ABSTRACT:

Refractive surgery is a procedure that requires excellence.The capabilities of the technology include not only the creation of corneal flaps for laser-assisted in situ keratomileusis, but limitless corneal- and lens-based incisions, as well as glaucoma and retinal applications that can break old paradigms. The expectations are huge and future studies will show how far we can go with the technology

WHAT IS REFRACTIVE SURGERY?

Refractive eye surgery is any eye surgery used to improve the refractive state of the eye and decrease or eliminate dependency on glasses or contact lenses. This can include various methods of surgical remodeling of the cornea or cataract surgery. The most common methods today use excimer lasers to reshape curvature of the cornea. Successful refractive eye surgery can reduce or cure common vision disorders such as myopia, hyperopia and astigmatism.

WHAT IS EXCIMER LASER?

The excimer laser is based on the combination of two gases : a noble gas and halogen. These gases are stable in their normal low-energy state. When a high-voltage electrical discharge is delivered in a laser cavity containing these gases, the gases combine to form a high energy excited-gas state compound. The term "excimer" is derived from a contraction of excited dimer. This wavelength of light energy is amplified in the laser system and results in the production of a high-energy discrete pulse of laser energy. The specific wavelength of an excimer laser depends on the composition of the gases used in the laser system. The current excimer laser systems use argon and fluorine gases. The argon-fluorine excimer lasers emit energy at a wavelength of 193 nm. This wavelength falls in the UV-C range of the light spectrum. In contrast, the kryptonfluoride excimer laser used in early laboratory studies emits a wavelength of 248 nm..

WORKING OF EXCIMER LASER:

The 193-nm excimer laser energy is well absorbed by the proteins, glycosaminoglycans, and nucleic acids that make up the cornea. Because a 193-nm photon is of higher energy than the molecular bond strength of these compounds, absorption of the laser energy results in a breaking of the bonds. The molecular fragments that thus result are ejected from the surface of the cornea at supersonic speeds. The excimer laser tissue removal process is termed

"ablative photodecomposition," and it involves the removal of tissue from the corneal surface, rather than cutting tissue like a scalpel. When this procedure is used clinically, the ablated tissue appears as an effluent plume. Analysis of this plume has shown it to comprise a variety of high-molecular-weight hydrocarbons. Currently approved lasers have beam diameters of 6.0 to 6.5 mm. Wherever this broad beam impinges on tissue, molecular bonds will be broken and tissue removed. Hence, relatively large areas of the cornea can be treated with each pulse. The excimer laser technique is, thus, qualitatively different from refractive surgical techniques such as radial keratotomy, which achieves corneal reshaping through biomechanical changes mediated through thin knife incisions.

WHY 193-NM EXCIMER LASER?

Several attributes of the argon-fluoride excimer laser ablation make it particularly appropriate for corneal sculpting. The laser energy is well absorbed near the corneal surface and, thus, should have few deep direct or secondary mechanical (shock-wave) effects on the corneal tissue. The ablation process is rapid, and excess energy is ejected with the effluent plume.6 There is minimal thermal damage to the surrounding tissue. Because of these qualities, the 193-nm excimer laser can be used to meticulously reshape large areas of the corneal surface while minimizing damage to remaining tissue.

NORMAL EYE SIGHT: EMMETROPIC:

Refracting power of the eye is perfect.

VARIOUS EYE PROBLEMS:

MYOPIC:

In this case the refracting power of the eye is too strong. The light rays from a distant object focus to a point in front of the retina. HYPEROPIC:

In this case the refracting power of the eye is too weak. The light rays from a distant object focus to a point behind the retina. ANTIGMATISM:

In this case the anterior refracting surface of the eye is slightly elliptical rather than spherical. This causes light rays from a distant object to focus at 2 discrete points in the eye.

TECHNIQUES : FLAP PROCEDURES:

1)Automated lamellar keratoplasty (old technique): The surgeon uses an instrument called a microkeratome to cut a thin flap of the corneal tissue. The flap is lifted like a hinged door, targeted tissue is removed from the corneal stroma, again with the microkeratome, and then the flap is replaced. 2)Laser Assisted In-Situ Keratomileusis (LASIK): The surgeon uses a microkeratome or femtosecond laser to cut a flap of the corneal tissue (usually with a thickness of 100-180 micrometres). The flap is lifted like a hinged door, but in contrast to ALK, the targeted tissue is removed from the corneal stroma with an excimer laser. The flap is subsequently replaced.

