Quid Refert, Dummodo non Desinas, Tardius Ire

LASER IN OPTHALMOLOGY
OPTHALMOLOGY DR. GEORGE PILE

INTRODUCTION diagnostic imaging of ocular structures

In 1917, Einstein hypothesized that a stimulated atom would release a OCULAR LASER SYSTEMS
packet of light known as a photon.
Atoms could either be in a “LASER” is an acronym for 
ground state L- Light
excited state A- Amplification by
metastable or intermediate (state can exist with the atoms locked in S- Stimulated 
phase with a stimulating light. ) E- Emission of 
R- Radiation 
ELECTROMAGENTIC SPECTRUM Most sources of visible light radiate energy at different wavelengths and
at random intervals.
CHARACTERISTICS
non-divergent (collimated or parallel)
it travels in a parallel manner
The laser light energy can be emitted continuously or in pulses,
which may have pulse durations of nanoseconds or less
Low divergence which has a little tendency to spread out
monochromatic –
single color
light produced has the same wavelength
all of the light waves in phase with each other
coherent (in phase)
WAVELENGTHS OF LIGHT light waves follow closely parallel courses with almost no
tendency to spread out
TYPES OF LASERS
Argon
Krypton
Dye
Semiconductor diode: For Photocoagulation
YAG
Double Yag Laser: For photocoagulation
Nd Yag laser: For photodisruption
Visible wavelength s of light it’s just like the rainbow. So there is gamma Excimer Laser: For Photoablation
rays and infrared ray.

PRICIPLES OF LASER ARGON LASER FOR PHOTOCOAGULATION

Used in photocoagulation for proliferative diabetic retinopathy

Argon laser to the macula should be sufficient to produce only light
burns, as laser scars can expand and affect vision.
The principle of laser is that you release a photon that’s why you have
stimulated emission. ND: YAG LASER FOR PHOTODISRUPTION
Ophthalmology was the first medical specialty to utilize laser energy in
patient treatment
MAIN Use
Treat various intraocular conditions
The transparency of the optical media allows laser light to be
focused upon the intraocular structures without the need for
endoscopy
OTHER Uses
refractive surgery
cosmetic eyelid surgery

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 Neodymium: Yttrium aluminum garnet. Used for posterior capsule
opacification due to cataract surgery. Remember when you have This is the example lens put on top of the cornea. A 3 mirror lens
cataract extraction you put the lens on the capsule sometimes its wherein you can focus a particular part of the eye.
opacify. So the YAG Laser is being used for photodisruption. These particular type of lens used for glaucoma and also for doing
In the past upto 50% of eyes developed opacification of the laser at the periphery of the retina.
posterior capsule (“after cataract”) after uncomplicated adult
extracapsular cataract extraction. INDIRECT LASER OPTHALMOSCOPE
ND: YAG laser provides noninvasive method for discussion of the
posterior capsule
Pulses of laser energy cause small explosion in target tissue
creating an opening in the posterior capsule in the pupillary axis
Complication of this technique
Transient rise in IOP
Damage to the intraocular lens
Rupture of the anterior hyaloid face rhegamtogenous
detachment or crystalloid macular edema
Instead of using a contact lens in the eye the doctor hold a lens to
DIODE LASER FOR PHOTOCOAGULATION
focus the posterior eye.

INDIRECT OPTHALMOSCOPE DIRECT OPTHALMOSCOPE

 Image is inverted  Image is upright
 Has wider field of viewwith  Smaller view
less overall magnification  Focus on the retina itself
 Viewing an image of the
retina formed by a
handheld condensing lens
 3 distinct advantages
1. Brighter light source
2. Using both yes
Also used for photocoagulation same thing with argon laser also 3. Used to examine the entire
used for diabetic retinopathy and glaucoma. retina
 Used in pre-op and intra-
COMPONENTS op evaluation
Laser Source – builds up the laser power  Disadvantage:
Delivery system 1. provides inverted image
Ophthalmoscope requiring metal adjustment on
Direct the examiner parts
Indirect 2. bright light source can be
treatment probe uncomfortable for the patient
telescope
Slit Lamp
UNIQUE PROPERTIES OF LASER ENERGY 
SLIT LAMP DELIVERY SYSTEM Monochromaticity- single wavelength
Spatial coherence
High density of electrons
These allow focusing of laser beams to extremely small spots with very
high energy densities
A laser consists of a
transparent crystal rod (solid-state laser)
gas- or liquid-filled cavity (gas or fluid laser)
fully reflective mirror at one end
partially reflective mirror at the other
OPTICAL OR ELECTRICAL SOURCE OF ENERGY
Population inversion a process raising the energy level of the
atoms within the rod or cavity to a high and unstable level
MECHANISM
When excited atoms spontaneously decay back to a lower energy
Through the mirror the laser is focused to the back of the eye
level excess energy is released in the form of light light
What do you put on top of the cornea before you put the contact
emitted in any direction
lens? ANS: short acting anesthesia which is proparacaine
In a LASER CAVITY
You used contact lens to focus a particular are in the eye.
light emitted in the long axis of the cavity light bounce
back and forth b/w the mirrors creates a standing wave
LASER LENS
stimulates the remaining excited atoms to release their
energy into the standing wave produce intense beam of
light that exits the cavity through the partially reflective mirror
light beam produced is all of the same wavelength
Monochromatic Property
all of the light waves in phase with each other
Coherent Property
light waves follow closely parallel courses with almost no
tendency to spread out
Non-Divergent Property

