Fiber optic Laser systems

applications in medicine

Chapter 9

PHYS 3616E, Winter 2017 Dr. Bassam Aharmim

1) Introduction
Therapeutic applications of lasers, and in particular surgical applications, call for using
relatively high laser power (10-50 W)..
Laser beams sent through power fibers (inserted inside the human body) may then be used
for a variety of medical applications: coagulation, ablation, incision, etc.

The operation of an integrated laser-fiber system may be illustrated by a se­ries of

hypothetical steps:

 If possible, find the exact location of the diseased area by using nonin­vasive imaging
methods, such as x-ray fluoroscopy, CT, MRI, etc... If not possible use endoscopy
 Determine the nature of the disease and choose a course of therapy (heating, surgery,..)
 Choose the most suitable laser and the mode of operation (short pulses, long pulses,
CW, etc.), for treatment.
 Choose the optical fiber delivery system (fiber type, special tip).
 Insert the optical fiber through the endoscope and place it in the correct location.
 Send a laser beam for therapy.
 Control both the posi­tion of the fiber and the action of the laser during the procedure
(could be performed by fiberoptic imaging or sensing).
 At the end of the procedure use diagnostic or imaging techniques to assess the effect of
the treatment.
Fiberoptic delivery unit
The transmission of laser beams for therapy or diagnosis requires a fiberoptic delivery
unit.
A typical delivery unit consists of several components:
(i) Optical fiber: The fiber itself, with well-polished ends.
(ii) Connector: The input end of the fiber is often held in a connector.
(iii) Holder: The connector is inserted in a special holder that is fixed with respect to the
laser beam.
(iv) Tip: A transparent window or tip at the output end of the fiber.
(v) A plastic jacket that strengthens and protects the fiber and may serve to hold the
window or tip.
(vi) A lens that focuses the laser beam into the input end of the fiber.

Either
  or both ends of the fiber may be overheated by the absorbed laser en­ergy (when
continuous-wave (CW) lasers are used).

Cooling liquids or gases are often used

Fiber End Connections

The fiber end connections serve several purposes:

Since the fiber core diameter and the size of the focused spot are quite small (< 1 mm),
they help with alignment and stability.
At the same time, easy replacement of fibers is required, ideally without the need for
realignment.
At a glass-to-air interface (such as the end of the fiber), a percentage of the laser power
can be reflected from the surface (this reflection is referred to as Fresnel losses).
Typically, the reflected power is about 4% of the incident power (for 50 watts input, about 2
watts is reflected).
The connection system must be capable of dissipating the reflected energy without
damaging the fiber.
The ideal connection system will employ a method to reduce the Fresnel losses at the
surface.
This increases the amount of power delivered to the material to be processed, and it also
reduces the requirements to dissipate the reflected energy.
Possible methods to reduce the Fresnel losses include depositing an anti-reflection (AR)
coating on the fiber ends.
The fiber end connection typically consists of a mechanical connector (with mating socket)
which rigidly holds the fiber.
Output Coupling Optics

The purpose of the output coupling optics is to collect the radiation leaving the fiber, and
re-focus it onto the material to be processed.

The parameters of the focused beam, which vary with the specific application, include spot
size, beam profile, depth of focus, and working distance.

The output coupling optics generally includes two separate lens assemblies.

The first lens assembly collimates the beam leaving the fiber.

The ratio of the focal length to the diameter of the aperture of the output coupling optics
system (f/D) must be low enough to collect all of the radiation leaving the fiber.

The second lens assembly focuses the collimated beam onto the target spot.

The final spot size is a function of the fiber core diameter, the aperture of the focusing
optics and the working distance of the focusing lens assembly.
Some of the problems involved in using optical fibers for power transmission are:
Damage to the end of the fibers:
The power density at each end of the fiber is very high
Any defect on the fiber end, a splattered drop of blood or a fingerprint, may increase the
absorption of laser beam on the end face.
With these high power densities, the end face will be damaged.

Bending:
One cannot bend the fibers beyond a certain value.
Bending increase the loss, and again the fiber may be damaged at the bend.

Divergence:
The light emitted from fibers is not collimated, like regular laser beam.
It is highly divergent, and the divergence is determined by the numerical aperture.
When transmitting the beam through the fiber, the end face of the fiber has to be kept clean,
and it must not touch the tissue.
If this end is held 2-3 mm away from the tissue, the power density at the tissue may be too
low for incision.

