Laser Techniques in Ophthalmology: A Guide To YAG and Photothermal Laser Treatments in Clinic 1st Edition Anita Prasad

Laser Techniques in Ophthalmology: A
Guide to YAG and Photothermal Laser

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Laser Techniques in
Ophthalmology
Laser Techniques in
Ophthalmology
A Guide to YAG and Photothermal
Laser Treatments in Clinic
Anita Prasad, MBBS, FRCOphth

Royal Gwent Hospital, Aneurin Bevan University Health Board
First edition published 2022
by CRC Press
6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742
and by CRC Press
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© 2022 Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, LLC
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in this book is intended for use by medical, scientific or health-care professionals and is provided strictly as a
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Library of Congress Cataloging‑in‑Publication Data
Names: Prasad, Anita G., 1978– author.
Title: Laser techniques in ophthalmology: a guide to YAG and photothermal
laser treatments in clinic/by Anita Prasad.
Description: First edition. | Boca Raton, FL: CRC Press, 2022. |
Includes bibliographical references and index. |
Summary: “This is a practical guide to using lasers in the eye clinic and includes all commonly performed lasers
for a range of ocular conditions. It standardizes laser procedures and serves as a reference guide for ophthalmic
trainees learning the technique that can be transferred to their clinical practice”– Provided by publisher.
Identifiers: LCCN 2021062227 (print) | LCCN 2021062228 (ebook) |
ISBN 9780367700324 (hardback) | ISBN 9780367700317 (paperback) | ISBN 9781003144304 (ebook)
Subjects: MESH: Eye Diseases–surgery | Laser Therapy–methods |
Lasers, Solid-State–therapeutic use | Handbook
Classification: LCC RE80 (print) | LCC RE80 (ebook) |
NLM WW 39 | DDC 617.7/1–dc23/eng/20220113
LC record available at https://lccn.loc.gov/2021062227
LC ebook record available at https://lccn.loc.gov/2021062228
ISBN: 9780367700324 (hbk)
ISBN: 9780367700317 (pbk)
ISBN: 9781003144304 (ebk)
DOI: 10.1201/9781003144304
Typeset in Palatino
by Newgen Publishing UK
To my husband, Ajay, and children, Aditya and Tapasya, my pride and joy,
for inspiring me to excel in everything I do.
To my parents for encouraging me to believe in myself.
To my family and friends for being there for me.
To my teachers and mentors, who have taught me over the years, and trainees,
who have been a source of inspiration, learning, and constant evolution.
Table of Contents
Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi
Trainee Feedback. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
About the Author. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
0.1 Lasers in Ophthalmology (Diagnostic and Therapeutic). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Section 1: Basic Principles of Laser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1.1 Laser Physics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1.1 Properties of Laser Light . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1.2 Understanding Laser Physics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1.3 How Does an Atom in the Ground State Move to an Excited State?. . . . . . . . . . . . . . 5
1.1.4 Stimulated Emission. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.1.5 Parts of a Laser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
1.2 Parameters of Laser Light – Determines Its Tissue Biological Effects . . . . . . . . . . . . . . . . . . . 9
1.2.1 Laser Wavelength . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
1.2.2 Tuneable Lasers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.2.3 Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.2.4 Mode. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.3 Laser Delivery Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.3.1 Slit Lamp Laser Delivery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
1.3.2 Binocular Indirect Ophthalmoscopy (BIO); Laser Indirect
Ophthalmoscopy (LIO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
1.4 Laser Tissue Interaction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
1.4.1 Principles of Laser Tissue Interactions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.4.2 Laser Mechanisms in the Retina. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.4.3 Starling’s Law and Macular Oedema. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.4.4 How Does Focal Laser Treatment Reduce Macular Oedema?. . . . . . . . . . . . . . . . . . . 18
1.5 Laser Hazard and Laser Safety Protocols. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1.5.1 Laser Classification and Safety (ANSI Standards). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1.5.2 Laser Safety Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
1.5.3 Laser Safety Eyewear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
1.6 Laser Lenses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
1.6.1 Advantages of Contact Lenses in Lasers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
1.6.2 Safety Principles of Contact Lenses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
1.6.3 Laser Cone Angle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
1.6.4 Lens Classification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
1.6.5 Common Features of Laser Contact Lenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
vii
Table of Contents
1.6.6 Lens Used with YAG Laser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

1.6.7 Contact Lenses Used in Conjunction with Photothermal Lasers. . . . . . . . . . . . . . . . . 28
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Section 2: YAG Laser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

2.1 The Nd-YAG Laser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
2.1.1 Getting Started. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
2.2 YAG Laser Posterior Capsulotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
2.2.1 Pathophysiology of Posterior Capsular Opacification . . . . . . . . . . . . . . . . . . . . . . . . . 36
2.2.2 Posterior Capsular Opacification in Paediatric Patients. . . . . . . . . . . . . . . . . . . . . . . . 36
2.2.3 Types of Capsular Opacification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
2.2.4 How Does YAG Laser Work? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2.2.5 YAG Capsulotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
2.2.6 YAG Capsulotomy Techniques –Two Main Techniques. . . . . . . . . . . . . . . . . . . . . . . . 40
2.2.7 Treatment Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.2.8 Size of the Posterior Capsulotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
2.2.9 YAG Capsulotomy with Eccentric Pupil. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.2.10 Complications of YAG Capsulotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.2.11 IOL Pitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
2.2.12 Newer Concepts in Posterior Capsulotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
2.2.13 Re-opacification of Posterior Capsule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
2.2.14 IOL Opacification/Calcification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
2.3 Capsular Block Distension Syndrome. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
2.3.1 Pathophysiology of CBDS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
2.4 Anterior Capsulotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
2.5 Inflammatory Pupillary Membrane and Synechiolysis in Pseudophakes. . . . . . . . . . . . . . . 53
2.5.1 Clearance of Inflammatory IOL Deposits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
2.5.2 Clearance of Retained SLM in the Visual Axis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
2.6 YAG Laser Vitreolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
2.6.1 Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
2.6.2 YAG Vitreolysis for Vitreous Wick. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
2.7 YAG Laser Hyaloidotomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
2.7.1 Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Section 3: Lasers in Glaucoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

3.1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.1.1 Outflow Enhancing Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.1.2 Inflow Reducing Procedures (Aqueous Production). . . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.2 YAG Laser Peripheral Iridotomy (LPI). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
viii
Table of Contents
3.2.1 Indications for YAG LPI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

3.2.2 How Does YAG LPI Work?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
3.2.3 Laser Peripheral Iridotomy –Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
3.2.4 Complications of LPI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.2.5 Sequential Argon/PASCAL Iridoplasty with Nd:YAG PI . . . . . . . . . . . . . . . . . . . . . . 69
3.2.6 Outcomes of LPI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
3.3 Pigment Dispersion Syndrome (PDS). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
3.4 Plateau Iris. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
3.4.1 Mechanism of Glaucoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
3.5 Iridoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
3.6 Selective Laser Trabeculoplasty (SLT). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
3.6.1 SLT vs ALT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
3.6.2 Mechanism of Action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
3.6.3 SLT Laser Technique. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
3.6.4 Recent Advances. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Section 4: Photothermal Lasers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

4.1 Introduction –Treatment Concepts and Current and New Laser Technology. . . . . . . . . . . 81
4.1.1 Current Concepts in Laser Photocoagulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
4.1.2 New Laser Treatments/Technology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
4.2 Getting Started with Laser Retinal Photocoagulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
4.2.1 PASCAL Laser Machine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
4.3 Pan Retinal Photocoagulation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
4.3.1 Methods of PRP Delivery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
4.3.2 Normal Ocular Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
4.3.3 How Does PRP Work? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
4.3.4 Getting Started with Pan Retinal Photocoagulation . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
4.3.5 Schematic Approach to PRP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
4.3.6 Understanding Laser Parameters for PRP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
4.3.7 Exceptions to Treatment Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.3.8 Aggressive Laser Treatment in Ischaemic Retinal Vasculopathy. . . . . . . . . . . . . . . . 105
4.3.9 Pan Retinal Photocoagulation –Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
4.3.10 Starting PRP Treatment –Lesson Based on Treatment-Naïve Eye. . . . . . . . . . . . . . . 108
4.3.11 Risks of PRP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
4.4 Sectoral PRP. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
4.4.1 When Is Sectoral Laser Treatment Appropriate in BRVO?. . . . . . . . . . . . . . . . . . . . . 114
4.4.2 Sectoral PRP in BRVO or HRVO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
4.5 Focal Laser Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
4.5.1 Indications for Focal Laser Treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
ix
Table of Contents
4.5.2 Is It Essential to Target Microaneurysms?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

4.5.3 Pre-Laser Investigations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
4.5.4 Grid Laser Treatment –Including the Papillo-Macular Bundle. . . . . . . . . . . . . . . . . 135
Suggested Reading. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
4.6 Focal Laser Treatment for Non-Diabetic Maculopathies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
4.6.1 Retinal Vein Occlusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
4.6.2 Retinal Artery Macroaneurysm (RAM). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
4.6.3 Central Serous Chorioretinopathy (CSCR). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
4.6.4 Idiopathic Juxtafoveal Telangiectasia (IJFT). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
4.6.5 Laser Treatment for Age Related Macular Degeneration. . . . . . . . . . . . . . . . . . . . . . 163
4.7 Laser Retinopexy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
4.7.1 Peripheral Retinal Degenerations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
4.7.2 Diagnosis of Retinal Holes and Tears. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
4.7.3 Role of Posterior Vitreous Detachment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
4.7.4 Formation of Retinal Holes and Tears. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
4.7.5 Operculated Retinal Holes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
4.7.6 Horseshoe Tear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
4.7.7 Treatment of Retinal Holes and Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
4.7.8 Laser Retinopexy –Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
4.7.9 Special Situations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Section 5: Approach to Retinal Vascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