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 The laser light energy can be emitted continuously or in MECHANISM OF LASER EFFECTS
pulses, which may have pulse durations of nanoseconds PHOTOCOAGULATION
or less
ADVANTAGES OF USING LASERS THERMAL LASERS
concentrated inside the eye Principal lasers used in ophthalmic therapy
decreased risk of infection and bleeding
Tissue pigments absorb the light and convert it into heat,
do not need operating rooms
recovery time is reduced thus raising the target tissue temperature high enough to
no need for activity restrictions coagulate and denature the cellular components
Uses
Retinal photocoagulation (Diabetic Retinopathy)
PRINCIPLES OF LASERS Retinal Vein Occlusions
Retinopathy of Prematurity
TISSUE OPTICS Sealing of Retinal Holes
Refracted Photocoagulation of the trabecular meshwork, iris and ciliary
scattered body
absorbed Benign and malignant intraocular tumors
Reflected The laser photocoagulators operate in continuous mode or very
LIGHT ABSORPTION rapidly pulsed ( thermal mode)
photon absorption increases energy of biological molecules Standard modality green argon laser
heat in the tissue is produced PASCAL ( patterned scanning laser)
10 to 20 degree C rise is the threshold of photocoagulation Produce patterns of burns  5x5 sq. grid of 25 burns of .02
- This is the reason why you need to control the parameters of seconds duration
laser in photocoagulation because if it’s not controlled Reduce duration and discomfort of extensive treatment for
instead of treating the patient you are creating damage PRP ( panretinal photocoagulation)
especially to the surrounding tissue.
CONTROL PARAMETERS IN PHOTOCOAGULATION Table 23-1
spot size
duration – how long the laser will fire
energy

INDICATION OF LASER

PHOTOCOAGULATION
CHORIORETINAL ADHESION
- When you have a retinal hole or retinal tear you want to
create adhesion by using laser “it’s like doing welding to the XANTHOPHYLL- yellow macular pigment
hole”. This is usually done to prevent retinal detachment
PHOTODISRUPTION
caused by the hole because the fluid in the vitreous can go
inside the hole. Release a giant pulse of energy with pulse duration of a few
PANRETINAL PHOTOCOAGULTION nanoseconds.
Used in diabetic retinopathy With pulse focused at 15–25 μm spot
Focal Photocoagulation nearly instantaneous light pulse exceeds a critical level of
Retinopathy of Prematurity energy density "optical breakdown" occurs in which the
Branch Retinal Vein Occlusion temperature rises so high (about 10,000 °K) that electrons
Transcleral Photocoagulation are stripped from atoms results in a physical state
PHOTODISRUPTION known as a plasma.
Usually done when the patient undergo cataract surgery and PLASMA
the posterior capsule opacify. Make a hole on the posterior expands with momentary pressures as high as 10 kilobars
capsuel. (150,000 psi) cutting effect upon the ocular tissues
CAPSULOTOMY initial plasma size is so small, it has little total energy and
Yag Capsulotomy produces little effect away from the point of focus.
LASER DCR (DACRYOCYSTORHINOSTOMY) INDICATION
- used in epiphora or excessive tearing due to nasolacrimal incision of posterior capsular thickening  posterior
duct obstruction capsulotomy
Laser Iridotomy anterior capsular contraction following cataract surgery
Closed Angle Glaucoma peripheral laser iridotomy
Argon Laser Trabeculoplasty
PHOTOABLATION anterior laser vitreolysis
LASIK TYPES OF LASER USED
PRK Q-SWITCHED NEODYMIUM:YAG LASER.
Used for Myopia error of refraction principal laser used
SOLID-STATE NEODYMIUM:GLASS LASER
Take note: binibigay daw sa exam to…. AKA: IntraLase
has femtosecond laser
pulse duration is even shorter (10–15 second range)
not absorbed by optically clear tissues

