LASER IN OPHTHALMOLOGY

~: Moderator :~ DR. (MRS.) B. DEVI Professor & Head ~: Presenter :~ DR. ASHOK KUMAR Postgraduate Trainee

DEPARTMENT OF OPHTHALMOLOGY, ASSAM MEDICAL COLLEGE & HOSPITAL, DIBRUGARH

INTRODUCTION
LASER is an acronym for:

L A

: Light : Amplification (by)

S
E R

: Stimulated
: Emission (of) : 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.

PROPERTIES OF LASER LIGHT

Coherency Monochromatism

Collimated
Constant Phasic Relation Ability to be concentrated in short time interval Ability to produce non linear effects

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 : 1971 :

L Esperance developed the argon laser. Neodymium yttrium aluminum garnet

(Nd.YAG) and Krypton laser develop.

1983 :

Trokel developed the eximer laser.

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.

LASER Vs. LIGHT

LASER

LIGHT

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

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

CLASSIFICATION OF LASER

Solid State Ruby Nd.Yag Erbium.YAG Molmium.YAG

Gas Ion Argon Krypton He-Neon CO2 Metal Vapour Cu Gold

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

LASER TISSUE INTERACTION

LASER VARIABLE:

TISSUE VARIABLE:

Wavelength Spot Size Power

Transparency Pigmentation Water Content

Duration

THREE TYPE OF OCULAR PIGMENT

Haemoglobin: Argon Green are absorbed, depending on its oxygenation , Krypton yellow. These laser are found to be useful to coagulate the blood vessels. Xanthophyll: Macular area, Lens 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

LASER TISSUE INTERACTION

LASER

TISSUE

Thermal Effect Photocoagulation Photodisruption

Photochemical Photoradation Photoablation

Ionizing Effect

Photovaporization

THREE BASIC LIGHT TISSUE INTERACTIONS

(1) Photocoagulation:
Laser Light Target Tissue Generate Heat Denatures Proteins (Coagulation) Rise in temperature of about 10 to 20 0C will cause coagulation of tissue.

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 Infrared : : Photocoagulation Photoablation 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

PHOTODYNAMIC THERAPY

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

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.

TYPES OF OPHTHALMIC LASERS

LASER INSTRUMENTATION
Three Main Components

Console: It contain laser medium and tube, power supply and laser control system. Control Panel: It contain dials or push buttons for controlling various parameters. Contain a standby switch as a safety measure. Delivery System:

Slit Lamp Microscope

Indirect Ophthalmoscopes Endophotocoagulation

ACCESSORY COMPONENT

Aiming Beam Laser Switch Safety Filter Corneal Contact Lenses for Laser use

Cleaning of the Contact Lens

ACCESSORY COMPONENT
Contd.

Slit Lamp Laser Delivery lenses: Single mirror gonio lens Abraham or wise iriditomy lens Goldman style 3-mirror lens Panretinal lenses

e.g. Rodenstock, Mainster, Volk-Quadrispheric

Indirect Fundus Lenses for Indirect Ophthalmoscopes

USING THE OPHTHALMIC LASER

PREPARATION OF THE PATIENT FOR SURGERY:

Investigation Local Anaesthetic

Position of the patient at Slit Lamp

THE SURGEON:

Comfortable position at Slit Lamp Semi-darkened Room Appropriate Contact Lens

LASER SAFETY

Class-I :
Class-II :

Causing no biological damage.

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.

CLINICAL USE OF LASER

DIAGNOSTIC USE:

Laser Interferometry Scanning Laser Ophthalmoscopy (SLO) Laser Flare Cell Photometry

Optical Coherence Tomography (OCT)

CLINICAL USE OF LASER

Contd.

Optical Coherence Tomography (OCT):

It is non invasive, non contact imaging system that uses super luminescent diode uses laser to give high resolution cross sectional real time tomographic image of retina. OCT produces light resolution upto 10. Interpretation of OCT Images:

Red-yellow colours represent areas of maximal optical reflection and back scattering.
Blue-black colours represent area of minimal signals.

CLINICAL USE OF LASER

Contd.

THERAPEUTIC USES: Laser in Lacrimal Surgery: Laser DCR.