5.1 Multimodal Treatment of Retinal Vascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
5.1.1 Anti-VEGF Agents Used Alone or in Combination. . . . . . . . . . . . . . . . . . . . . . . . . . . 171
5.1.2 What’s ‘Visually Significant’ DME?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
5.1.3 Real-World Implications of Visual Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
5.1.4 Steroids +Laser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
5.2 Approach to Diabetic Eye Disease. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
5.2.1 Pathogenesis of Diabetic Retinopathy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
5.2.2 ETDRS Classification and Clinical Signs of DR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
5.2.3 Management of Diabetic Retinopathy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181
5.2.4 Treatment Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
5.3 Approach to Retinal Vein Occlusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
5.3.1 Risk Factors for RVO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
5.3.2 Pathogenesis of RVO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
5.3.3 Location of RVO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
5.3.4 Laser Treatment for Neovascularization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Acknowledgement of Images Borrowed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 207
x
Acknowledgements
Writing this book has been a rewarding and A big thanks to Amy, Tom, and Mike from
fulfilling experience. I hope to bring a trainer’s medical illustration, for their help and advice in
perspective, giving essential laser training collating images for the book.
some structure, based on knowledge and To the trainees who jogged my memory,
clinical experience. and proofread the book in its early stages
The book concentrates on common laser with encouraging feedback. Thank you, Luke,
techniques in the eye clinic, bringing clarity Francis, Alex, James, Connor, Sejal, Shoaib, and
on treatment concepts, techniques, and plans, Ellie. I hope you learnt as much from me as
developing good clinical practice and skill I have from teaching you.
sets, with an easy to understand, user-friendly Thanks to Gwyn and Patrick for their initial
approach, using multiple digitally enhanced input and encouragement, and to Shivangi,
illustrations, for ready reference in the laser Himani, and everyone on the publishing team.
clinic. I could not have done this without your help.
xi
Trainee Feedback
I am not aware of any existing book that The pictures are good, in particular I like the
approaches this subject in this way. I think treatment plan ones with areas you might deliver
ophthalmic trainees nationally and internationally lasers. I would have felt a lot more confident having
would find appeal in a book that provides a read this before doing my own cases. I think the
structured theoretical grounding in the subject format with boxes is good with good snippets of
with a practical approach to using ophthalmic information.
lasers. The use of illustrations is vital for teaching
JP
this subject and the approach used by annotating
these images in this book is ideal for demonstrating
techniques.
LP
xiii
About the Author
Anita Prasad is an ophthalmologist with an enhanced images to highlight learning points
interest in medical retina, with over 25 years and simplify techniques, making it easy for
of experience, and a laser lead and trainer at learners to get started with lasers. Outside of
ABUHB Trust for over 20 years. It has given medical work, Anita is an artist, dabbling in oils
her a unique insight and approach into an and acrylics, and enjoys reading, cooking, and
area that is not well taught, using digitally community work.
xv
Glossary
Absorb: To transform radiant energy into a Hertz (Hz): Measurement of frequency of light
different form, usually with a resultant rise (cycles / second)
in temperature Intensity: Magnitude of radiant energy / light
Amplification: Growth of the radiation field per unit time or area
in the resonator cavity from multiple Joules: Measurement of laser energy in time –
reflections between the cavity mirrors watts / second, for pulsed laser
Amplitude: The maximum value of Lifetime: Time taken for an excited atom to
electromagnetic wave height spontaneously decay back to ground state
Bandwidth: The width of the optical spectrum or a lower energy state
of light, expressed in wavelength units Luminance: The flux / unit area
(m) or frequency units (Hz) Monochromatic: Light consisting of single
Brightness: The luminous power of a light beam wavelength of light
Coherence: Waves that are synchronized, with Nanometre: Unit of length =1 billionth of a
phase difference between their oscillations meter, used to measure wavelength
remaining constant as they propagate. This OHT: ocular hypertension
allows laser light to be concentrated into Optical density: Protection factor of eyewear
small spots, or ultra-small pulses filter used with lasers. Each unit of OD
Collimation: Process by which divergent rays represents ×10 increase in eye protection
(natural light) are converted to parallel rays Optical fibre: Light or laser transmitting optical
CNV: Choridal neovascular membrane material for great distances
CW mode: Continuous emission of Optical pump: Exciting a lasing material using
electromagnetic wave of constant light as the external source
frequency or wavelength and amplitude, at PCO: Posterior capsular opacification
constant power Photon: Smallest packet of light energy. Energy
Depth of field: The working range of the beam, is directly proportional to the frequency
based on wavelength and laser focusing of light
mechanisms Population inversion: State when the atoms
Energy: Measurement of laser light to induce in the excited state exceed atoms in the
change (heating / cutting), measured in ground state; forms the basis for stimulated
watts. Energy is inversely proportional to emission
wavelength. Power: Energy / unit time measured in watts.
Excited state: State of higher energy of an atom Power is constant in CW laser or variable
or molecule in a pulsed laser
Flashlamp: Source of powerful light used Power density: Laser power / surface area
to excite stimulated emission in a solid- (spot size) on which it works. Increasing
state laser power or decreasing spot size will increase
Flux: The radiant or luminous power of a power density. Excessive power density
light beam can rupture Bruch’s membrane and
Fluence: All laser irradiance =laser irradiance + cause choroidal neovascularisation.
any backscattered irradiance. POAG: Primary Open angle glaucoma
Frequency: Number of light waves / complete Pulsed mode: Light emitted in short bursts
vibrations in a fixed period of time. or pulses of highly concentrated energy.
Frequency is inversely proportional to the Energy of laser in pulsed mode is much
wavelength of light greater than CW lasers
IOL: Intraocular lens Q-switch: Shutter device that allows laser
Irradiance: Laser power per unit area =watts / energy to be released in small pulses.
cm2. It is a measure of how strongly laser Energy is only released when it reaches a
works on a given tissue higher power
Gain: The increase in energy through Radiance: A measure of how strong a laser is
amplification Raman effect: When a wavelength of light can
Gain medium: The lasing medium that provides be changed by molecular scattering
the atoms / molecules for stimulated Refractive Index: Property of a medium that
emission and coherent amplification determines how light propagates through
Ground state: The state of lowest stable energy it. RI of vacuum is 1 and of water is 1.33
level in an atom or molecule (This means that light travels 1.33 times
Heat sink: Substance or device used to absorb more slowly in water than vacuum). RI
or dissipate unwanted heat determines how light bends when passing
xvii
newgenprepdf
Glossary
through a medium. RI of lens –1.386, inversion; forms the basis of laser light
vitreous –1.336, RI of silicon oil > RI of generation
vitreous Wavelength: The distance an EM wave travels
Resonator: The optical cavity with mirrors on during 1 cycle of oscillation. Property of
each end that amplifies the stimulated light that determines its colour, measured
emission, generating a laser beam in nanometres. Monochromatic light has
Spontaneous emission: Emission of a photon a single wavelength, while polychromatic
of light by spontaneous decay of an light is multi-coloured. Wavelength
excited atom determines how effectively light penetrates
Stimulated emission: External source of ocular media and how well it is absorbed
energy / photon that stimulates atoms by the target tissue
to get excited and achieve population
xviii
Introduction
Introduction
LASER is an acronym for Light Amplification haemorrhages. Surgical lasers can cut,
by Stimulated Emission of Radiation. To lase coagulate, and remove tissues, with minimal,
is to absorb energy in one form and emit a new no-touch techniques, improving outcomes. New
more useful form of energy. concepts and advances have improved laser
Lasers were first conceptualized by safety and delivery including eye-tracking
Albert Einstein (1917). The first prototype feature, subthreshold, shorter pulse and
photothermal laser was built by Theodore multispot lasers.
Maiman (1960), and they have since become Lasers have branched into diagnostic
essential tools in ophthalmic practice. Recent realms, including the laser-based microscopic
technological advances and new concepts have technique for early diagnosis of ocular (ARMD,
renewed interest in the topic. glaucoma) and neurodegenerative conditions
Lasers can be generated in a spectrum like Alzheimer’s disease. Laser technology is
of wavelengths (short UV to long IR) with used in investigative techniques such as laser
a multitude of applications including interferometry, spectroscopy, microperimetry
electronics, information technology, science, mapping of macula, confocal scanning laser
medicine, entertainment, military, industry, ophthalmoscope (CSLO), optical coherence
and law enforcement. Modern fibre-optic tomography (OCT and OCT-A), and laser
communication technology such as the Internet retinal Doppler flowmetry.
uses lasers.
0.1 L
ASERS IN OPHTHALMOLOGY
(DIAGNOSTIC AND THERAPEUTIC)
Lasers can reshape corneas to improve focus,
improve IOP in glaucoma and cauterize
Anatomical site Laser procedure Type of laser

Ocular adnexa Removal of lid lesions, blepharoplasty, removal of CO2 laser
wrinkles, capillary haemangioma, and port-wine stain,
DCR
Cornea (keratorefractive PRK (photorefractive keratectomy), laser in-situ Excimer laser
surgery) keratomeleusis (LASIK), laser subepithelial
keratectomy (LASEK), phototherapeutic keratectomy
(PTK), laser for corneal neovascularization
Sclera Laser scleroplasty, laser suture lysis (post Holmium YAG
trabeculectomy) Argon/PASCAL
Iris Peripheral iridotomy (PI), laser iridoplasty, laser Nd-YAG laser,
pupilloplasty Argon/PASCAL
Angle Selective laser trabeculoplasty (SLT), PASCAL SLT Nd-YAG laser
Ciliary Body Cyclophotocoagulation (CPC) scleral/pupillary/ Diode, Nd-YAG
endoscopic
Lens Cataract surgery (incision, capsulorhexis, nuclear Femtolaser
photo-fragmentation) –FLACS –femtolaser assisted Nd-YAG laser
cataract surgery, PCO
Vitreous Viterolysis Nd-YAG laser
Posterior Segment PRP, FLT, Sectoral PRP, retinopexy, laser for ARMD, IO Argon, PASCAL, Diode
tumours, and other vasculopathies
DOI: 10.1201/9781003144304-1 1
Laser Techniques in Ophthalmology
Other Medical Applications of Lasers

Speciality lasers Uses
Dermatology Cosmetic surgery –removal of tattoo, birthmarks, sunspots,
CO2 (10600 nm), Pulsed dye (585– stretchmarks, scars, wrinkles, hair removal, skin resurfacing and
595 nm), Nd-YAG (1064 nm), Ho- rejuvenation, management of burns, surgical scars, scar contractures,
YAG (2090 nm), Er-YAG (2940 nm), lipolysis, body contouring, removal of freckles, naevi, keratosis, viral
ruby laser (694 nm), alexandrite warts, vascular/pigmented congenital lesions, acne, cellulite, and
(755 nm), HeNe laser, diode laser striae reduction.
Urology –YAG, thallium fibre laser Renal stones –lithotripsy, BPH.
Rheumatology, gynaecology, ENT, Soft tissue surgery, laser scalpel.
surgery –CO2, Er-YAG, HeNe,
GaAs laser
Dentistry –HeNe, GaAs, diode, Teeth whitening, endodontic, and periodontic procedures.
mid-IR lasers
Neurosurgery –CO2, Nd-YAG, Precise removal of brain and spinal cord tumours.
argon
Orthopaedic –diode laser Cartilage resurfacing and reshaping.
Oncology –dye, metal vapour Superficial skin cancers (BCC, SCC), endothelial –penile, vulval,
laser laser induced interstitial vaginal, cervical, early non-small cell lung cancer.
thermotherapy (LITT)
Cardiothoracic –argon laser, Nd- Coronary artery disease, ventricular and supraventricular
YAG laser, CO2 laser arrhythmias, hypertrophic cardiomyopathy, laser thrombolysis,
trans-myocardial laser revascularization.
2
Basic Principles of Laser
THERAPEUTIC ROLE OF LASERS IN OPHTHALMOLOGY

Section 1 Basic Principles of Laser
This section deals with basic laser principles (light emitting diodes) have narrower
and their applications in the eye clinic. It bandwidth, and He-Ne laser bandwidth
gives an overview and understanding of laser is extremely narrow at 632.8 nm (red).
physics, delivery, safety, and pathophysiology
◾ Monochromaticity is not essential; some
for safe laser treatment.
lasers emit a range of wavelengths.
1.1 LASER PHYSICS
4. Collimated –all waves are unidirectional,
Laser light differs from ordinary light, with
parallel over long distances and remain
special properties, making it clinically
intense and focused (ordinary light diverges
useful.
and becomes less bright). Collimation allows
1.1.1 Properties of Laser Light precise focus without losing beam intensity.
Lasers can be manipulated to make them useful
1. Coherent –all wavelengths are in phase, to
in practice:
accurately focus the beam, allowing precise
experiments and measurements. ◾ Ability to be concentrated in short
intervals, generating intense pulses.
◾ Coherence allows laser light to be
manipulated longitudinally to create short ◾ Ability to produce non-linear effects –
pulses or transversely to get small spots. non-linear absorption, refraction, decrease
transmission, frequency doubling, Raman
2. Polarized –all wavelengths vibrate in effect, frequency amplification, mode
one plane. locking, and Q-switching.
3. Monochromatic – light of single wavelength
or frequency or colour. Monochromaticity 1.1.2 Understanding Laser Physics
reduces chromatic aberration and allows Molecules are made up of atoms, with a
selective tissue targeting, based on the tissue central positively charged nucleus (protons
absorption spectrum. and neutrons), orbited by negatively charged
electrons.
◾ Ordinary light (natural or artificial) is
Ground state (non-excited state) is the lowest
multicoloured, with a range of visible
possible energy state of an atom. Electrons
and invisible (ultraviolet and infrared)
in ground state absorb energy and rise to an
wavelengths. A fluorescent lamp has a
excited state (higher orbit).
narrow spectral emission, coloured LED
Figure 1.1 Ordinary light vs laser light.
DOI: 10.1201/9781003144304-2 3
Figure 1.2 Properties of laser light.
Figure 1.3 Atom and energy levels.
◾ Light is an electromagnetic wave, emitting ◾ Wavelength is inversely related to frequency.