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 ADVANTAGE
produce precise cuts within the cornea, either as PRK (photorefractive keratectomy)
part of corneal refractive surgery
assist in corneal dissection for penetrating or
lamellar keratoplasty

PHOTO-EVAPORATION

Produces a wavelength infrared heat beam that is absorbed by
water, and therefore will not enter the interior of the eye.
Used for evaporating away surface lesions such as
Lid tumors
Sclera incision
Photoincision and photocoagulation
Controlled superficial skin burns tighten the eyelid
cosmetic improvement Used moderate myopic and Astigmatic refractive errors
Correction of hyperopia by altering corneal surface can correct by controlled re-contouring of the cornea by using
These types of laser includes CO2, erbium, and holmium lasers multiple pulses and progressively changing spot size to evaporate
successive thin layers of the cornea
PHOTODECOMPOSITION Used to correct myopia because when you are myopic your
eyeball is longer than normal. The laser flattens the top so that
produce very short wavelength ultraviolet light the focus will be exactly on the retina.
interacts with the chemical bonds of biologic materials 5 layers of the cornea (EBCDE--- E-A…. S-C)
breaks the bonds and converts biologic polymers into small Corneal epithelium
molecules that diffuse away Bowmans layer
collectively called as excimer ("excited dimer") lasers Stroma
cavity contains two gases Descemets membrane
argon Endothelium
fluorine In PRK you just reach upto the stroma so sa taas lang siya hindi na
Gases react into unstable molecules, which then emit the siya umaabot sa descemets membrane and endothelium..
laser light.
INDICATIONS
correcting refractive errors by precisely recontouring the PRK FOR MYOPIA
cornea
photorefractive keratectomy [PRK]
laser epithelial keratectomy [LASEK]
laser in situ keratomuileusis [LASIK])
removing superficial corneal opacities resulting from injuries
or dystrophies
treating recurrent corneal erosions
Phototherapeutic keratectomy [PTK].

FEMTOSECOND LASER

LASIK
Is a focusable infrared (1053 nm) laser with femtosecond (10-15
seconds) pulses.
Tissue can be incised with minimal inflammation or collateral
tissue damage
Used for fashioning stromal flaps for LASIK and is being studied
for other corneal procedures, including corneal grafting

USES OF LASERS
The difference with PRK you will do a flap. First you cut to the
stroma and flip the top and do laser again on the stroma and then
PRK, LASIK you put the cover back. In PRK you have to wear contact lens for 1
Panretinal photocoagulation week. In LASIK because of flapping, you put it back. The danger
Focal photocoagulation with flapping is it can move kahit matagal ba siya.
Laser iridotomy use to preserve Bowman’s membrane
Used in Acute angle closure glaucoma consists of cutting a hinged lamellar flap of cornea with a
YAG capsulotomy mechanical keratome, performing the refractive laser ablation in
Transcleral photocoagulation the corneal bed, and then replacing the flap LASIK provides faster
Endolaser photocoagulation visual recovery and less discomfort than
Usually done when you are going to operate inside the eye. PRK but carries a slightly higher risk of long-term complications.
So you will put endolaser probe inside the eye.
Laser DCR

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LASER IRIDOTOMY IN GLAUCOMA of vision again. For the management you have to do laser of
the posterior capsule. But please don’t hit the IOL
(intraocular lens) because if you hit this it can cause cracks in
the lens.

LASER TREATMENT

ocular complications of diabetes mellitus

control the pressure inside the eye used to seal holes in the retina
If the flow of aqueous cannot go out it presses the iris to the and prevent or treat retinal detachments
angle so the IOP would increase. after cataract surgery, to improve upon vision if necessary
3 things to consider before you label the patient withy helps prevent vision loss in macular degeneration
glaucoma correct certain types of errors of refraction
High IOP
Visual field defect THERAPEUTIC APPLICATIONS OF LASERS
Cup disk ratio DIABETIC NEPHROPATHY