Dry field:
Blood will coagulate under laser radiation.
In order to prevent coagulation during fiber optic laser surgery, one has to replace the blood
near the face end of the fiber by saline solution, or push the blood back using pressurized
carbon dioxide gas.
3) Clinical Applications
3-1) Fiberoptic laser systems in cardiovascular disease
The heart, coronary arteries, and peripheral arteries all constitute a rather complex
system of tubes, pumps, and valves which lends itself to the use of fiber­optic treatment.

Laser angioplasty has been performed to recanalize blockages in the coronary or

peripheral arteries.
Lasers can also be used for endarterectomy (the removal of plaque) or for tissue
welding in the cardiovascular system.
 Angioplasty
In the cardiovascular system a major role is played by the coronary arteries, which supply
blood to the heart muscle.
A common problem with the arteries is a build up of atherosclerotic plaque on the interior
walls.

The plaque, consisting of fatty material, calcium, etc.,

starts blocking the coronary arteries, and the blood flow
through them is reduced.
When substantial blockage of the coronary is observed,
a laser beam sent through a power fiber could be used
to vaporize the plaque and open a clear channel
through which blood flow can resume.
A schematic cardiovascular laser catheter for
recanalization of arteries and its operation is shown in
the front figure.
This procedure makes use of a special catheter that
include a tiny balloon.
The balloon is inflated, and CO2 gas (or saline solution)
pushes the blood away. Laser beam vaporizes the
plaque.
The artery is recanalized and blood flow resumes.
Lasers used in angioplasty

In order to remove the plaque, the laser beam must be absorbed by the plaque or by a
coloring agent that has been selectively retained in the plaque.
A laser beam that is absorbed in the coloring agent heats up the plaque, causing it to
vaporize.
The first laser used for laser angioplasty was the Ar-ion laser.
The blue-green light of the Ar-ion laser is highly absorbed by blood and tissue which
contains blood.
The radiation of this laser, however, is not absorbed well in white or yellowish plaque
tissue.
The Ar-ion laser beam therefore does not cut plaque faster than it cuts the arterial wall.
In addition, this is a continuous-wave (CW) laser that causes thermal damage.
Another laser that has been tried is the excimer laser, which has two advantages: the UV
is highly absorbed in plaque, and the laser beam is pulsed.
The pulsed mode leads to tissue removal with little thermal damage.
Other pulsed lasers that are highly absorbed in plaque, such as Er:YAG lasers or CO 2
lasers, may also cut tissue with little thermal damage.
When the plaque has been colored by dye, a laser with an emission wavelength tuned to
the absorption peak of the dye must be used.
Tunable dye lasers are the most suited for this purpose.
Fibers used in angioplasty
With angioplasty, fused silica fibers can be used for near infrared, visible, and the longer-
wavelength excimer lasers (λ > 300 nm).
Infrared-transmitting fibers must be used both for the Er:YAG and the CO2 laser.

Blood
The presence of blood presents a special problem in laser angioplasty.
The fiber tip can be positioned a few millimeters from the atherosclerotic plaque.
There is a layer of several millimeters of blood between the fiber tip and the blockage.
Whether an excimer or CO2 laser is used, this blood layer absorbs nearly 100% of the
laser radiation.
Several methods have been proposed to solve this problem.
Blood can be pushed away with a saline solution.
Although this is helpful with visible laser beams, it does not work with excimer, Er: YAG, or
CO2 lasers, whose radiation is highly absorbed in water.
Alternatively, the blood flow can be stopped for 10-20s with pressurized gas (CO 2 gas).
The laser beam passes through the gas, vaporizing the plaque.
After the 10-20s period, the blood flow resumes and the procedure is repeated until the
blockage is recanalized.
3-2) FIBEROPTIC LASER SYSTEMS IN GASTROENTEROLOGY