radiant energy in tiny packets called High frequency =short wavelength, and
photons or quanta. vice versa. Wavelength (λ) is measured in
nanometres.
◾ E =hv (E is energy in joules, h is frequency
of light in hertz, and v is Planck’s ◾ One wavelength is the distance between 2
constant =6.626×10-34 joules times second). successive wave crests or troughs.
◾ Each photon has a characteristic frequency ◾ Frequency is the number of waves per
or wavelength. second, measured in hertz. Higher frequency
light has more waves/second (shorter
◾ The energy of a photon depends on its
wavelength).
frequency or wavelength.
4
◾ Energy is directly proportional to ◾ The blue and UV end of the spectrum has
frequency –higher frequency has higher more energy than the red or IR end of the
energy and a shorter wavelength. spectrum.
Figure 1.4 The electromagnetic spectrum.
Figure 1.5 Principles of laser emission.
1.1.3 How Does an Atom in the Ground of light stimulates it, electrons absorb the
State Move to an Excited State? photon energy and move up to an excited,
higher energy state –absorption.
◾ Normally, atoms in a medium are in a stable,
low-energy ground state. When a photon
5
◾ Electrons do not stay excited forever. They electrons at ground state to get excited or
decay spontaneously by releasing energy already excited atoms to reach higher levels
and move down to a lower level of energy or of energy. Eventually, a point is reached
back to the ground state. where the number of excited electrons is
greater than electrons in ground state –
◾ The decay time is called lifetime.
population inversion.
◾ Decay to a lower orbit releases a photon
◾ Population inversion leads to spontaneous
(energy) – spontaneous emission.
emission of higher energy photons, which
◾ The energy of an emitted photon is the stimulates more electrons –stimulated
difference between the stimulating energy emission.
and end energy (same as the stimulating
◾ If this process is repeated multiple times, it
energy if decay is to ground level or lower if
generates an extremely high level of energy –
decay is to a less excited level).
light amplification.
◾ The emitted photon has the same
◾ The newly emitted photons have the same
phase, direction, and wavelength as the
frequency and direction as the stimulating
stimulating photon.
photons. Stimulated emission is effectively
◾ So, transition of electrons up or down the a process of cloning photons, amplifying
orbit is accompanied by absorption or light, and forms the core principle of laser
emission of a replica photon. action.
1.1.4 Stimulated Emission The photons generated are monochromatic,

collimated, coherent, highly energized, and
◾ Absorption excites atoms. If more photons very bright. These are all features of
strike the atom, it stimulates more and more laser light.
Figure 1.6 How is laser light generated?
6
Figure 1.7 Parts of a laser.
1.1.5 Parts of a Laser ◾ Gain/lasing medium (provides atoms for

A laser comprises a pump, lasing medium, and stimulated emission)
resonator cavity. ◾ Optical resonator –cavity around the lasing
◾ A laser pump is the external energy source medium with mirrors to amplify stimulated
that excites the lasing medium and triggers emission and an aperture to allow release of
stimulated emission. a laser beam for clinical effect.
Laser pump –External energy to excite atoms and start process of stimulated emission.
Pumping can be by Variety of laser pumps used
• Continuous discharge lamp for CW laser • Optical pump –flashlamp, arc lamps, light from
another laser (diode).
• Intermittent flashlamp for intermittent pulses. • Chemical reactions
• Explosive devices
• Electric currents in semiconductors.
• Pulse duration varies from CW to femtoseconds.
• A laser can fire a single shot or repetitive bursts
of pulses.
Laser or gain medium –Determines laser properties and emitted wavelength.
Provides atoms, electrons, or ions to be excited by the pump.
Gas lasers –Gas enclosed in a tube and pumped by electrical discharge. Three types:
Atomic lasers Ionic lasers Molecular lasers
Example Helium-neon Argon, krypton CO2 laser
Pump Electric Electric Electric, radio waves
Lasing medium Neon atoms Argon, krypton ion CO2 molecule (10–15% CO2 gas)
Role of other Helium carries Nitrogen is transport gas
molecules electric charge to Helium is heat sink gas
neon atom
Wavelength emitted 633 nm, used in 315–529 nm 10600 nm –thermal IR in cutting,
optical research labs 458, 488, 514 nm welding, used in dermatology
Liquids lasers –Active medium is an organic dye (rhodamine), dissolved in a liquid solvent (ethanol or
ethylene glycol), in a glass chamber, pumped by another laser; emits across entire EM spectrum.
Free Electron Lasers (FEL) –Active medium is an electron beam from a particle accelerator. Generates
tuneable wavelengths in widest frequency range of any laser.
Excimer lasers –excited diatomic molecule (excited dimer) –electrical pumping forms an unstable diatomic
molecule (from union of 2 rare gases or a rare gas with a halogen). UV emission occurs when unstable diatom
dissociates back to the constituent atoms. Examples: argon fluoride –193 nm, krypton chloride –222 nm, krypton
fluoride –248 nm, xenon chloride
7
Metal-vapor lasers –hybrids lasers (features of atomic and ionic lasers). Examples: helium-cadmium laser,
helium-copper, helium-gold lasers.
Chemical lasers –two highly reactive gases form a molecule which becomes the lasing medium. Emit IR
spectrum (2700 nm–3800 nm). Example: hydrogen fluoride (HF).
Solids state lasers –use cylindrical crystal (YAG, sapphire) or glass rod that has been doped with the active
lasing medium. The crystal is used for its mechanical, thermal, and optical properties.
•
The dopant or lasing medium is a 1% impurity such as chromium, erbium, neodymium, titanium,
holmium, and ytterbium ions added to the crystal.
•
Normally, solid state lasers emit in the infrared spectrum but can be made to emit a wide range of
wavelengths by using a variety of crystals and harmonic generation or frequency doubling.
•
Example: Nd-YAG emits 1064 nm (IR), but can be frequency-doubled 532 nm PASCAL (green, visible), tripled –
355 nm, and quadrupled –266 nm (UV) rays, by using KTP crystal.
•
They are pumped by a flashlamp or light from another laser. A flashlamp is not the most effective as 70% is
wasted as heat in the crystal, requiring cooling.
•
A laser-generating higher frequency-monochromatic light is a better pump (diode laser).
• A CW solid laser causes tissue heating (IR emissions), and is best operated in a pulsed mode, using
Q-switch or mode lock to generate ultra-short pulses.
Dopant Examples of laser Wavelength generated
Neodymium Nd –yttrium aluminium garnet (YAG) Near IR –1064 nm, can be made to emit other
Nd –yttrium orthovandate (Nd-YVO4) wavelengths (tuneable)
Nd –yttrium lithium fluoride (Nd-YLF)
Titanium Ti –sapphire laser IR, highly tuneable
Holmium Ho –YAG laser Far IR –2097 nm
Chromium Cr –sapphire laser (ruby laser) Near IR spectrum
The resonator cavity –optical cavity around the laser medium with highly reflective mirrors at each end, to
reflect photons multiple times, cause amplification, and improve laser efficiency.
•
Amplification and directionality of beam –multiple reflections increase energy exponentially; only
parallel beams get reflected.
•
Use of other optical devices –spinning mirrors, modulators, absorbers, filters, and crystals, placed in the
cavity to alter laser wavelength or pulses’ duration.
•
Provides means of controlling laser usage –output mirror is 95% reflective, allowing controlled release of
laser for tissue effect.
8
1.2 PARAMETERS OF LASER LIGHT –DETERMINES ITS TISSUE BIOLOGICAL EFFECTS

Laser is defined by three parameters: wavelength, power, and mode.
1.2.1 Laser Wavelength

Spectrum of wavelengths (measured in nanometres and micrometres) –Determined by the lasing medium
and defines tissue penetration, allowing optimal wavelength selection for specific tissue targets.
Spectrum Laser type Wavelength
CO2 laser 10,600 nm Infrared wavelengths
Far IR Er-YAG 2940 nm cause thermal effects on
Mid IR Ho-YAG 2120 nm tissues
Nd-YAG 1064 nm
Near IR Diode 810 nm
Visible Diode laser 680 nm Visible range
spectrum Ruby laser 694 nm –red wavelengths cause
400 nm–750 nm Krypton 647 nm –red photochemical reactions
HeNe laser 632 nm –red–orange
HeNe laser 543 nm –green
Dye laser 570–630 nm –yellow
PASCAL laser 532 nm –green
Argon laser 514 nm –green
488 nm –blue
Ultraviolet Excimer laser 351 nm Shorter wavelengths
XeF –xenon fluoride 308 nm have higher energy
XeCl –xenon chloride 266 nm (freq quad) UV lasers energy > IR
Nd-YAG solid laser 263 nm (freq quad) lasers energy
Nd-YLF solid laser 248 nm
KrF –krypton fluoride 193 nm
ArF –argon fluoride
Common Lasers Used in Ophthalmology
IR lasers Visible lasers UV lasers
High wavelength lower energy Red, yellow, and green Shorter wavelength
lasers higher energy
Laser CO2 –9.2–10.8 μm, CW or Ruby laser-694 nm, 1–250 μs ArF Excimer laser –
type and ms pulsed Krypton –531, 568, 647 nm, 193 nm, 3–20 ns
wavelength Er-YAG –2.94 μm, 100–250 ns CW or ms pulsed pulsed
and pulse pulsed HeNe –633 nm, CW KrCl (222 nm), KrF
duration Ho-YAG –2.1 μm, 100–250ns PASCAL –532 nm (freq (248 nm), XeBr
pulsed doubled Nd-YAG), (282 nm), XeCl (308
Nd-YAG –1064 nm, 100ps –CW ms pulsed nm), XeF (351 nm)
Nd-YLF –1053 nm, 100ps –CW Nd-YLF (freq-doubled) – Gas lasers –second
Ti-Sapph –700–1000 nm, 60fs – 532 nm harmonic bands
10ps pulsed Argon –488 and 514 nm, of ionic and metal
Diode –635–1550 nm, 1ns –CW CW or ms pulsed. Argon vapour lasers such as
Alexandrite –720–800 nm, blue (488 nm) no longer argon –363–275 nm
50 ns–100 μs used due to risk of krypton –356,
macular burn 350, 337 nm
He-Cd laser –325 nm
gold (Au) laser –312 nm.
These are examples of
visible lasers emitting
in UV range by using
frequency doubling.
Laser effect Absorbed by tissues with high Red, green, and yellow High energy breaks
water content, useful for surgical lasers are well absorbed molecular bonds and
and thermal effects. IR lasers by the RPE, making ionizes tissues, without
generate heat used in cutting and them ideal for thermal thermal effects. Allows
welding. photocoagulation. Thermal precise tissue sculpting
Thermal, mechanical, Imaging (HeNe) laser and useful in corneal
photochemical remodelling and cataract
surgery – photoablation
9
1.2.2 Tuneable Lasers niobate), BBO (beta-barium borate), LBO

Wavelength output of lasers depends on the (lithium triborate), GaSe (gallium selenide),
lasing material, its refractive index (RI), length, ZnGeP2, and LilO3 (lithium iodate).
and optical features of the resonator cavity (that Example: Nd-YAG laser normally emits a
alter laser oscillations), wavelength of laser 1064 nm wavelength in harmonic generation,
pump, and substances or crystals added, to and can emit at
alter properties of the lasing material. ◾ 532 nm at second harmonic (green) –
◾ Frequency doubling –alters long IR frequency doubling;
wavelengths into short visible and UV ◾ 355 nm at third harmonics (UV) –frequency
ranges; tripling; and
◾ Raman scattering converts shorter ◾ 266 nm at fourth harmonics (ultraviolet) –
wavelengths into longer wavelengths frequency quadrupling.
(far IR).
Lasers can be made to emit variable 1.2.3 Power
wavelengths by altering the optical cavity, Laser generates high energy light. When
lasing material, pumping mechanism, or the focused, energy per unit area reaches extremely
addition of frequency-changing crystals. high levels, capable of damaging tissues,
Common non-linear crystals used are KTP making them medically useful but potentially
(Potassium titanyl phosphate), KDP (potassium dangerous to work with.
dihydrogen phosphate), KNbO3 (potassium
Terminology Description Measurement unit Symbol

