, or intermittently in the case of a pulsed laser. The optical resonator, with its arrangement of mirrors, allows amplication or optical gain to occur as photons stimulate the emission of more and more photons. The laser light travels to and fro along the same axis with some photons eventually exiting the partially silvered mirror at one end.

Properties of a laser beam

The three Cs can be used as a simple aide-mmoire: e  Colour: consisting of just one wavelength of light (monochromatic)  Coherence: all light particles (photons) are in phase  Collimated: the photons minimally diverge from their point of origin and are considered as being parallel.

Damage mechanisms
Lasers cause tissue damage through various mechanisms, mainly determined by power density or irradiance (W/cm2) and exposure time.

Figure 2

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 Photoacoustic or photomechanical e a high-power, brief pulse of laser light results in an explosive expansion of tissue, for example the holmium:YAG (yttrium aluminium garnet) laser used to disrupt urinary calculi by the heating of water contained within.  Photothermal e occurs from less intense but more sustained laser pulses and causes tissue coagulation or vaporization, for example the CO2 laser used to cut tissue and secure haemostasis.  Photodissociation e the non-thermal breakdown of covalent bonds within protein molecules, for example ophthalmological lasers used for corneal reshaping.  Photodynamic e a photosensitizer is a chemical compound that can be excited by light of a specic wavelength. When irradiated by the laser, reactive oxygen compounds are generated which can cause selective cell lysis. Examples of lasers and their practical applications in medicine are given in Table 1.

classes of lasers based on the maximum permissible exposure levels and effects on the eyes and skin (1, 1M, 2, 2M, 3R, 3B, 4). The maximum permissible exposure (MPE) is the highest power or energy density (W/cm2 or J/cm2) of a laser that is considered safe. It is usually about 10% of the dose that has a 50% chance of creating damage. The MPE is measured at the cornea of the human eye or at the skin, for a given wavelength and exposure time. The eye is most susceptible to damage. Red and nearinfrared light (400e1400 nm) can be focussed up to 2 105 times greater intensity by the lens onto the retina. Most of the light is absorbed by melanin in the pigment epithelium just behind the photoreceptors and causes painless burns on the retina. Infrared light (>1060 nm) is particularly dangerous as it will not elicit the protective blink reex due to its invisibility. Ultraviolet light (<400 nm) tends to be absorbed in the cornea and lens, where it can produce burn injuries and cataracts at relatively low powers due to photochemical damage.

Laser safety
Maiman recognized the hazards of lasers at an early stage, and stated that his ruby laser had the power of 2 Gillette. This measure was simply the number of razor blades through which the laser could burn a hole! Since the 1970s, lasers have been classied by maximum output power into four broad classes according to their ability to harm unprotected persons, ranging from class 1 (no hazard during normal use) to class 4 (severe hazard for eyes and skin). The revised system, implemented in 2002 is part of the revised International Electrotechnical Commission standard 60825 (2007).2 This standard denes seven

Safety measures
Protocols should exist within hospitals that govern the safe use of lasers in surgery.3 The key safety measures are as follows:  The category of a laser in use and its hazard classication should be clearly marked on its outer casing.  A laser protection advisor should be appointed with responsibility for assessing risk, advising on safety, implementing protocols and investigating clinical incidents.  A laser protection supervisor (LPS) should be appointed for every clinical area in which a laser is used. The duty of the

Physical characteristics and medical applications of lasers in medicine

Laser CO2 Wavelength (nm) 10,600 Spectrum Far infrared Medium Gas Pumping Electrical Clinical uses Removal of dermatological lesions, tumours of naso-oro-laryngo-tracheal area, neurosurgical vascular tumours Tissue ablation, lithotripsy, dentistry Surgery for bronchial tumours, GI bleeding, skin cancers, peripheral iridotomy for acute glaucoma and treatment of posterior capsular opacication post- cataract surgery Prostate surgery, endometriosis, removal of vascular lesions (i.e. haemangiomas), port-wine stains, spider naevi Retinal phototherapy and glaucoma, arteriovenous malformations, pumping for other lasers Port-wine stain removal, tattoo removal and scar treatment Corneal vision correction

Ho:YAG Nd:YAG

2100 1064

Mid infrared Near infrared

Solid Solid

Laser diode Flash lamp, laser diode

KTP

532

Green

Solid

Flash lamp, laser diode

Argon

500

Blue-green

Gas

Electrical current

Dye Excimer (Ar:F)

390e640 193

Yellow Ultraviolet

Liquid Gas

Other laser, ash lamp Electrical current

Ar:F, argon:uoride; GI, gastrointestinal; Ho, holmium; Nd, neodymium; KTP, potassium titanylphosphate; YAG, yttrium aluminium garnet.

Table 1

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LPS is to ensure that the laser is used safely and that clinical staff are instructed in its use. An appropriate non-water-based re extinguisher should be immediately available in the clinical area in which the laser is used. All staff should wear suitable eye protection when a laser is in use. Eyewear must be selected for the specic type of laser, to absorb the appropriate wavelength range. All doors should be locked and all windows covered to protect those outside the treatment area. Laser warning signs should be clearly visible to denote a laser controlled zone.

lasers. High-pressure water necessary for cooling the laser and other associated electrical equipment can pose greater risks of electrocution and burns than the beam itself. During tissue vaporization, the laser can generate airborne contaminants such as gaseous toxic compounds, dead cellular material or viruses. In orthopaedics and dentistry, it is also possible to generate particulates and metal fumes which may cause ocular and upper respiratory tract irritation, hence a requirement for proper ventilation or smoke evacuators. A

Fire hazards Fires are a very real risk during laser surgery. The triad of heat (laser energy), oxidizing agent (oxygen, nitrous oxide) and fuel (tube, circuit, drapes, skin preparation) may cause a theatre or airway re. Methods employed to reduce risk include:  avoiding use of nitrous oxide  minimum acceptable inspired oxygen concentration  non-reective matt-black instruments to reduce stray reected beams (specular reection)  protecting surrounding tissues with wet swabs  saline-lled cuffs on laser-resistant tubes to which methylene blue dye may be added to identify inadvertent cuff perforation  water-based lubricants and gel coating on facial hair  short laser bursts to reduce energy  low-power laser aiming beam to avoid inadvertent damage. Non-beam hazards Lasers are high-voltage devices, ranging from 400 V for lowenergy pulsed lasers to several kilovolts in higher-powered

REFERENCES 1 Maiman TH. Stimulated optical radiation in ruby. Nature 1960; 187: 493e4. 2 BS EN 60825-1:2007 Safety of laser products. Equipment classication and requirements. BSI, 2007. 3 Medicines and Healthcare products Regulatory Agency. DB 2008(03) Guidance on the safe use of lasers, IPL systems and LEDs. Also available at: http://www.mhra.gov.uk/Publications/Safetyguidance/ DeviceBulletins/CON014775; (accessed 1 November 2010).

FURTHER READING Davis PD, Kenny GNC, eds. Basic physics and measurement in anaesthesia. 5th edn. Oxford: Butterworth-Heinemann, 2003. Laserfest: celebrating 50 years of laser innovation, http://www.laserfest. org; (accessed 21 October 2010). Laser: fundamentals, http://prn1.univ-lemans.fr/prn1/siteheberge/ optique/M1G1_FBalembois_ang/co/M1G1_anglais_web.html; (accessed 22 October 2010). (An online educational resource designed by physicists Francois Balembois and Sbastien Forget, University of Maine, France.) e

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