LASER IRIDOTOMY SEVERE NONPROLIFERATIVE DIABETIC RETINOPATHY

Example of slit lamp delivery system. The doctor trying to in the picture you can see the optic disk, optic cup, exudates,
make a hole in the iris from the back. hemorrhages which part of macular edema… normal optic
disk ratio is 0.3-0.4
POST LASER RIRODTOMY but if you have asymmetric disk you have to consider
possible glaucoma
normal AV ratio 2:3…. Kapag 1:2 you suspect hypertensive
retinopathy
You can use PRP (Pan retinal photocoagulation). Laser
around the retina except the macular area because if you
laser the macula it can cause scotoma ( black spot in the
visual field)
Do laser (PRP) because the retina lacks of oxygen and as a
consequence it makes a lot of abnormal new blood vessels
(neovascularization) and this will cause retinal detachment.
From the angle to the schlemms canal So when you do your laser you are decreasing the need for
Remember that glaucoma cannot be treated but it can be oxygen preventing from forming new blood vessels by
controlled. Especially when your optic nerve is damage tearing/ tripping the peripheral part of the retina
already, so you really have to control the pressure to prevent
further damage. NONPROLIFERATIVE DIABETIC RETINOPATHY
Vision may be impaired by macular edema and exudates
YAG CAPSULOTOMY resulting from breakdown of the inner blood-retinal barriers
at the level of the retinal capillary endothelium.
Patient with long-term diabetes mellitus will gradually
develop diffuse obliteration of the retinal microcirculation,
especially of the capillaries generalized retinal ischemia
neovascularization of the retina and iris
Neovascularization is partly mediated by diffusible
vasoproliferative factors released from the ischemic retina
into the ocular fluids.
COMPLICATIONS
Retinal Neovascularization
 Left untreated vitreous hemorrhages
traction retinal detachment
In the picture there are already opacities of the posterior Iris neovascularization
capsule. So if this opacify the patient will complain of blurring

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  May lead to neovascular glaucoma Acts by augmenting the function of the retinal pigment
 rare unless the patient has had vitreo-retinal epithelium.
surgery Burns 50–100 μm in diameter are applied, avoiding the
foveal avascular zone, which is approximately 500 μm in
TREATMENT diameter.
TREATMENT FOR LEAKAGE AREAS
PANRETINAL PHOTOCOAGULATION (PRP) fluorescein angiography  areas of discrete or diffuse
fluorescein leakage and areas of capillary non-perfusion
associated with retinal thickening
clinical examination  zones of retinal thickening
OCT ( optical coherence tomography)- usually used
nowadays
Diode micropulse and argon green laser equally effective
in reducing the edema

MOST EFFECTIVE treatment for retinal and iris VITRETOMY SURGERY FOR DIABETIC RETINOPATHY WITH ENDOLASER
neovascularization TREATEMENT
Requires a total of at least 2000 and sometimes 6000 or
more burns, usually delivered over two or more sessions
spaced 1–2 weeks apart.
Can treat the entire retina except for the area within the
temporal vascular arcades
Retrobulbar, peribulbar, or sub-Tenon anesthesia
sometimes required
particularly if areas of the retina need to be treated
again because of recalcitrant or recurrent
neovascularization
Highly effective in producing regression of Vitrectomy is able to clear vitreous hemorrhage and relieved
neovascularization. vitreo-retinal traction
MECHANISM OF ACTION Early vitrectomy is indicated for type I DM with extensive
not been established vitreous hemorrhage and severe, active proliferation.
ADVANTAGES Endolaser treatment is another type of delivery system.
reduction in the degree of retinal ischemia Usually used for patient with diabetic retinopathy and
Production of diffusible vasostimulative substances. traction retinal detachment. So you remove the membrane
Reduction of ocular blood, suggesting reduction of and put the retina into its original position and do laser
oxygen demand in the retina, has been demonstrated inside the eye. So you insert a TROCAR so that you can go
after PRP. inside and laser directly on the retina using endolaser probe.
DISADVANTAGES
Does not cause regression of the fibrosis associated with RETINOPATHY OF PREMATURITY
retinal neovascularization, which is responsible for
tractional retinal detachment.
Can be precluded by vitreous hemorrhage.
Treatment is staged to reduce the incidence of complications
such as detachment and edema
(+) macular edema treat with focal macular coagulation
before or together eith PRP to avoid increasing edema
Intravitreal or orbital floor steroid ( triamcinolone) 
prevent rebound macular edema after PRP

FOCAL OR GRID PATTERN LASER PHOTOCOAGULATION

In retinopathy for prematurity your patient are young… so

you have 5 stages…Stage III you will do photocoagulation of
the avascular retina because young patient still has no
normal blood vessels. As baby you need to mature up to 9
months so that the vasculature of the retina reaches the
periphery.
In ROP hindi pa siya umaabot sa periphery creating abnormal
blood vessels due to lack of oxygen.
One causes of blindness in premature baby so it has to be
Treatment for Diabetic maculopathy (macular edema)
address and treated.