SURFACE PROCEDURES:

Photorefractive keratectomy (PRK) is an outpatient procedure generally performed with local anesthetic eye drops . It is a type of refractive surgery which reshapes the cornea by removing microscopic amounts of tissue from the corneal stroma, using a computer-controlled beam of light (excimer laser). The difference from LASIK is that the top layer of the epithelium is removed (and a bandage contact lens is used), so no flap is created. Recovery time is longer with PRK than with LASIK, . Laser Assisted Sub-Epithelium Keratomileusis (LASEK) is a procedure that also changes the shape of the cornea using an excimer laser to ablate the tissue from the corneal stroma, under the corneal epithelium, which is kept mostly intact to act as a natural bandage. The surgeon uses an alcohol solution to loosen then lift a thin layer of the epithelium with a trephine blade (usually with a thickness of 50 micrometres).[2] During the weeks following LASEK, the epithelium heals, leaving no permanent flap in the cornea. This healing process can involve discomfort comparable to that with PRK. EPI-LASIK is a new technique that uses an epi-keratome (rather than a trephine blade and alcohol), to remove the top layer of the epithelium ( thickness of 50 micrometres). For some people it can provide better results than regular LASEK in that it avoids the possibility of negative effects from the alcohol, and recovery may involve less discomfort.

C-TEN:

C-Ten (Customized TransEpithelial Non-contact ablation) is a refinement of Lasek, EPI-Lasik, and PRK. It is the newest and the fastest Laser treatment. C for Customized refers to the individualization of the treatment for each patient, conforming to each individuals requirements determined by the shape of the cornea and the topography of its surface, the extent of the correction, pupillary size and reaction, and the patients lifestyle requirements. TEN (Trans Epithelial, Non-Contact) means that the ablation of the epithelial layer, the regenerative surface of the eye, is accomplished with the laser alone, with no direct contact with the eye. CTen is the only treatment technique done without actual contact with the eye. Prior to the start of the procedure each eye is examined and measurements are made using two instruments specially designed for the laser treatments. The Precisio measures the corneal topography, both its shape and thickness. The "Pupillometer measures the size of the pupil under various light relationships. These measurements ensure that the area undergoing treatment is neither too small ( with the danger of ensuing halos or blinding) nor too large (which could cause ablation of excessive tissue). After the Laser treatment the epithelium regenerates within a few days, all the while being protected by a contact lens .

ADVANTAGES OF C-TEN:

The technique, causes the least post-operative discomfort. C-Ten has a very low incidence of dry eye Absence of flap associated complications that can occur after Lasik and changes in corneal stability are minimal. C-Ten is especially suited to the treatment of myopia and irregular astigmatism Up 12 diopters of myopia and over 6 diopters of corneal distortions can be corrected.

CORNEAL INCISION PROCEDURES:

Radial keratotomy (RK) uses spoke-shaped incisions (usually made with a diamond knife) to alter the shape of the cornea and reduce myopia or astigmatism; this technique has now been largely replaced by the other methods (that use excimer laser). Arcuate keratotomy (AK) is similar to radial keratotomy, but the incisions on the cornea are done at the periphery of the cornea. Arcuate keratotomy is used to correct astigmatism. Although most incisional procedures are replaced nowadays by Lasik, AK is still used in some special cases (correction of residual astigmatism after a keratoplasty procedure or during cataract surgery). Limbal relaxing incisions (LRI) are incisions near the outer edge of the iris, used to correct minor astigmatism (typically less than 2 diopters). This is often performed in conjunction with an Intraocular Lens implantation.

Other procedures:

Thermal keratoplasty is used to correct hyperopia by putting a ring of 8 or 16 small burns surrounding the pupil, and steepen the cornea with a ring of collagen constriction. Laser thermal keratoplasty (LTK) is a non-touch thermal keratoplasty performed with a Holmium laser, while conductive keratoplasty (CK) is thermal keratoplasty performed with a high-frequency electric probe. Thermal keratoplasty can also be used to improve presbyopia or reading vision after age 40. Intrastromal corneal ring segments (Intacs) are approved by FDA for treatment of low degrees of myopia. Lens implantation inside the eye can also be used to change refractive errors. For presbyopia correction, a corneal inlay consisting of a porous black ring surrounding a small clear aperture was originally developed by D. Miller and a group at Acufocus. The inlay is placed under a lasik flap or in a stromal pocket.

CONCLUSION:
In this paper we have dealt about the various eye problems and the various laser technologies used to do refractive surgeries to improve the refractive state of the eye and decrease or eliminate dependency on glasses or contact lenses.

REFERENCES:
1)google books 2)wikepedia 3)yahoo search

APPLICATION OF LASER IN MEDICAL FIELD

SUBMITTED BY,

1)R.KARTHIK(1-EEE) 2)M.GANAPATHY(1-EEE) TRICHY ENGINEERING COLLEGE KONALAI

E-MAIL-ID: firekarthik106@gmail.com PHONE : 9629897527

SYNOPSIS:
ABSTRACT WHAT IS REFRACTIVE SURGERY? WHAT IS EXCIMER LASER? WORKING OF EXCIMER LASER NORMAL EYE SIGHT VARIOUS EYE PROBLEMS TECHNIQUES 1)FLAP PROCEDURES 2)SURFACE PROCEDURES 3)INCISIONAL PROCEDURES CONCLUSION