Radiance Laser energy measurement Joules J
Fluence Laser energy per square meter Joules/square metre J/m2
Power All laser energy (transmitted, emitted, Watt =joules/second W
reflected) per unit time
Irradiance or intensity Laser power per square surface area Watts/square metre W/m2
Power is measured in watts =Joules/sec (energy/time)
Threshold power is the least power needed to obtain a just visible tissue effect. Subthreshold energy uses
lower power, to achieve effects without visible burns.
Power is modulated by altering energy or time (P= E/t), so increasing laser energy or reducing pulse duration
will increase laser power.
Irradiance/power density = power/area = watts/cm2. Increasing power or reducing spot size will increase
power density, for a more intense effect.
1.2.4 Mode (<1 pulse/second) to exceedingly high rates

CW mode –Lasers emit continuous radiation (>100/second)
and are more damaging than pulsed lasers ◾ Solid-state lasers usually operate in the
due to longer tissue exposure. Emission >0.25 pulsed mode, to achieve higher power for
second is regarded as CW. photo-disruption with reduced risk of heat
Pulsed mode –emissions occur in short bursts generation and collateral damage.
of highly concentrated energy.
A CW laser can be made to operate in the
◾ Pulses can be long (millisecond), short pulsed mode, by
(microsecond), Q-switched (nanosecond –
extremely short pulse), or mode locked, ◾ modulating the pump to stimulate
emitting picosecond pulses. intermittently or
◾ Number of pulses delivered per second is ◾ modulating the output, to release
the repetition rate, which can vary from low intermittently, using locks and switches.
10
Modes of Laser Emission

Laser mode Laser type Wavelength
CW –emits constant laser output from a CO2 laser 10,600 nm
constant pump source. Generates lower Argon 488 nm, 514 nm
power than pulsed mode.
Quasi CW –mechanical shutter KTP laser, PASCAL 532 nm
produces bursts of CW output, or Copper bromide vapour laser 510 nm, 514 nm
shorter pulses of milliseconds, with Argon pumped tuneable dye laser 577 nm, 585 nm
slightly higher energy. Krypton laser 568 nm
Pulsed mode –generate higher energy Pulsed dye laser (PDL) 585–595 nm
than CW output. Q-switched ruby laser 694 nm
High energy –v. short pulse Q-switched alexandrite laser 755 nm
The repetition rate can vary from short Q-switched Nd-YAG laser 1064 nm
to long intervals. PASCAL 532 nm
Er-YAG 2940 nm
CO2 pulsed laser 10,600 nm
Very short pulse laser (picosecond) Nd-YAG 1064, 532 nm
Alexandrite laser 755 nm
Generation of Pulsed Laser
• Pulsed pumping –Intermittent stimulation, using external switch/modulator (shutter).
• Pulsed release –internal modulation or switches that release laser intermittently.
Various techniques are used to alter pulse durations, allowing stored energy to be released as a giant pulse of
extremely high energy, in a short pulse duration. Energy generated in a pulsed mode is much higher than a
CW mode.
Device/technique to alter pulse duration Laser pulse duration

Electronic shutters 1 ms
Pulsed flash lamps 1 us
Q-switching 1 ns
Mode locking 1 fs
Generation of pulsed laser –Turning the laser on and off by internal modulation is more efficient in
generating higher energy, which is stored and released as a giant pulse when needed.
Gain switch Q- Switch Cavity dumping Mode locking

Pulsed pumping (with Q-switch blocks one Both mirrors 100% Uses constructive
flash lamp or another mirror, preventing laser reflective, allowing interference to mode
laser), using shutters or amplification, but pump build-up and storage lock or couple ultra-
switches. continues to stimulate of high energy. Use short pulses by altering
Inefficient method. (energy stored as crystals to diffract laser resonant cavity length.
Generates lower power population inversion). release via a different It generates ultrashort
and longer pulses. When activated it outlet (acoustic-optic pulses (picosecond and
generates high energy in a deflectors, electro-optic femtosecond) with a high
short pulse. modulators). repetition rate.
Generates less power – examples are Nd-YAG laser, Ti-Sapphire laser (can use cavity dumping, or q-switch or
mode locking to generate pulse
Excimer laser Nd-YAG laser Generate less power Ti-Sapphire laser
Metal vapour laser than Q-switch.
Three Ways to Achieve Q-Switching
Use mirror or prism rotating opposite to, but not aligned to the output mirror in the resonant cavity,
•
preventing amplification. Periodically, alignment is achieved, producing a Q-switched pulse.
Insertion of electro-optic or acoustic-optical device in the in the resonator cavity, which modulates the laser
•
pathway and its release in short bursts.
Insertion of a non-linear absorbent element in the cavity, which blocks one of the mirrors and only becomes
•
transparent when a certain amount of energy is attained in the resonant cavity, generating a Q-switched pulse.
1.3 LASER DELIVERY SYSTEMS a standardized spot size, due to a stable

Laser treatment can be delivered by various working distance.
routes. 2. Indirect ophthalmoscopy with a +20D
1. A slit lamp Slit lamp – Contact lens contact condensing lens. Spot size varies, based
lens is the commonest, safest, and most on working distance and power of
controlled method of laser delivery, with condensing lens.
11
3. Trans scleral –cyclodiode. below (Zeiss), to provide a bright light, which is

projected onto the eye under examination.
4. Endo-laser – during vitrectomy.
The illumination tower can be swivelled 180°
5. Fundal camera-based delivery (Navilas). on the horizontal axis and 20° on the vertical
axis (slit lamp tilt). It houses filters, including:
1.3.1 Slit Lamp Laser Delivery ◾ Neutral density and heat absorption filter
The slit lamp is a high-powered, compound (reduces brightness and discomfort for
microscope with a long focal length, flexible photosensitive patients).
slit-shaped illumination, and variable
◾ Cobalt blue filter (for tonometry, and corneal
magnification, to provide a binocular,
examination).
stereoscopic, and dynamic view of the eye.
Accessory lenses (contact or non-contact) are ◾ Red-free (green) filters enhance blood vessels
used for fundal view. Contact lenses offer better and haemorrhages.
control, focus spots, and improved laser safety.
Biomicroscope observation system –Provides
Basics of slit lamp –a slit lamp has three
an enlarged, stereoscopic image of the eye.
main parts: mechanical system, illumination
The LED filament is imaged on to the objective
tower, and biomicroscope.
lens, but the mechanical slit is imaged on to the
The mechanical system –provides coupling
patient’s eye –Kohler’s Principle (ensures a
(common axis of rotation) of the microscope
bright beam with no glare).
and illumination systems, which coincides with
The observation system comprises:
their focal plane (parfocality), to ensure that
light will always fall where the microscope is ◾ Objective lens –Two plano-convex lenses
focused. (power +22D and telescope system (between
The illumination system/tower –Consists eye piece and objective lens) to alter
of a light source, condensing lens, filters, magnification (Grenough flip lever ×10, ×16,
horizontal and vertical slit diaphragms, or Galilean magnification wheel ×6, ×10, ×16,
projection lens, and reflecting mirror or prisms. ×25, and ×40).
Illumination comes from above (Haag Streit), or
Figure 1.8 Parts of a slit lamp.
12
Figure 1.9 The illumination tower.
Figure 1.10 The biomicroscope.
13
◾ Eyepiece lens –Magnifying lenses (+10/ corneal or lenticular damage, with media
+12D), with refractive adjustments from +7 opacities or poor focus.
to −7 dioptres, housed in converging tubes
◾ Defocused beam delivery (Ellex) –beam
(10–16°), to provide good stereopsis. Eyepiece
has high divergence, which reduces laser
IPD can be adjusted, from 52mm to 78mm.
energy at the cornea and minimizes risk of
The slit lamp has three types of laser delivery inadvertent corneal burns. As the 2 focal
systems: planes are not the same, the spot is less well
defined.
◾ Parfocal system (Zeiss, PASCAL) –Slit
lamp and laser have the same focal plane, ◾ Surespot system (Lumenis) –defocused
with low beam divergence (parallel beam), system with a more controlled spot, to
leading to a sharp spot, uniform energy improve precision, reduce power density at
delivery and well-defined retinal burn. The the cornea, and increase laser efficacy and
size of the beam is the same at the cornea, safety.
lens, and retina, leading to potential risk of
Slit lamp examination and laser treatment is preferably done in a semi-dark room
Adjust eyepieces, for IPD, refractive errors, and focus.
• Set IPD slightly less than normal to account Setting slit lamp eyepiece focus.
for proximal convergence of slit lamp. •
Use focusing rod (in slit lamp drawer). Mount it in front of
• Set a fraction more minus than user microscope, by removing the flat groove alloy plate. Set slit
refractive error to overcome proximal beam 1–2mm wide and direct it at the centre of the rod.
accommodation and convergence of the •
Set one eyepiece at a time, by moving from the +side of
eyepieces. scale, until the image first appears sharply focused (to avoid
• Set focus of eyepiece when first using slit stimulating accommodation)
lamp or laser. •
Make a note of the readings on the eyepiece and use this in the
future. You do not need to use the focusing rod after this first
occasion.
• Adjust table height and chin rest for comfort.
• Ensure slit beam is evenly illuminated with sharply demarcated edges.
• Pull joystick back and move slit lamp in to focus on area of interest. The final focus is sharpened by
small movements of the joystick.
Set Slit Parameters
•
Slit brightness –Just visible level. Excessive brightness causes glare, adversely affecting procedure and
safety.
•
Slit height –Tallest position (remains unchanged during treatment).
•
Slit width –moderate wide (5–6mm), keeping disc and fovea in view.
•
Narrow slit –reduces FOV (smaller area of illumination) but increases depth of focus, useful to identify
subtle details, treat mA, and sharpen focus.
•
Wide slit –allows larger FOV, good for faster treatment in PRP.
•
Do not make the slit so narrow that you lose your bearings on the retina.
Set slit lamp magnification
Low ×6 for initial examination and PRP
High magnification ×10 or ×16 for details and FLT
1.3.2 Binocular Indirect Ophthalmoscopy ◾ Fundal view and spot size are influenced by
(BIO); Laser Indirect Ophthalmoscopy (LIO) lens used, working distance, and patient’s
BIO offers good illumination, stereopsis, refractive error.
and FOV but lower magnification and can be Indirect ophthalmoscope-delivered laser (LIO) –
difficult to learn. Movements affect size and For retinal vasculopathies and peripheral retinal
clarity of the fundal image. diseases, in patients where slit lamp delivery
◾ Fundal image is inverted and laterally is difficult (anxious, physically or mentally
transversed. handicapped patients, paediatric patients,
presence of media opacities, perioperative laser
◾ Power of condensing lens determines treatment after surgery). Patients lie supine –a lid
retinal magnification and field of view. speculum is used to keep the eye open and saline
◾ The 20D lens with working distance drops to keep the cornea moist.
of 47mm provides a reasonable FOV, LIO is a less controlled method of laser
stereopsis, and magnification, and is the delivery, with no standardization of spot size
most common lens used. and inability to treat the posterior pole safely.
14
Figure 1.11 BIO.
Figure 1.12 Documentation of BIO.

