Principle of Laser Application in Medicine & LASER SAFETY

Peter Hasan H.W., MD. Laser Clinic, Dept. of Surgery, Pluit Hospital, Jakarta, Indonesia.

APA LASER ITU ?

Singkatan dari : L ight A mplification by the S timulated E mission of R adiation.

Laser =/= X-ray =/= Gamma-ray

=Usual light with unique character

Wavelength from far infra-red to visible light and near ultra violet

SINAR LASER
Sama seperti sinar biasa Ciri Unik : Monokromatik Kolimasi Koheren

Thermal Injury to cells

< 43 C : the skin remain unharmed 43 - 50 C : tissue necrosis (after several minutes) 45 C : fibroblast die after about 20 minutes 70 - 100 C : irreversible thermal damage

Laser Effect on Tissue

Collagen Reaction to Temperature Elevation - Less than 40o C : no effect - 40o 53o C : Protein Denaturation - 55o 60o C : Protein Degradation - 63o 90o C : Protein Coagulation. - 90 = 100 C : Evaporization - > 200 C : Carbonization

Coagulation
Maybe reversible or irreversible 61 63 C : reversible non-lethal thermal damage = collagen shrinkage 61- 71 C : The goal of laser resurfacing Achieve the desired shrinkage of collagen without completely denaturating collagen

Vaporization
70 - 100 C : irreversible thermal damage and denaturation tissue necrosis 100 C : vaporization 100 - 120 C : fluctuation between vaporization and charring 120 - 200 C : charring occurs

Thermal Injury to cells

< 43 C : the skin remain unharmed 43 - 50 C : tissue necrosis (after several minutes) 45 C : fibroblast die after about 20 minutes 70 - 100 C : irreversible thermal damage

LASER SYSTEM

INTENSE COHERENT LIGHT

POTENTIAL HAZARDS

SKIN

EYE

OTHERS

Comparison : Sunlight, Light Bulb, and Laser

source
Light Bulb
DISTANCE
D = 1.0 m.

IRRADIANCE
0.2 mwatt / cm2 ( 0.002 ) 0.1 watt / cm2 (1.0 )

------------------------100 w light bulb

D = 150,607,200 km -------------------------------

Sunlight

The Sun

LaserBeam

D = ??? ------------------------1.0 Watt Laser

130 watt / cm2

( 1,300 )

LASER Hazards Recorded in USA (1964 -1982)

53 cases of Laser incidents. 15 cases were Medical Laser Incidents involving : - patients - medical personnel - laser representative - observer

MEDICAL LASER HAZARDS

Burns : Skin, eye, drapes, etc. Blindness : - Total - Partial - Temporary - Permanent Explosion : - Airway - Digestive tract - intra-cavity - Endoscopic, flammable anesthetics.

Laser is Hazardous to Eye

Eye function : to see Cornea/oculi/retina unprotected by overlying skin, living organ exposed to environment The Eye = highest risk to be injured Self protection by build in blinking reflex/aversion response = 0,25 sec Not enough to prevent macular burn if>MPE Hazards are depending on Wavelength used.

Hazards correspond -Wavelength

Type of LASER Wavelength
200-315 315-400nm

Damage
Photokeratitis Cataract formation
Retinal (Macular) burn injury

Excimer/UV

Argon, KTP, Pulse Dye, HeNe, Krypton, Ruby, dsb. IR, Diode Alexandrite, Nd.YAG, Er.Glass

400-700 nm. (Visible) 700-780 nm.

780-1400 nm.

Retinal burn, Cataract Corneal burn, Aqueous flare, Cataract formation

Ho.YAG, Er.YAG

1400-3000 nm.

Carbondioxide

3000-80000 nm.

Corneal burn

A.N.S.I.
(American National Standards Institute)

N.C.D.R.H.
(National Center for Devices and Radiological Health) ANSI/NCDRH Standard : Laser Classification : 4 Major Hazard Categories / Class

Class I Laser
Low energy laser Cannot emit radiation of known hazard (eye) Less than MPE (= Maximum Permissible Exposure) No need for control, no safety requirement. Example : - Completely enclosed diagnostic laboratory equipment. - Video laser disc player - etc.

Class II Laser
Low power laser, visible, up to 1-2 mW. Incapable to cause injury within aversion reflex/response of the eye (0,25sec.) Hazard can exist only if stares directly into the laser beam or point directly to the eye. Need to have a CAUTION label and indicator light. Example : laser pointer/alignment

Class III Laser

Medium Power laser Capable to cause injury to the eye within 0,25 sec. Divided into 2 subgroups: - Class IIIA laser - Class IIIB laser

Class IIIA Laser

Output in the range 1-5 mW Not hazardous if exposed in short period. Low laser beam density (irradiance) less than 2.5 mW/cm2 Usually large beam diameter/expanded diameter (with diffusing/diverging lens) Need a CAUTION label

Class IIIB Laser

Power range 1-500 mW. Can be hazardous if eye expose to direct laser beam. Need a DANGER & Laser Aperture label Examples : - Laser pain attenuator - Laser acupuncture apparatus - Ophthalmic laser photo-coagulator

Class IV Laser
High Power laser Are Hazardous to view either directly or indirectly Most surgical lasers are Class IV laser Can cause serious damage to skin and eye within less than 0.25 sec. Need a DANGER & Laser Aperture" label

MEDICAL LASER PROTECTION

Organ prone to laser injury : - Skin - Eye Protection toward : Skin = wet gauge, inflammable drape, etc. avoid direct or indirect exposure to laser Eye : CO2 laser = Ordinary Goggles Argon, KTP, Nd.YAG, Ruby lasers = Goggles for specific wavelength. Avoid using flammable material. Use black coated /non reflecting instrument

LASER DANGERS
No comprehensive list Each procedure have : - different situations - different conditions - different hazards To achieve successful laser applications : Mastering Laser Physics, Laser Tissue Interactions, Laser Safety, Laser Operating Principles/Technique is a MUST

Qualification and Training

Staff / Personnel involve in Laser Treatment should have laser safety training. Only Qualified and Authorized Operators are permitted to operate the laser. Every Safety precaution provided by the manufacturer of each individual laser equipment should be followed routinely, particularly Class III & IV Lasers.

Conclusion
Laser Applications/treatment are beneficial and superior to conventional treatment when done in Good Hands and Correct indications. In the Contrary Laser Treatment have the potential to harm the Patient, the Operator as well as the Personnel assisting the Laser Treatment.

Pedoman bagi Pemula

Pahami Fisika Laser dan Interaksi Jaringan Gunakan jenis laser yang sesuai Gunakan tehnik dan asesori yang sesuai Set daya seuai kebutuhan, mulai dengan daya yang paling rendah yang masih berkhasiat Tingkatkan daya secara bertahap setelah mendapat pengalaman/perasaan(feeling)