Gastrointestinal bleeding is a common cause of emergency hospitalization, with a mortality

rate of about 10%.
This high mortality rate may be, in part, due to the complications of emergency surgery
and may be reduced by less invasive methods.
Laser endoscopic photocoagulation offers a less invasive method which is controllable
and potentially useful for the management of acute hemorrhage and reduction of recurrent
hemorrhage.
Laser photocoagulation has been used to treat bleeding from peptic ulcers,
esophagogastric varices, benign mucosal le­sions, and gastric polyps.
To treat such bleeding, a laser endoscope is introduced and brought to the vicinity of the
bleeding site.
One of the most severe problems involves the ability to identify the exact site and nature of
the bleeding.
Blood must be re­moved around the distal tip of the endoscope.
This is often accomplished by send­ing pressurized CO2 gas through the ancillary channel
in which the power fiber is located.
The excess gas in vented through a second ancillary channel, to prevent discomfort to the
patient and gastric over-distention.
The gas flow also serves to cool the tip of the power fiber during power transmission and
clears secretions from the tip.
Both Ar and Nd:YAG lasers have been used for coagulative laser therapy.
The Ar laser emission at 488 and 514 nm is highly absorbed in blood.
It immediately generates a layer of coagulum that will stop the bleeding.
The Nd:YAG emission at 1064 nm is not so highly ab­sorbed in hemoglobin.
It is transmitted through blood, penetrating deeper into the tissue around the bleeding site.
It results in better coagulation.
The higher power may also be advan­tageous when there is a need to control bleeding
from large vessels.

Endoscopic Nd:YAG Laser Therapy

A laser endoscope may be inserted into the
esophagus and advanced to the outer margin of
the tumor.
Laser energy of several kilojoules (100 W peak
power) is transmitted through the power fiber,
causing vaporization and thermal damage to the
central area of the tumor.
After 2 days, the treatment is resumed.
The laser-treated tissue is necrotic and is
removed through the endoscope.
Laser energy is reapplied to a deeper region of
the tissue.
It again necroses in 2 days and is removed.
3-3) FIBEROPTIC LASER SYSTEMS IN ONCOLOGY

Three distinct ways in which lasers are used for cancer therapy:
(i) laser vaporization of malignant tumors,
(ii) laser heating for hyperthermia or for coagulation necrosis,
(iii) photo- radiation therapy.

Laser Vaporization of Malignant Tumors

Laser energy transmitted through optical fibers in laser en­doscopes is able to vaporize or
cut malignant tissue.
The most suitable lasers for this procedure are the pulsed CO2, excimer, and Er:YAG
lasers, which remove tissue efficiently.
Although tumors may also be cut with mechanical tools which are inserted endoscopically,
laser vaporization causes much less damage to the surrounding tissues.
Laser methods cause less spreading of the malignant cells to healthy regions than
mechanical tools.
Laser vaporization is a useful technique for the treatment of early malignant disease or for
palliative removal of large tumors.
The main limitation of this method is that the pulsed laser treatment does not coagulate the
blood.
If bleeding occurs, one must use CW lasers, such as Nd : YAG laser or CO2 lasers, to stop
the bleeding.
Laser Photocoagulation

The Nd:YAG laser is most suitable for this application because its light is easily transmitted
through fused silica fibers and it deeply penetrates tissue.
This is particularly important in cases which are unsuitable for conventional surgery or
radiotherapy.
In regular laser endoscopy proce­dures, the distal tip of the laser endoscope is brought to
the vicinity of the tumor and the distal tip of the power fiber is kept a few millimeters from the
tumor.
The tip of the power fiber may be inserted inside the tumor and the laser energy is then
applied interstitially.

Laser Hyperthermia

Hyperthermia cancer treatment is based on heating tissue to temperatures between 42.5

and 43.5°C for tens of min­utes.
In fiber-laser hyperthermia, the heating is performed by laser energy (using an Nd : YAG
laser beam -delivered through a power fiber- which penetrates deep into tissue).
As in laser photocoagula­tion, the distal tip of the power fiber is placed a few millimeters from
the tumor.
Several fibers may be inserted into the tumor with their tips placed (endoscopically) at
various depths, facilitating a more even temperature distribution inside the tumor.
 Photodynamic Therapy Diagnosis: HPD is injected
intravenously.
After 24-48 hr, the com­pound is
concentrated in malignant
tumors.
A whole area may now be il­
luminated by a UV laser beam.
The physician may look at the
whole area through glass filters
that transmit only red light (600-
700 nm).
A region emitting red light
involves a malignant tissue.

When a ma­lignant tumor has been

detected using the laser endoscope,
the tip of the power fiber is placed
next to or inserted inside the tumor.
Red light from an argon pumped dye
laser is transmitted through the
power fiber.
This red light photoactivates the
sensitizer, which in turn causes a
controlled lysis (gradual destruction)
of the tumor cells.