Proceedings of the Symposium on Photonics Technologies for 7th Framework Program Wroclaw 12-14 October 2006


Therapeutic application of lasers in ophthalmology
Misiuk-Hojlo M¹., Krzyzanowska P.¹, Hill- Bator A.¹ ¹ Department of Ophthalmology, Wroclaw Medical University, Poland Laser effects in biological tissues can be divided into three general categories: photochemical, thermal, and ionizing. With the improvement of laser technology, the techniques with using different types of lasers (ruby, neodymium, neodymium: yttrium- aluminum- garnet, erbium, and argon) allowed to utilize lasers in the treatment and diagnostics of many eye disorders. Photoradiation takes place when photosensitized tumor tissues are exposed to laser light for the purpose of producing photochemical damage. During photoablation, tissue is removed in some way by light, such as when intermolecular bands of biological tissues are broken, disintegrating target tissues, and the disintegrated molecules are volatilized. This can be effected with, for example, excimer laser. Photocoagulation causes denaturation of biomolecules when temperatures are sufficiently high, about 600 C or more. Temperature rise in tissues is proportional to the amount of light absorbed by that tissue. Absorption of certain light frequencies is high in pigmented trabecular meshwork, iris, ciliary body, and retinal pigment epithelium (owing to melanin), and in the blood vessels (owing to hemoglobin). Lasers commonly used photocoagulation are argon, krypton, or diode Nd:YAG lasers. Photovaporization occurs when the tissue temperature quickly reaches the boiling point of water, causing disruption (evaporation) before denaturation (photocoagulation). Examples of clinical uses of these lasers are holmium: YAG or erbium: YAG laser sclerostomy. In photodisruption, short-pulsed, high-power lasers disrupt tissues by delivering enormous irradiance to tissue targets. The high level of irradiance ionizes molecules in a small volume of space at the focal point of the laser beam, disintegrating into collections of ions and electrons called plasma. This plasma expands rapidly, producing shock and acoustic waves that mechanically disrupt tissues adjacent to the region of laser focus. (6) Examples of photodisrupter lasers are the Q-switched and pulsed Nd:YAG laser. Glaucoma laser treatment is often recommended when medical therapy alone is insufficient in controlling intraocular pressure, for those patients who have contraindications to glaucoma medications or, for any reason, are unable to use eye drops. The most common glaucoma laser procedure is laser peripheral iridotomy (PI). A laser iridotomy is performed for patients with narrow angles, acute angle closure glaucoma, in the fellow eye of a patient with acute or chronic primary angle closure, or pupillary-block glaucoma. (17) Laser peripheral iridotomy involves creating a tiny opening in the peripheral iris, allowing aqueous fluid to flow from behind the iris directly to the anterior chamber of the eye. This typically results in resolution of the forwardly bowed iris and thereby an opening up of the angle of the eye. (9) There are two types of lasers in use today - Nd:YAG Q-switched laser (2 – 8 mJ) or argon laser (800 – 1000 mW). Argon laser began to replace surgical iridectomy as a safer, non-invasive method of making an iridotomy in the late 1970s. It was demonstrated to be safe and effective, (15) but required melanin for tissue absorption of the energy, making it less easy to penetrate lightly pigmented blue irides. The Nd:YAG laser replaced argon as the most common means of performing LPI in the late 1980s. The Qswitched mode of the Nd:YAG laser causes photodisruption of tissues by the formation of a