15
1.4 LASER TISSUE INTERACTION wavelengths significantly. Laser effects (heating

Chromophores are pigments that absorb laser and coagulation) occur primarily in the
light to achieve tissue effect. The main ocular pigmented outer retina.
chromophores are melanin and haemoglobin. The depth of penetration increases with
Understanding laser absorption spectrum of longer wavelengths (red and IR) and absorption
ocular tissues helps appropriate laser selection. occurs more at the level of the choroid. Red
(Example: Blue lasers are not used for macular krypton (647 nm) and the IR diode laser
treatment. Red lasers can be used with macular (810 nm) are absorbed mostly by choroidal
haemorrhages.) melanocytes (only 8% RPE uptake).
Light falling on the retina is absorbed Yellow krypton (568 nm) or diode (577 nm)
by melanin (RPE and choroid) and blood are absorbed by oxyhaemoglobin, but not by
haemoglobin. The neurosensory retina xanthophyll pigment, making them useful in
is transparent and does not absorb laser the treatment of juxta foveal microaneurysms
and telangiectasias.
Chromophore (endogenous Wavelengths absorbed optimally Lasers used in practice

pigment)
Melanin in RPE and Choroid IR and visible spectrum (300–1300 nm) Argon, PASCAL, Krypton laser
Haemoglobin (oxy and Blue, green, and yellow (420–520 nm) Argon, PASCAL, Krypton laser
deoxyhaemoglobin) (red light is not absorbed)
Melanin absorbs green, yellow, and red wavelengths efficiently. Peak absorption is at 577 nm –yellow
wavelength.
Oxy-haemoglobin in vascular tissues strongly absorbs 418, 542, and 577 nm (blue, green, yellow)
wavelengths. Peak at 577 nm.
Xanthophyll –ocular pigment concentrated at the macula has maximum absorption of blue light and
minimal absorption of red light. A blue laser (Argon –488 nm) should not be used in FLT, due to a high
risk of macular burns (patients and doctor). Green, yellow, and red lasers are safer for treatment close to
the macula.
Water –IR lasers vaporize cellular and extracellular water to achieve effect (Nd-YAG, Diode, CO2 lasers).
Exogenous pigments injected intravenously to accumulate in ocular tissues can also contribute in laser
action, for example PDT.
Penetration of lasers –depends on wavelength and scattering. As wavelength increases, depth of penetration
increases and scattering decreases. Visible ranges and near IR wavelengths penetrate tissues more than UV
wavelengths.
Media opacity will increase scattering and reduce the laser effect.
Factors that affect laser – tissue
interaction
Laser variables:
Laser wavelength (affects energy)
Spot size (affects irradiance=
power/area)
Laser power (watts=energy/time)
Pulse duration –affects power
Tissue variables:
Tissue transparency
Tissue pigmentation
Tissue water content
Figure 1.13 Laser effects in relation to power and pulse.
16
1.4.1 Principles of Laser Tissue Interactions

As irradiance (power) increases and pulse decreases, the effect varies from photochemical (at low power and
long pulse) to photodisruption (high power and extremely short pulses).
Tissue effect Irradiance=watts/cm2 Pulse duration=sec
Photochemical effect Low power T >1 sec (CW)
Photothermal Slightly higher power T <1 sec–1 μs
Photoablation Higher power T <1 μs–1 ns
Plasma induced ablation and Very high powers in a very small T <1 ns
photodisruption area
Photodisruption or Photoionization
Mechanical effect, with high-energy, short-pulse lasers. Causes optical breakdown of tissue molecules,
generating a plume of plasma, which generates an acoustic shockwave that moves forwards to disrupt the
target tissue nearby without any heat generation.
(Plasma is a pool of highly energized electrons that cause a precise optical breakdown.
Useful in breaking down tissues (YAG PI or capsulotomy), gallstones, or renal stones.)
Photoablation
• UV wavelengths (high-power lasers) break chemical or ionic bonds that hold tissues together, without
heating, to cause clean-cut incisions. Excimer lasers in photorefractive keratectomy and Lasik.
Photovaporization
• When temperature rises to 60–100°C, cellular and extracellular water vaporize causing damage and
disintegration, incision, and heat-related cauterization. Forms the basis of treatment in CO2 and
Femtolasers.
Photothermal
• Laser energy generates heat in target tissue, causing denaturation and coagulation of tissue proteins. The
effect varies from photocoagulation and photoevaporation to photocarbonization (charring), based on
energy levels used
• Photothermal effect is utilized to cauterize blood vessels and weld tissues without sutures.
• Temperature rises of 10–20°C cause coagulation, protein denaturation, thrombus formation, and collagen
contraction, and form the principle of PRP and FLT. Examples: argon, krypton, diode (810), and PASCAL
lasers.
Photochemical
• Laser light triggers photochemical reaction (biostimulation) in target tissues to achieve therapeutic effects.
Example: PDT, in treatment of ocular tumours and CNV.
• An exogenous photosensitizer (hematoporphyrin, benzoporphyrin) injected intravenously is selectively
absorbed by blood vessels in metabolically active tissues such as CNV or tumours. When activated
by a diode laser, the temperature rises and cytotoxic free oxygen radicals are released, to cause CNV
destruction.
Photoradiation
• Laser light-generated cytotoxic effects to damage or kill cells. Dye lasers and wavelengths are absorbed by
the injected dye to generate cytotoxic radicals.
1.4.2 Laser Mechanisms in the Retina Retinal vascular homeostasis is a balance

Ischaemia-driven vascular diseases, between factors that promote neovascularization
characterized by capillary non-perfusion and and leakage, and those that inhibit it. Hypoxia
reduced oxygen availability, predominantly stimulates production of pro-inflammatory
involve the inner retina. How does destroying factors, cytokines, and angiogenic factors,
the outer retina influence the inner retina? such as VEGF, angiotensin II, leucocyte
The retina has a dual blood supply (retinal adhesion factor, inducing vasodilatation, and
capillaries and choriocapillaris). Oxygen neovascularization. Retinal photocoagulation
from choriocapillaris diffuses into the outer improves tissue oxygenation and reverses the
retina and is consumed by photoreceptors but consequences of hypoxia.
does not reach the inner retina under normal
circumstances.
17
Retinal changes following laser photocoagulation

Laser energy absorbed by RPE heats retinal tissue causing scarring and pigment migration. Damage in the
centre of the spot is greater than surrounding tissues (gaussian beam).
Temperature up to 42°C induces reversible changes –vasodilatation, release of chemical mediators, damage
to intracellular organelle, endothelium, and reduced enzyme activity. New non-damaging, subthreshold
lasers work in this region.
Temperature >50°C causes irreversible damage –cellular death reduces hypoxia and VEGF production, and
increases production of PEDF. Current lasers work in this zone.
Figure 1.14 Retinal injury following PRP.

High energy, long exposure time and a large spot cause larger areas of retinal injury.
Level 1 –damage confined to choriocapillaris, RPE, and outer photoreceptors.
Level 2 –damage from choriocapillaris to outer nuclear and plexiform layers.
Level 3 –extends from deep choroid to ONL, IPL, and ganglion cell layer.
1.4.3 Starling’s Law and Macular Oedema and proteins leak out, tissue oncotic pressure
Starling’s law explains water exchange between increases, attracting more fluid out and increasing
vascular and extracellular tissue compartments the oedema. The process is controlled by VEGF,
in formation of vasogenic oedema, stating that which in turn is influenced by oxygen levels.
◾ If hydrostatic pressure =oncotic 1.4.4 How Does Focal Laser Treatment
pressure –there is no movement between 2 Reduce Macular Oedema?
compartments.
The exact mechanism is unclear and likely
◾ If oncotic pressure > hydrostatic pressure, to be multifactorial. It is established that
fluid will leak out, causing oedema. retinal blood flow and vessel diameters
are inversely related to oxygen tension.
◾ If hydrostatic pressure > oncotic pressure, it
FLT increases retinal oxygenation, causing
will drive fluid out, causing oedema.
vasoconstriction, reducing blood flow,
Retinal arterioles are resistance vessels that hydrostatic pressure, and oedema.
control hydrostatic pressure downstream.
Diameter of retinal arterioles is controlled ◾ Direct coagulation of leaky capillaries
by oxygen levels. In hypoxia, arterioles dilate, reduces vascular permeability and oncotic
reducing resistance and increasing blood flow pressure.
downstream, increasing the hydrostatic pressure, ◾ Reduced hydrostatic pressure (improved
causing capillary dilatation and leakage. As fluid oxygenation causing vasoconstriction).
18
◾ Improved RPE pump mechanism to ◾ Laser scars decrease local production of

drain fluid. Regeneration and migration of VEGF and inflammatory factors.
surrounding healthy RPE cells, explains how
gentle, subthreshold laser is effective.
Photothermal effects are dependent on:

Duration of laser action (pulse duration)
• Longer exposure causes deeper tissue penetration and heat dissipation, leading to larger burns. A CW
laser causes more scarring than pulsed laser. Reducing pulse duration shortens treatment time, reduces
pain, and minimizes scarring.
• Thermal relaxation time (TRT) is time taken for tissue to dissipate 60% of absorbed energy. Pulse duration
<TRT vaporizes intracellular water (no time for heat diffusion), causing an explosive effect, with rupture of
Bruch’s membrane, and occurs with use of very high energy with an extremely short pulse.
Power density or irradiance (mW/cm2)
Increasing laser power or reducing spot size results in increased power density, with increased thermal
effects.
Photoreceptors are mitochondria-rich, high oxygen-consuming cells. Destroying them is an effective way of
reducing oxygen consumption in the outer retina, allowing choroidal oxygen flux to reach the inner retina,
improving hypoxia, and reducing neovascularization.
A typical PRP session reduces photoreceptors and oxygen consumption of outer retina by approximately
20%.
Improved oxygenation
• Reduced demand –photoreceptors have high metabolic activity and oxygen demand. PRP destroys them,
reducing oxygen requirement.
• Improved availability –loss of some photoreceptors, improves oxygen supply to remaining
photoreceptors, reducing hypoxic drive for angiogenesis.
• Oxygen bridges –loss of photoreceptors at site of laser allows oxygen flux from the choroid to travel
through glial scars to the inner retina.
• Vasoconstriction, reduced leakage –improved oxygenation and direct coagulation of mA.
Reversal of angiogenic drive
PRP reduces angiogenic burden by removing ischaemic retina from the equation. This reduces release of
•
angiogenic factors (VEGF reduced by 70% after PRP).
Remaining healthy retina produces anti-angiogenic factors.
•
Angiogenic factors that promote NV Anti-angiogenic factors that inhibit NV
VEGF –vascular endothelial growth factor PEDF –pigment epithelium derived factor
SDF-1 –stromal cell derived factor. TIMP3 –tissue inhibitor metalloproteinase 3
PDGF –platelet derived growth factor Endostatins
Ang-2 –angiopoietin 2 Angiotensin
EPO –erythropoietin TSP –Thrombospondin
Cytokines and multiple growth factors (TNF, Integrin)
Long-term effects of laser treatment
Gene regulations provide sustained effects. (Increased expression of genes related to healing and repair
of organelles, inhibition of angiogenesis and axonal growth promotion, and reduced gene expression of
angiogenic and inflammatory factors).
Gene upregulation Gene downregulation Repair / RPE stimulation
regeneration
Improve photoreceptor metabolism, Decrease endothelial Activation, Gentle laser with
cell renewal/remodelling. proliferation/ migration short pulses and
Increase axonal growth and synaptic dysfunction. Decrease polarization, and sub-threshold
function. Increased heat shock angiogenic and vascular phagocytic activity treatment
protein (HSP), increase matrix permeability factors of microglia. causes thermal
metalloproteinases (MMP) for (Fibroblast Growth Injured stress (photo-
structural repair. factor-FG14, FG16), IL-1, photoreceptor stimulation).
Increase TSP-1, Agtr2 anti-angiogenic plasminogen activator releases endothelin Promotes cell
factors. inhibitor-2, inhibitors of and activates Muller repair and
MMPs, calcitonin like cells, leukocyte remodelling.
receptor (CLR). infiltration. Anti-angiogenic,
RPE healing, and anti-inflammatory,
migration over Neuroprotective
treated area. effects.
19
1.5 L
ASER HAZARD AND LASER dangerous, as they do not stimulate the
SAFETY PROTOCOLS protective blink reflex. Skin injury is more
Lasers are associated with potential hazards likely with prolonged exposure. UV rays cause
for patients and clinicians, and laser safety is sunburn type injury, while visible and IR rays
paramount to avoid laser related accidents. cause thermal damage.
The hazards relate to phototoxicity from The extent of injury depends on laser
high radiance (brightness) and high irradiance wavelength, energy, exposure time, spot size,
(ability to be focused into a small spot of and target tissue factors (reflectivity, absorption,
concentrated energy), making lasers extremely dispersion, and thermal properties). Short
dangerous to work with. wavelengths and short pulses equate to higher
Visible and near IR light (400–1400 nm energy with higher risk of injuries.
wavelength) can penetrate ocular media,
1.5.1 Laser Classification and
causing retinal damage. UV and IR wavelengths
Safety (ANSI Standards)
(<400 nm and >1400 nm) are absorbed by the
cornea and lens, causing corneal burns and Lasers’ safety is classified by their wavelengths
cataracts. IR wavelengths are particularly and their maximum output power.
Classification of lasers –based on accessible emission limits (AEL) –maximum power (watts) or energy (joules)
that can be emitted in a specified wavelength range and exposure time.
Class 1 lasers Safe under all conditions, due to low output or enclosed laser –no risk of exposure.
Example: CD player, laser printer
Class 2 lasers Associated with exposure to very bright light. Output power is up to 1 mw. Relatively safe
because blink reflex reduces exposure to <0.25 sec. If blink reflex was supressed or patient
stared into laser light, eye injury can occur. Example: supermarket scanner, laser light toys.
Class 3 lasers 3A lasers –output power is up to 2.5 mw, dangerous if used with optical instruments that
focus light and increase power density. Examples:Laser pointers, laser sight on firearms.
3B lasers –output is 5–500 mw. Dangerous if enters the eye, protective eyewear
recommended, risk of skin burns, fire hazard. Diffuse reflection is safe, but specular
reflection is dangerous.
Class 4 lasers Power output >500 mw, high risk of ocular and skin injury, dangerous with both specular
and diffuse reflections. Includes all industrial, scientific, military, and medical lasers.
Protective eyewear recommended.
MPE –maximum permissible exposure –highest irradiance (power density w/cm2), or fluence (energy
density – J/cm2) of light that is considered safe, measured at the cornea at a given wavelength and exposure
time. It is usually 10% of the dose causing damage 50% of the time. MPE for UV and IR rays > visible rays,
with a higher risk of injury.
Laser hazards are classified as non-beam and Skin injuries –photochemical effects of mid/
beam related hazards. far UV rays cause sunburns, reddening, blisters,
Ocular injury can be reversible or permanent. premature ageing, and skin cancers (UV –290–
Inadvertent exposure causes headache, 320 nm). Thermal burns are rare –they occur
lacrimation, gritty sensation, floaters, sudden with high energy and prolonged exposure (CO2
visual loss with macular burn, or gradual loss and some IR lasers). There is a higher risk of
from cataract, reduced retinal sensitivity, and burns in photosensitive patients (idiopathic or
colour vision. drug related).
Non beam related hazards –safety related to:

Laser path Avoid reflectors –jewellery, metal fittings, mirrors.
Avoid absorbers –trapped eyelash, mascara.
Avoid flammables –oxygen cylinder, cleaning solution, chemicals.
Unregulated equipment Unregulated laser pointers, toys available on the internet, may cause ocular
injury with flash blindness. Regulations may vary in countries.
Electrical hazards Lasers are high voltage devices with electrical and fire hazards. Risk is
higher during maintenance and servicing. Ensure cables are not frayed and
floor is not wet.
Chemical hazards Chemicals in lasing media can be toxic/hazardous substances, dyes,
flammable solvents, heavy metal vapours. Toxic plume (dust, metallic,
chemical, biologic fumes) can contaminate the air with industrial lasers.
Room must be well ventilated, and protective masks may be used.
Mechanical hazards Explosions, laser leakage from damaged cables, unstable table. Periodic
checks and laser maintenance are essential.
20
Beam-related hazards
Wavelength ranges Pathological effects
180–315 nm (UV-B, UV-C) Photokeratitis, corneal inflammation, erythema, increased skin
pigmentation, accelerated skin aging, skin cancer
315–400 nm (UV-A) Photochemical cataract, skin pigmentation, skin burns
400–780 nm (visible light) Photothermal retinal injury, skin pigmentation, light photosensitivity,
cataract, skin burn
780–1400 nm (near IR) Cataract, retinal burn, skin burn
1400–3000 nm (IR) Aqueous flare, cataract, corneal burn, skin burn
>3000 nm (far IR)
Type of beam exposure
Direct exposure or indirect exposure (reflections from grade 4 lasers).
Specular reflection –from flat reflectors (mirror) –risk of harm is high.
Diffuse reflection –from irregular reflectors (jewellery, metal tools) –lower risk of harm.
A surface may be a diffuse reflector for one, but specular for another wavelength.
Factors that affect laser hazards
Laser parameters
Wavelength (determines UV rays (180–390 nm), mid-far IR (1400 nm–1 mm) –corneal and lens injury.
energy and absorption) Visible and near IR (400–1400 nm) penetrates ocular media, absorbed by the
retina and macula. Maximum retinal absorption is at 400–570 nm, making
Argon and PASCAL lasers hazardous for eye injuries.
Energy Higher energy –higher risk of injury.
Shorter wavelength (UV) has higher energy than longer (IR) wavelengths.
Spot size Smaller spot (focused laser) has higher energy density with higher risk of
injury, especially if used with high energy. (Reduce power with small spots.)
Pulse duration A short pulse is associated with a risk of photomechanical injury, while a
long pulse is associated with photothermal injury (longer exposure).
Pulse Repetition Faster rate – associated with less heat dissipation and phototoxicity.
Eye factors –the biconvex lens acts as a magnifier and focuses laser light on the retina. Even a low-powered
laser or diffuse laser reflection can cause retinal injury.
Self-defence mechanisms –blink reflex, light aversion, and head turn protect against visible light. UV and IR
lasers do not stimulate the blink reflex and can be harmful. Sustained exposure with laser pointer directed at
an eye can cause injury.
Size of pupil –small pupil is associated with lesser exposure.
Degree of pigmentation in target tissue –dark fundi have a higher risk of injury.
Aphakia and Pseudophakia –aphakes have a clear media and pseudophakic IOL focuses laser light,
increasing the risk of injury.
1.5.2 Laser Safety Protocols

Know Your Laser Safety Officer in the Hospital.
Ensure treatment is performed in a controlled environment, to mitigate laser hazards.
Laser Room
Figure 1.15 Laser hazard image.
21
Best practice in the laser eye clinic

Always laser in a controlled area –dedicated room, proper ventilation, and sign-posted.
Switch on the red warning light outside the door, to ensure the room becomes a restricted area and prevent
inadvertent entry.
Do not open the door while the laser is operational. The room may be locked during use, although this
may hinder access in case of an emergency. Knock and wait for the operator to allow entry (the laser can be
stopped temporarily, if entry is essential).
When the treatment session is finished, switch off the laser and red light, remove/return key to the nurse.
Laser machine, users, and maintenance –Familiarize yourself with machine, procedure, and hazards.
Treatment should only be done by trained and authorized users.
Always switch on and off with the key, not the emergency button.
Always keep the laser in stand-by mode, until ready for treatment –This prevents inadvertent laser
emission as the safety shutter is closed (activated in ready mode).
Do not leave the room unattended with the key in situ. Keep the laser on standby, shut the door, or ask a
nurse to keep watch, if leaving the room for a short period.
Keep people in the room to the minimum (2–4) –doctor, patient, nurse if help required, relative (anxious,
young patients, language barrier, disability). All in the laser room must wear appropriate, undamaged safety
glasses (except doctor –protected by inbuilt filters).
Use a wheel lock to prevent excessive movement; do not trap wires, put anything heavy on the table, or raise
the table too high –risk of toppling.
Laser maintenance –ensure the laser is protected when not in use.
• The machine should be serviced once a year, including slit lamp focus, aiming beam focus, laser
parameters and bodywork –table movement and stability.
• Do not use the laser if you see error codes/messages on the display screen–switch off and on again. If the
error persists –inform the laser safety officer.
Laser treatment –Do not laser if view not clear, aiming beam not visible, error codes seen, or there is
excessive patient movement. Document error codes for manufacturer reference.
Use just visible illumination and complete treatment in the shortest time (reduce phototoxicity).
Always perform laser with appropriate lenses –stabilizes eye and improves safety.
Use threshold power –least power needed to get just visible effect.
Use a smaller spot, shorter pulse duration, and smaller grids.
If patient complains of pain –reduce the exposure time, laser power, grid size, or use a magnifying CL.
Consider 2× paracetamols 1 hour prior to treatment or pre-laser sub-tenon/peribulbar anaesthesia, or LIO
with GA in patients with low pain threshold.
Seek help with anxious patients or difficult cases. Preparation is key.
Document treatment parameters, including adverse events or potential difficulties for future reference and
treatment planning.
Dealing with emergency hazards:
Patient related emergency –fainting, fits, collapse. Use the emergency stop button (stops laser
immediately), call for help, then see to the patient. Do not use the emergency stop button unless necessary.
Key ignition will not work if the button is activated. Press it again to deactivate it.
Fire alarm –do not panic. Stop treatment. The nurse should take the patient to a safe area. Switch off
normally at the machine and mains. Remove key, and evacuate room. A fire extinguisher should be handy/
available.
Water leak –do not use the laser until it is checked and declared safe for use by engineers.
An incident report should always be filled with details of the adverse event.
Guidance is provided by the laser safety officer and the health board ‘Health and Safety officer’.
1.5.3 Laser Safety Eyewear permanent ocular injury without suitable

Lasers are extremely bright sources of EMR protection, particularly during inspection of
(electromagnetic radiation), with a risk of delivery system.
Risk of Eye Damage

• Visible and near infrared wavelengths –retinal damage
• UV and IR wavelengths –corneal and scleral damage
• Prescription glasses –concentrates laser energy, worsening the damage.
22
Figure 1.16 Laser safety glasses.

Reducing beam related hazards with protective eyewear:
• Glasses with appropriate filters protect eyes from direct or reflected laser light.
• A coloured filter should be selected to prevent transmission of the relevant wavelength. (Example: Orange
filter absorbs 532nm, but transmits wavelengths >550nm, useful with argon laser, but not with a diode laser, 800nm.)
• Eyewear is also rated for optical density, which quantifies the amount of light transmitted. They reduce
beam power below MPE and reduce risk of ocular exposure, but also reduce vision in general.
• Eyewear should also be able to withstand direct laser exposure without breaking.
The ANSI Z136.1 standard
Eyewear not recommended Eyewear recommended
Class 1 laser –not hazardous Class 2M –visible (400–700nm)
Class 1M lasers (visible 400–700 nm), Class 3R –MPE ×5 for class 2 visible laser, or ×5 for class 1 invisible
used without magnifying optics lasers (high risk)
Class 2 lasers –visible lasers safe Class 3 B –high risk from direct exposure
with blink reflex of 0.25 sec Class 4 –from direct and diffuse exposure
Safety glasses must be used by all in the room, except doctor (protected by filters).
Glasses must be wavelength specific and appropriately labelled.
Glasses colour Suitable wavelength Used with lasers
Orange 450–532 nm (visible) Argon, KTP lasers
Magenta 500–600 nm (visible) Freq-doubled YAG, PASCAL
Pink 720–830 nm (near IR) Alexandrite, diode lasers
Green 1064 nm (IR) YAG laser
Clear Glass 10600 nm (far IR) CO2 laser
190–360 nm (UV) Excimer laser
Optical density filter –dictates how much light is transmitted through the glasses. Varies from 0 (100%
transmission) to 7 (0.00001% transmission) of laser light. OD of 3 allows 0.1% transmission and offers good
protection, without affecting vision. Higher OD will blur the user’s vision.
The laser machine has an inbuilt filter to protect the operator from exposure.
Safety eyewear needed is based on Maximum Permissible Exposure (MPE), Nominal Ocular
Hazard Area (NOHA), and Nominal Ocular Hazard Distance (NOHD) for each delivery device and
configuration of treatment room. For additional information, refer to the laser device’s user manual
and international laser standards and guidelines.
1.6 LASER LENSES single optical system to improve visualization