Skin: Removal of Small Lid Lesion e.g. Seborrhoeic keratitis Removal of Capillary Haemangiomas Blepharoplasty Aseptic Phototherapy Pigmentation lesion Laser Hair Removal Technique Tattoo Removal Resurfing

LASER IN ANTERIOR SEGMENT

CORNEA:
Laser in Keratorefractive Surgery:

Photo Refractive Keratectomy (PRK) Laser in situ Keratomileusis (LASIK) Laser Subepithelial Keratectomy (LASEK) Epi Lasik

Laser Thermal Keratoplasty

Corneal Neovascularization
Retrocorneal Pigmented Plaques Laser Asepsis

PRK

LASIK

LASER IN GLAUCOMA

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

LASER IRIDOTOMY

PUPILLOPLASTY

ARGON LASER TRABECULOPLASTY

LASER IN GLAUCOMA

Laser Filtration Procedures (sclerostomy): Ab Externosclerostomy (Holmium) Ab Internosclerostomy (Nd.YAG) Contact Non-contact

Contd.

Cyclodestructive Procedures (cyclophotocoagulation)

Transscleral Cyclophotocoagulation Trnaspupillary Cyclophotocoagulation Diode Laser Endophotocoagulation

SCLEROSTOMY

AB INTERNO SCLEROSTOMY

LASER IN GLAUCOMA
Contd.

Laser Sinusotomy:
Procedure of unroofing the canal of schlemm, allowing aqueous humour to percolate into subconjunctival space.

Laser Bleb Revision and Remodeling

Iris Cyst
Displaced Pupil

LASER IN LENS

Posterior capsulotomy
Laser phacoemulcification Phacoablation

LASER IN VITEROUS

Viterous membranes Viterous 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 Drainage of Subretinal Fluid Laser Scleral Buckling for Retinal Detachment

CLASSIFICATION OF CHORIORETINAL BURN INTENSITY

Light

Barely visible retinal blanching

Mild

Faint white retinal burn

Opaque dirty white retinal burn Dense white retinal burn

Moderate : Heavy :

DIABETIC RETINOPATHY
Diabetic Macular Edema:
Indication: Presence of CSME or any of the following:

Retinal thickening at or within 500 micron of the foveal centre.

Retinal thickening 1500micron or larger size any part of which is within 1500microns of the foveal centre. Hard exudate at or within 500 micron of the foveal centre if associated with thickening of the adjacent retina.

DIABETIC RETINOPATHY
Contd.

Focal thickening/leakage: Focal Photocoagualation

Diffuse thickening/leakage: Macular grid photocoagulation

Treat all avascular zones 500-3000 microns from the foveal centre.

Laser Parameter:

50-100 micron spot size, 0.05-0.1 sec( for focal spot size 50micron, for grid 100-200 micron) Spots must be atleast one burn width apart.

DIABETIC RETINOPATHY
Contd.
TYPE OF RETINOPATHY Background Maculopathy CSME Diffuse leakage around macula Circinate Pre-proliferative Retinopathy Proliferative retinopathy Advanced diabetic eye disease THERAPY Control of diabetes, regular review Focal photocoagulation Grid laser Focal photocoagulation Frequent review Pan retinal photocoagulation Vitreoretinal surgery with photocoagulation

PASCAL
PATTERN SCAN LASER:(Pascal)

Offering multiple, patterned burns in a single-session procedure.

Improved precision Safety

Patient comfort
Significant reduction in treatment time.

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 Cost ly

Contd.

FEMTOSECOND LASER

FUGO (plasma) BLADE

Dr. Daljit Singh Iris claw lens 1stUS FDA clear plasma incision device for use in eye Portable

USES
Anterior capsulotomy (yr 2000) Trance ciliary filtration (singh filtration yr 2004) Peripheral iridotomy ( yr 2005 ) Eyelid surgery.

IN THE DEPARTMENT

ARGON GREEN LASER (IRIDEX)

IN THE DEPARTMENT

Nd :YAG LASER (CARL ZEISS)

LASER HAZARDS
EYE Small lesion to extensive haemorrhage Disruption of retina and choroid Immediate loss of vision Epiretinal membrane formation Macular hole,gliosis SKIN Erythema Carcinogenesis

PREVENTION OF LASER HAZARDS

Engineering Control Measure: Increasing laser safety by designing of laser housing to prevent free access , provision of filters and shutter for safe observer viewing
Personal protective devices, like protective eye wear or goggles with side shields, protective clothes may be included Administrative and procedural controls, which help by implementation of laser safety program under laser safety officer.

COMPLICATION OF LASER TREATMENT

Increased IOP
Corneal Damage Iris Burn Cataract Internal Ophthalmoplegia

Pain
Seizure CD & RD Foveal Burn

CONCLUSION

In a relatively brief period , laser have evolved from an obscure research novelty to an invaluable clinical instrument.

The continual refinement of existing laser types, as well as the introduction of new laser technology, mark

this area of ophthalmology as one of its most

energetic and dynamic fields.

HAVE A NICE DAY.