blurred vision. the neodymium (Nd):YAG and diode lasers have been used for transscleral cyclophotodestruction.Proceedings of the Symposium on Photonics Technologies for 7th Framework Program Wroclaw 12-14 October 2006 352 high energy ionic plasma at the location of focus of very intense energy. traumatic glaucoma. which affects retinopathy through the relief of hypoxia and consequent change in growth factor production and hemodynamics. Since then. The procedure consists of placing contraction burns of low power. In most cases. Light coagulation and laser treatment of the retina were introduced to ophthalmology around middle of the last century. Patients with poor medical compliance can benefit from ALT before other surgical intervention is considered. chronic partial or total angle-closure glaucoma. iritis. neovascular glaucoma. Another glaucoma laser procedure is argon laser peripheral iridoplasty (ALPI). corneal injury or retinal burns. aniridia or iridocorneal endothelial syndrome. Due to the high complications rate. physically pulling open the angle. elevated intraocular pressure.7 second duration. eyes with poor visual potential.5 to 0. (10) In the ALT procedure. Indications for this procedure and complications (intermittent intraocular pressure elevation. or angle closure glaucoma. which typically requires about 40 to 80 laser applications. the eye surgeon directs a laser beam into the trabecular meshwork. Cyclodestructive procedures in glaucoma lower the intraocular pressure (IOP) by reducing aqueous inflow as a result of distruction ciliary processes. pseudoexfoliation glaucoma and pigment dispersion glaucoma. without incurring collateral thermal damage to adjacent non-pigmented trabecular meshwork cells and underlying trabecular beams. which is the primary aqueous (fluid) drainage region of the eye. 180 up to 360 degrees of the trabecular meshwork is treated with laser spots. these procedures are usually reserved for the following conditions: eyes with glaucoma refractory to other forms of surgical or medicinal therapy. iris hemorrhage. and large spot size in the extreme iris periphery to contract the iris stroma between the site of the burn and the angle. ALPI is recommended in plateau iris syndrome. ALPI is a method of opening an appositionally closed angle in situations in which laser iridotomy either cannot be performed or does not eliminate appositional angle-closure because mechanisms other than pupillary block are present. and the unpredictability of the amount of IOP reduction. long duration. 0. unlike ALT. Retinal laser photocoagulation improves inner retinal oxygenation. and. Modification of this procedure is selective laser trabeculoplasty (SLT) performed with a Q-switched 532 Nd:YAG laser. aphakic and pseudophakic glaucoma. (11. SLT works by using a specific wavelength to irradiate and target only the melanin-containing cells in the trabecular meshwork. It has the advantage of not requiring the presence of melanin pigment for iris absorption. Efficacy of the ALT procedure lasts for about 5 years. SLT is repeatable several times.(8) This is why. . The use of light energy to ablate the ciliary body was first proposed by Weekers and co-workers (21) in 1961 using xenon arc photocoagulation In 1972 Beckman and Waeltermann (2) performed the first transscleral cyclophotocoagulation (TSCPC) procedure with the ruby laser. 200-400 mW power). Argon laser trabeculoplasty (ALT) is a procedure which has been proven to be efficacious for different types of open angle glaucoma: primary open angle glaucoma. They are widely used for the treatment of diabetic retinopathy and other ischemic retinopathies.16) The argon laser is set to produce contraction burns (500 µm spot size. Complications of laser iridotomy include: irritation. The effect of the procedure is increased drainage of aqueous fluid out of the eye and intraocular pressure reduction to 20 – 25%. The laser beam bypasses surrounding tissue leaving it undamaged by light. iritis or heamorrhage) are similar like in ALT.

focal laser. panretinal photocoagulation. inhibits the leakage of fluid from the CNV. it may itself lead to decreased vision. edematous. branch retinal vein occlusion (BRVO) and central retinal vein occlusion (CRVO). Laser photocoagulation remains the only procedure recommended for severe nonproliferative or proliferative retinopathy and maculopathy. Dry AMD accounts for about 90% of cases. However. Argon or diode l ser treatment may be useful in managing these a complications. Central retinal vein occlusion is closure of the final retinal vein (located at the optic nerve) which collects all of the blood after it passes through the capillaries. can cause neovascularization to regress by making the retina less starved for oxygen. a disease of our civilization. There is presently no effective treatment available to prevent or restore the visual loss from acute CRVO. . can be used to close off areas of leakage from the blood vessels that cause macular edema.Proceedings of the Symposium on Photonics Technologies for 7th Framework Program Wroclaw 12-14 October 2006 353 Diabetic retinopathy is a leading cause of visual loss in industrialized countries. This. (14) The Diabetic Retinopathy Study (DRS) sho wed that the rate of severe visual loss in high. Prevention requires the tightest possible control of both blood glucose and blood pressure. There are two basic forms of laser treatment for exsudative AMD: conventional argon or diode laser therapy and the recently approved photodynamic therapy (PDT). is the milder form of the disorder. macular ischemia (non-perfusion) and neovacularization (growth of new abnormal blood vessels). high risk. such as photoreceptors or retinal pigment epithelium (RPE). moderate. AMD has two basic forms: dry and exsudative. Nowadays. since it also damages the normal retina structures. and severe or preproliferative diabetic retinopathy) and proliferative stages (low risk. and advanced). in turn. Macular degeneration is a progressive eye condition affecting the central vision and causing irreversible blindness in people over the age of 50. The non-thermal laser light activates the verteporfin producing the singlet oxygen that both coagulates and reduces the growth of abnormal blood vessels. nonproliferative (mild. (1) In PDT. Diabetic maculopathy (exudative. Hence. Exsudative AMD is the much more visually debilitating form of macular degeneration. Fifteen minutes after the start of intravenous infusion.risk proliferative diabetic retinopathy could be reduced by as much as 60% following the timely application of panretinal laser photocoagulation therapy. the verteporfin is activated by a red laser of a specific wavelength (689nm). Another type of laser treatment. or ischemic) may be associated with either nonproliferative or proliferative retinopathy. it is suitable only in selected cases where the new vessels are not very close to the central macular area. (4) Retinal vein occlusion (RVO) is a common retinal vascular disorder that frequently is associated with severe visual loss. The concept of the new treatment for exsudative AMD is the closure of subretinal choroidal neovascularization (CNV) without significant damage to the surrounding tissues. the primary concern is to treat the secondary complications: macular edema. a photosensitizer.(12) Following a vein occlusion. (20) Results from the Early Treatment Diabetic Retinopathy Study (ETDRS) demonstrated that focal laser photocoagulation treatment to the macula region could substantially reduce the risk of visual acuity loss in patients with clinically significant diabetic macular edema. One type of laser treatment. as well as the remainder of the body. Verteporfin is administered intravenously and allowed to perfuse the CNV. A branch retinal vein occlusion is essentially a blockage of the portion of the circulation that drains the retina of blood. laser treatment is also available in the age-related macular degeneration (AMD). which are the leaky vascular structures under the retina. There are two forms of retinal vein occlusion. Conventional laser burns the abnormal blood vessels and thus stops the leakage. often accompanied by choroidal neovascular membranes. Its classification includes preclinical.