An emmetropic eye emits parallel rays from and facilitate therapeutic intervention.
the fundus and cannot be examined at a short
distance. Contact lenses allow examination by 1.6.1 Advantages of Contact
creating an intermediate fundal image within Lenses in Lasers
the focal plane of the slit lamp. Laser treatment without the magnifying
Lenses are essential tools for safe laser delivery. and focusing mechanisms of lenses is less
The contact lens and eye work together as a controlled, requiring higher power, with
23
increased risk of damage to surrounding 1.6.2 Safety Principles of Contact Lenses

tissues. Laser power and energy density are inversely
Contact lenses, used with topical anaesthesia proportional to spot size.
and coupling lubricant: The spot is responsible for target effect
◾ Act as a speculum, keeping eyes moist and (cutting efficiency, thermal burns) and volume
lids out of the way. of tissue affected.
Small spots deliver more concentrated
◾ Stabilize the eye (prevents blink reflex and energy, and therefore require less power
reduce ocular movements). to achieve effects. Conversely, a large spot
requires higher energy for similar tissue
◾ Focus laser spots precisely on target areas. effect, with reduced laser safety.
◾ Some lenses magnify (useful in FLT), while
others offer wide FOV (beneficial in PRP). 1.6.3 Laser Cone Angle
Laser beams converge to and diverge beyond
◾ Reduce laser hazards and surrounding tissue a point of focus, forming a cone angle (angle
damage. of convergence and divergence). The sharper
the focus and smaller the spot (point of focus),
the larger the cone angle. The spot size has an
inverse relationship to the cone angle.
Unfocused spot without CL Focused spot with CL
Unfocused spot is large with smaller cone angle. This means Focused spot is small and cone angle is large. Laser
that the laser energy is still concentrated around the spot, with beam diverges quickly before and after the focused
a higher risk of damage to surrounding tissues (purple dot). spot, reducing risk of damage to surrounding tissues
• Cone angle is related to laser safety. A CL focuses the spot sharply, increasing the cone angle, with
sharp divergence of laser beam before and after, reducing laser concentration around the spot.
• A large cone angle means a small, focused spot with more intense tissue effects. This:
• Reduces laser energy requirement.
• Reduces risk of collateral damage, and increases laser safety.
1.6.3.1 Optical Characteristics of The size of the spot is directly proportional

Ocular Media to wavelength in vacuum (spot size increases
Alteration in optical characteristics of the with increasing wavelength) and inversely
media (e.g. after vitreous surgery) can affect to RI of the medium (spot size reduces with
RI of the eye/, create multiple interfaces, increasing refractive indices of a medium).
affecting, focus, magnification, and laser The spot size reduces as the laser beam moves
parameters (spot size, power density), from air into the eye (RI > 1), aided further by
resulting in suboptimal treatment. using CL.
•
Phakic eye –air in cavity (RI of 1.00) –Increases posterior lens convexity, increasing lens power
significantly (myopic shift).
•
Aphakic eye with air –posterior corneal surface changes from a weak concave to a strong concave lens,
neutralizing the power of the anterior cornea, allowing a fundal view without any optical aides/lenses.
•
Phakic eye with silicone oil –RI of silicone oil > normal lens, so silicone oil acts as a concave lens on the
posterior lens surface (normally a weak convex lens), making it into a weak concave (negative) lens –
hypermetropic shift.
•
Aphakic eye with silicone oil –the posterior corneal surface is normally a low-power concave lens.
Silicone oil in the cavity acts as a convex lens at the posterior corneal surface causing a slight myopic shift.
•
Pseudophakia with a flat posterior surface IOL –no change, as flat surfaces do not have any refractive
power.
24
1.6.4 Lens Classification 1.6.5 Common Features of Laser

Lenses are classified into anterior and posterior Contact Lenses
segment lenses.
◾ Concave posterior surface (conforms to
◾ Anterior segment lenses are used to corneal curvature, for a comfortable fit).
visualize lens capsule, IOL, and ocular angle.
◾ Flat, convex, or concave anterior surface, or
◾ Posterior segment lenses are used to planar mirrors, allow tissue visualization.
visualize vitreous and retina. They are
◾ PMMA shell with knurled edges to facilitate
further classified as:
lens manipulation.
◾ Concave CL (negative lens) –creates an
◾ Flanges to stabilize the eye and prevent
upright, virtual fundal image
blinking.
◾ Convex lens (positive lens) –creates an
◾ Anti-reflective coating on lens surface
inverted, real fundal image
reduces glare and laser hazards. Hazard
◾ Mirror lens distance is reduced from 7 metres to 1.6 metres
for coated lenses. Anti-reflective coating reduces
reflected light from 4% to 1%.
Contact lenses used in photothermal laser treatment

Concave lenses Convex lenses Mirror lenses
Image Erect, upright, virtual Inverted, real Laterally transverse image
FOV Less Wide FOV FOV increased by rotation
Magnification High Low High
Examples Goldmann (−67D), Mainster, Volk, panfundoscope Goldmann 3-mirror lens
Hruby (−58.6D)
Convex lenses and the 3-mirror lens are used most often in clinical practice.
Lens name Lens type Image Lens Magnifi FOV0 Spot Burn Uses
(anterior power cation static – magnification with
surface) (approx.) dynamic 200 μm
spot
Mainster Biconvex Real +61 ×0.96 90–121 ×1.05 210 μm FLT
M. Focal aspheric inverted +90 ×0.68 118–127 ×1.50 300 μm PRP
Mx1 +115 ×0.51 165–180 ×1.96 392 μm PRP,
M-165 pexy
Quad Biconvex Real +115 ×0.51 120–144 ×1.97 394 μm PRP,
Superquad aspheric inverted +120 ×0.5 160–165 ×2.0 400 μm pexy
Panfundoscope Convex Real +85 ×0.71 160–170 ×1.41 282 μm PRP
spheric inverted
Area centralis Biconvex Real +60 ×0.93 70-84 ×0.94 188 μm FLT
aspheric inverted
Volk widefield Biconvex Real +120 ×1.08 160–170 ×2.0 400 μm PRP
aspheric inverted
Goldmann Flat, Mirror Mirror ×0.93 360° ×1.08 216 μm PRP,
3-mirror mirror image rotation pexy
Wide field lens –Mainster-165, Volk Quad, Superquad, HR wide field, panfundoscope
Advantages –wide FOV, greater working distance, lens rotation not required. Good for retinal orientation
and quick PRP.
Disadvantages –minified view, difficult to see fundal details and laser burns clearly. Spot size doubles,
causing larger burns. Do not use spot >200 μm with widefield lenses. A 200 μm spot delivers a 400 μm
burn, and a 400 μm spot delivers an 800 μm burn, causing large scars. In addition, as spot size doubles, laser
energy required increases ×4, making treatment painful and increasing laser hazards.
How to select laser lenses appropriately: Selection depends on treatment planned, user experience, and
patient’s refractive error.
25
Focal/grid laser Mid-peripheral PRP or Complete PRP/far peripheral PRP or Retinopexy

retinopexy
• Mainster focal • Mainster ×1 • Mainster-165
• Area centralis • Goldmann 3-mirror • 3-mirror tall mirror
broad mirror • Volk Quad/Superquad
• Wide-angled lenses offer good view of entire fundus, allowing quick PRP, but double spot size, minify
view by 50%, and increase energy requirement by ×4.
• Patient’s refractive errors, will influence fundal magnification, except with 3-mirror lens. Myopia –
increased magnification, reduced FOV (widefield or 3-mirror lens good).
• Hypermetropia –decreased magnification, increased FOV (3-mirror lens better).
• Concave lenses increase degree of myopia and shorten working distance –patients with a high degree of
pre-existing myopia –select a convex lens or a 3-mirror lens.
• Mainster ×1 is ideal for training, and mid-peripheral PRP (good FOV +higher magnification).
• Select Volk Quad or Superquad with small eyes (PA) and small pupils.
1.6.6 Lens Used with YAG Laser

Stabilizes the eye, magnifies view, aids precise focus on PCO or iris, and reduces risk of IOL pits or
corneal burn, by increasing cone angle.
Figure 1.17 YAG laser lenses.

Gonioscopy –Light emanating from the angle undergoes total internal reflection (TIR) and is normally not
visible. The critical angle for the cornea–air interface is 45°, and light from the angle needs to strike the cornea
steeper than the critical angle to be visible.
RI of goniolens =RI of the cornea, eliminating cornea–air interface and allowing light to emerge at the new
lens–air interface, at a steeper angle, allowing direct visualization.
26
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pantu toimeen biologisia tutkimuksia Islannin vesien kalanrunsauden
ja kalain elämänlaadun ilmi saamiseksi.
Käsitöillä on Islannissa tähän saakka ollut verraten vähän sijaa.

Ainoastaan pari prosenttia saaren väestöstä on käsityöläisiä. Mutta
ammatit ovat elpymään päin. Kotiteollisuus sitä vastoin on
entisestään surkuteltavassa määrin rappeutunut. Viime vuosisadan
alkupuolella islantilaiset melkein yksinomaan käyttivät kotikutoisia
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Englantilaiset liikemiehet ovat ostaneet koskia kalsiumkarbiditehtaita
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Vuoriteollisuuden tuotteista on arvokkain kirkas kalkkisälpä, joka

omituisten valontaitto-ominaisuuksiensa vuoksi on erinomaisen
haluttua optillisiin koneisiin. Mutta tämä arvokas tuote, jota saadaan
kiteytyneenä laavakenttäin onkaloista, on vähenemään päin. Ennen
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rikkiteollisuus on nykyisin seisauksissa. Viime aikoina on löydetty
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Kulkuneuvoja on koetettu monella tavalla parantaa. Niitten hyväksi

on sen jälkeen, kun maa sai itsehallinnon, työskennelty enemmän
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Kautta maan on järjestetty postiliike. Ulkomaiden posti saadaan

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Sähkölennätysyhteyteen mannermaan kanssa Islanti vihdoin on
päässyt. Sähkölennätysyhteydestä on paljon hyötyä varsinkin
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Suuri lievennys kansalle oli, kun vihdoin saatiin järjestetyksi

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Islannista ei puutu yleisiä hyväntekeväisyyslaitoksiakaan. Niitten