holes. This is called laser subepithelial keratectomy (LASEK). Transpupillary thermotherapy (TTT) using an 810nm infrared laser has become one of the most popular treatments for small melanomas. cataract extraction. . A rapid explosion of argon laser techniques occurred in the late 1970s and early 1980s. direct flattening is achieved by the removal of a convex-concave lenticule of tissue from the outer surface of the central cornea. After the laser treatment.YAG laser. During PRK for the correction of myopia. (3) In this procedure. a new method has been developed and used. Laser photocoagulation is also mainly used in the retina abnormalities such as: tears. Visual loss occurring secondary to opacification of the posterior capsule after extracapsular cataract extraction is the major indication for laser capsulotomy. In the 1990s. and the safety for the adjacent tissues.Proceedings of the Symposium on Photonics Technologies for 7th Framework Program Wroclaw 12-14 October 2006 354 The first attempts to treat intraocular tumors by means of photocoagulation were carried out in the late 1950s by G. lattice degeneration or retinoschisis. (10) Lasers can be also used as an adjunctive tool in combination with other treatment modalities in therapy regimens for medium or even large melanomas. and good adhesion is usually obtained without the need for sutures. The main advantages of laser treatment compared to other modalities like irradiation are the broad availability. the epithelium is replaced. Surgical techniques such as photorefractive keratectomy (PRK) and laser in-situ keratomileusis (LASIK) are used to correct optical aberrations of the eye. (13) Nowadays. (19) The use of lasers to reshape the anterior corneal curvature to correct refractive errors has become an established clinical procedure. The development of lasers for plastic surgery. This flap is then repositioned on the exposed stroma. which predispose to a rhegmatogenous retinal detachment. In the recent years. another explosion occurred in the treatment of posterior segment disorders. lasers are an irreplaceable tool in the management of malignant and benign intraocular lesions. and this limits potential flow of fluid from the vitreous cavity through a break. the epithelial layer is completely removed. With argon laser photocoagulation a thermal burn is created to surround the lesion and any subretinal fluid associated with it. including macular dege neration and intraocular tumors. Posterior capsulotomy for creating openings in an opacified posterior capsule can be performed with the argon laser of the pulsed Neodymium. The interaction between corneal tissue and the excimer laser was first investigated in 1981 by Taboada. 120-160 µm) of anterior corneal stroma. which is equivalent to PRK. the relatively easy performance and thus reproducibility. as well as astigmatism. Clinical studies determined refractive success rates of between 80 and 95% for corrections up to –6 D of myopia. It is impossible to imagine ophthalmology today without lasers. (18) A modification of this technique involves the microkeratome to make a lamellar flap (average thickness. Meyer-Schwickerath with the xenon arc photocoagulator. This procedure was particularly investiga ted in eyes needing high myopic corrections if more than – 6 D. Corneal laser surgery with the modern excimer laser is known to be the most frequently applied laser procedure in medicine. such as myopia or hyperopia. who studied the response of the epithelium to the argon fluoride (AF) and krypton fluoride (KrF) excimer laser. The burn becomes an adhesion between the retina and retinal pigment epithelium. but about 900 of the circumference is allowed to remain as a short of hinge. breaks. followed by refractive ablation of the exposed stromal bed. ubiquitously and thoroughly do they dominate the field. the high precision during the treatment. and ocular imaging is progressing rapidly and is expected to find much greater use and usefulness in the coming years.

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