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Ikävakuutus on ratkaistu omituisella tavalla. Jokaiseen kuntaan
kautta saaren on perustettu rahasto heikkojen ja iäkkäitten
kansalaisten auttamiseksi. Jokainen, jolla on varoja, on velvollinen
vuosittain maksamaan jonkun pienen määrän näihin rahastoihin.
Niistä sitten jaetaan apurahoja semmoisille vanhuksille taikka
työkykynsä menettäneille, jotka eivät nauti vaivaisapua ja jotka ovat
aikanaan rahastoja maksuillaan kartuttaneet.
Uusin kultuurisaavutus on oma yliopisto. Se on Reykjavikissä

avattu ja alkanut toimensa. Mutta moni pudistaa päätään, että
lieneekö niin harvalukuisen väestön kesken sentään riittävää työalaa
niin vaativalle oppilaitokselle.
Suurta sitkeyttä ja itsetietoisuutta osottaa sekin, että näin pieni

kansa on voinut kautta aikain säilyttää omakielisen kirjallisuuden.
Huolimatta siitä, että Islannin väkiluku oli vähentynyt muutamaan
kymmeneen tuhanteen, huolimatta siitä, että saari joutui
sukulaiskansan ja -kielen vallan alaiseksi, — Norjan kirjakielen sama
vallanalaisuus muutti tanskalaiseksi, — säilytti Islanti omankielisen
kirjallisuutensa ja on kirjakieltään kehittänyt siihen määrään, että se
monessa suhteessa nykyisin on maanosamme kehittyneimpiä.
Ei kurjimpana rappioaikanaankaan Islanti kokonaan puuttunut

kirjallisuutta, vaikka kieli melkoisessa määrin ottikin itseensä
tanskalaisuutta ja vaikka vanhat runouden lajit aikain kuluessa
melkoisessa määrin rappeutuivat. Mutta vasta yhdeksännellätoista
vuosisadalla tapahtui saaren kirjallinen, samoin kuin valtiollinenkin
uudesta syntyminen.
Islannin uuden kirjallisuuden voimme sanoa syntyneen

uskonpuhdistuksen ajalla. Mutta kahtena sitä seuraavana
vuosisatana se kuitenkin vielä oli sangen yksitoikkoinen ja puuttui
alkuperäisyyttä. Runouden alalla viljeltiin varsinkin virsien tekoa.
Satuja, ritarijuttuja kirjotettiin runomuotoon. Kahdeksannentoista
vuosisadan loppupuoliskolla eli Jon Thorlaksson, pappi ammatiltaan,
joka oli Islannin huomattavin kääntäjä. Hän käänsi äidinkielelleen
paljon englantilaista, saksalaista ja tanskalaista runoutta, varsinkin
Miltonin »Kadotetun paratiisin», joka käännös on taiteentuntijain
arvostelun mukaan paras, mitä siitä on milläkään kielellä olemassa,
jopa monessa suhteessa alkuteostakin etevämpi. Tämä on sitä
huomattavampaa, kun Jon Thorlaksson'in täytyi suorittaa
käännöksensä tanskalaisesta käännöksestä. Koko elämänsä tämä
pappismies taisteli mitä suurinta köyhyyttä ja puutetta vastaan.
Hänen kirjallinen työnsä herätti niin suurta huomiota ulkomaillakin,
että eräs englantilainen seura hänelle myönsi melkoisen
runoilijaeläkkeen. Hän kuitenkin kuoli samana vuonna, kun sai ensi
kerran vastaanottaa tämän avustuksen. Tapaus osottaa, kuinka
suurella rakkaudella Englanninkin kirjallisissa piireissä vielä
muisteltiin sitä maata ja kansaa, joka säilytti Pohjoismaitten
suurenmoisen vanhan kansanrunouden.
Islannin kirjallinen uudistus tapahtui kuitenkin oikeastaan vasta

yhdeksännellätoista vuosisadalla, jolloin kolme etevää islantilaista
perusti »Fjöinir» nimisen aikakauslehden. Tämä kirjallinen
uudestasyntyminen, joka kävi käsi kädessä valtiollisen
vapausliikkeen kanssa, sai Europan mannermaalla tapahtuneen
heinäkuun vallankumouksen kautta virikettä. Kielen puhdistamisessa
ja jalostamisessa saivat islantilaiset tanskalaisen kielimiehen
Rasmus Raskin etevää ja uutteraa apua. Lyyrillisinä runoilijoina
olivat Bjarni Thorarenesen ja Jonas Hallgrimsson muita etevämmät.
Edellisellä oli aatteen syvyys ja tunteen voima, jälkimäinen taas
hallitsi muodon ja kehitti kielen runollista sanontaa. Edellistä on
sanottu Islannin Götheksi, jälkimäistä sen Schilleriksi. Näitten jälkiä
ovat sitten kulkeneet monet muut, ja niinpä Islannilla on arvokas
uudenaikainen kaunokirjallisuus, joka kunnialla pitää puoliaan
muitten pohjoismaitten kirjallisuuden rinnalla ja jatkaa saaren
vanhoja traditsioneja. Nuorin polvi on saanut vaikutuksia varsinkin
Georg Brandesin kautta Köpenhaminan yliopistossa, jossa saaren
nuoriso on viimeiseen saakka käynyt opiskelemassa.
Kielen uudistamisessa ovat islantilaiset koettaneet mikäli
mahdollista välttää muukalaisten sanojen lainaamista. He ovat
muodostaneet sangen paljon uusia sanoja, jonka vuoksi islantilaisen
kirjan lukeminen tuottaa vaikeuksia sillekin, joka on kansankieleen
perehtynyt.
Muut taiteet sitävastoin ovat Islannissa heikolla pohjalla, jota ei

olekaan ihmettelemistä, sillä ne aina tarvitsevat varakkaampaa
ympäristöä ja suurempia oloja menestyäkseen. Vanhoina aikoina oli
taidekäsityö saarella kuitenkin korkealla kannalla, taidekutominen,
koruompelu, hienompi metalliteollisuus ja puunleikkaus. Vanhain
islantilaisten kodeissa olivat pihtipielet, ovet, patsaat ja orret
koristellut kaikenlaisilla kuvanveistoilla, etenkin jumalankuvilla, ja
seinät verhottiin taidokkailla kuvakankailla, joihin usein oli kuvattu
pitkiä juttuja ja sankaritapauksia. Koko joukon muistoja on säilynyt
tämän muinaisen teollisuuden ajoilta. Taiteelliset käsityöt eivät
kuitenkaan ole vieläkään aivan lopen hävinneet.
Mutta varsinaisia kuvaavia taiteilijoita Islannilla tuskin on muuta

kuin nimeksi, lukuun ottamatta Thorvaldsenia, joka kokonaan eli
Tanskassa. Paremmalla menestyksellä on sävellystä harjotettu,
vaikkei Islanti olekaan synnyttänyt semmoista säveltäjää, jonka
maine olisi levinnyt saaren ulkopuolelle. Näytelmätaide on vielä
kokonaan seuranäytäntöjen pohjalla.
Islannin valtio koettaa varainsa mukaan edistää saaren taiteellista

ja kirjallista elämää. Muun muassa se maksaa vuotuisia avustuksia
viidelle runoilijalle, vaikkeivät nämä avustukset luonnollisestikaan ole
suuria.
Islanti on synnyttänyt useita huomattavia tiedemiehiä ja tutkijoita,
joista kuitenkin useat ovat suurimman osan elämäänsä vaikuttaneet
joko Tanskassa taikka muitten ulkomaitten yliopistoissa, koska
saaren omat varat eivät ole riittäneet varsinaisen tutkimuksen
kustantamiseen. Kuuluin Islannin nykyään elävistä tiedemiehistä on
Thorvaldur Thoroddsen, jonka teokset Islannin maantieteestä ja
maantieteen historiasta, sen geologisesta rakenteesta ovat
perustavaa laatua ja ovat tulleet useille sivistyskielille käännetyiksi.
Näin olemme tutustuneet tuohon syrjäiseen omituiseen maahan

Atlanninmeren ja Jäämeren välillä. Olemme tutustuneet sen
sankariaikaan ja vanhaan runouteen, jonka vuoksi sillä kaikkien
germanisten kansain kesken on niin vakaantunut maine ja suuri
mielenkiinto, olemme tutustuneet sen voimalliseen luontoon ja
valtaviin luonnonilmiöihin, joitten puolesta se voittaa kaikki, mitä
maanosassamme on nähtävää, ja olemme nähneet, kuinka tämän
saaren pieni kansa vähitellen ulkonaisesta holhouksesta
vapauduttuaan on alkanut kehittää elinkeinojaan ja aineellista ja
henkistä viljelystään vakaalla aikomuksella edelleenkin pysyä
kansana, lisääntyä ja vaurastua kaikilla kultuurin aloilla. Islannin
esimerkki on kieltämättä rohkaiseva muillekin pienille kansoille, jotka
epäedullisissa oloissa koettavat olemuksensa säilyttää. Arvokkaana
apuna olemassa olon taistelussa ja edistysriennoissa Islannilla
kieltämättä on se yleinen myötätunto, jota se varsinkin
germanilaisten kansain kesken nauttii. Ne suosivat sitä
muinaisuutensa säilyttäjänä ja tuntevat sitä kohtaan
sankarimuistojen heimohellyyttä. Sen vuoksi Islannin pyrkimykset ja
saavutukset herättävät suurempaakin huomiota kuin muutoin olisi
asian laita.
*****
Tätä teosta varten on mukaillen käytetty seuraavia lähteitä:
C. Rosenberg: Traek af Livet paa Island i Fristaats-Tiden.

Köpenhamina, 1871,
J. C. Poestion: Island, das Land und seine Bewohner. Wien, 1885.
Th. Thoroddsen: Vulkaner og Jordskjaelv paa Island.

Köpenhamina, 1897.
Valtyr Gudmundsson: Islands Kultur ved Aarhundredskiftet 1900.

Köpenhamina, 1902.
Paul Herrmann: Island in Vergangenheit und Gegenwart, Leipzig,

1907—1910.
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Trainee Feedback. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii

About the Author. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Section 1: Basic Principles of Laser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1.6.6 Lens Used with YAG Laser. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Section 2: YAG Laser . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Section 3: Lasers in Glaucoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

3.2.1 Indications for YAG LPI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Section 4: Photothermal Lasers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

4.5.2 Is It Essential to Target Microaneurysms?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121

Section 5: Approach to Retinal Vascular Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

Acknowledgement of Images Borrowed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205

Anatomical site Laser procedure Type of laser

Other Medical Applications of Lasers

THERAPEUTIC ROLE OF LASERS IN OPHTHALMOLOGY

Figure 1.1 Ordinary light vs laser light.

Figure 1.2 Properties of laser light.

Figure 1.3 Atom and energy levels.

◾ Light is an electromagnetic wave, emitting ◾ Wavelength is inversely related to frequency.

Figure 1.4 The electromagnetic spectrum.

Figure 1.5 Principles of laser emission.

1.1.4 Stimulated Emission The photons generated are monochromatic,

Figure 1.6 How is laser light generated?

Figure 1.7 Parts of a laser.

1.1.5 Parts of a Laser ◾ Gain/​lasing medium (provides atoms for

1.2 PARAMETERS OF LASER LIGHT –​DETERMINES ITS TISSUE BIOLOGICAL EFFECTS

1.2.1 Laser Wavelength

1.2.2 Tuneable Lasers niobate), BBO (beta-​barium borate), LBO

Terminology Description Measurement unit Symbol

1.2.4 Mode (<1 pulse/​second) to exceedingly high rates

Modes of Laser Emission

Device/​technique to alter pulse duration Laser pulse duration

Gain switch Q-​ Switch Cavity dumping Mode locking

1.3 LASER DELIVERY SYSTEMS a standardized spot size, due to a stable

3. Trans scleral –​cyclodiode. below (Zeiss), to provide a bright light, which is

Figure 1.8 Parts of a slit lamp.

Figure 1.9 The illumination tower.

Figure 1.10 The biomicroscope.

Figure 1.11 BIO.

Figure 1.12 Documentation of BIO.

1.4 LASER TISSUE INTERACTION wavelengths significantly. Laser effects (heating

Chromophore (endogenous Wavelengths absorbed optimally Lasers used in practice

Figure 1.13 Laser effects in relation to power and pulse.

1.4.1 Principles of Laser Tissue Interactions

1.4.2 Laser Mechanisms in the Retina Retinal vascular homeostasis is a balance

Retinal changes following laser photocoagulation

Figure 1.14 Retinal injury following PRP.

◾ Improved RPE pump mechanism to ◾ Laser scars decrease local production of

Photothermal effects are dependent on:

Non beam related hazards –​safety related to:

1.5.2 Laser Safety Protocols

Figure 1.15 Laser hazard image.

Best practice in the laser eye clinic

1.1.5 Parts of a Laser ◾ Gain/lasing medium (provides atoms for

1.2 PARAMETERS OF LASER LIGHT –DETERMINES ITS TISSUE BIOLOGICAL EFFECTS

1.2.2 Tuneable Lasers niobate), BBO (beta-barium borate), LBO

1.2.4 Mode (<1 pulse/second) to exceedingly high rates

Device/technique to alter pulse duration Laser pulse duration

Gain switch Q- Switch Cavity dumping Mode locking

3. Trans scleral –cyclodiode. below (Zeiss), to provide a bright light, which is

Non beam related hazards –safety related to:

Focal/grid laser Mid-peripheral PRP or Complete PRP/far peripheral PRP or Retinopexy