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 ROP is a vasoproliferative retinopathy that affects premature TREATMENT
and LBW infants

CENTRAL RETINAL VEIN OCCLUSION FOCAL & GRID-PATTERN ARGON GREEN LASER PHOTOCOAGULATION

FUNDOSCOPIC FINDINGS
disk swelling
marked venous dilation
almost confluent retinal hemorrhages
COMPLICATION
retinal neovascularization
vitreous hemorrhage
fibrosis
rubeosis iridis with neovascular glaucoma
more common complication
60% chance if w/ severe retinal ischemia seen on Focal photocoagulation in branch retinal vein occlusion
fluorescein angiography
In neovascular glaucoma substances produced by the If you have high blood pressure you can have a branch retinal
ischemic retina diffuse forward and stimulate formation of a vein occlusion. Because of the pressing of artery to vein
fibrovascular membrane that grows across the iris surface causing occlusion leading to hemorrhage.
and covers the trabecular meshwork Angle Closure You can do focal photocoagulation in branch retinal vein
Glaucoma occlusion
CHARACTERISTICS
very high pressure obliterate areas of retinal leakage demonstrated by
pain fluorescein angiography
marked resistance to medical and surgical therapy Used to treat macular edema when vision is 20/40 and 3
 enucleation of the blind and painful eye may mos. Have elapsed since the venous occlusion
be required.

TREATMENT RETINAL TEARS

PANRETINAL PHOTOCOAGULATION (PRP) peripheral retinal tear usually due to posterior vitreous
Scatter Laser Photocoagulation detachment causing vitreous traction
treatment for proliferative diabetic retinopathy MANIFESTATIONS
Preferred Laser to avoid preretinal fibrosis caused by heat sudden appearance of dot-like floaters
absorption in the hemorrhages: COMPLICATION
krypton red RETINAL DETACHMENT
diode infrared laser if it is detected prior to the accumulation of subretinal
hyphema fluid, it can be walled off by applying a double ring of
Alternative treatment for ESTABLISHED neovascular laser burns around it to create an adhesion of the
glaucoma if PRP cannot be performed adjacent attached retina to the pigment epithelium
cyclophotocoagulation With modern contact lens such as the
enucleation Superquad 160, this can be achieved in most cases
prophylactic PRP may be advisable in all cases of ischemic with a slitlamp laser delivery system
central retinal vein occlusion In the remaining few, indirect laser should be
suggestive of ischemia considered.
relative afferent pupillary defect Once retinal detachment has occurred
vision worse than 20/200 surgery is required
multiple retinal cotton wool spots
MACULAR DEGENERATIONS AND RELATED DISEASE
MACULAR GRID LASER THERAPY
Done AFTER intravitreal steroid or anti-angiogenesis therapy
Bruch membrane forms a barrier layer between the retinal
may be beneficial for Macular edema
pigment epithelium and the choriocapillaries
Results usually INEFFECTIVE considered in patients <50 y.o.
Bruch membrane is damage or deteriorates it can cause
Grow of choroidal neovascularization
BRANCH RETINAL VEIN OCCLUSION Exudative pigment epithelial detachment
Hemorrhage and fibrosis with destruction of retinal function
Localized areas of venous congestion and hemorrhage to Most frequent cause is age related macular degeneration
hemiretinal involvement from occlusion of the superior or inferior presenting initially as DRUSEN ( asymptomatic yellowish deposits
division of the central retinal vein. in the macula)
principal complications Xanthophyll
chronic macular edema (with or without exudates) yellow macular pigment
retinal neovascularization followed by vitreous hemorrhage strongly absorbs blue light
weakly absorbs green
Does not absorb yellow, orange or red light

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Hemoglobin ring, pulling the trabecular layers apart with reopening of the
Strongly absorbs blue, green , yellow and orange light intertrabecular spaces and of Schlemm's canal
Weakly absorbs red light Trabeculoplasty increase the outflow and has no influence
Melanin upon aqueous secretion
Absorbs all visible wavelengths Lies in reducing or avoiding the risk of drainage surgery
Most effective in patients with pseudoexfoliation and
TREATMENT pigmentary glaucoma
Main side effects rise in pressure for 1-4 hrs. --. Can be
ANTI VEGF  preferred treatment for choroidal prevented by apralonidine drops
neovascularization associated with age related MD SELECTIVE LASER TRABECULOPLASTY (SLT)
PHOTODYNAMIC THERAPY delivers very high energy of extremely short duration
an intravenous injection of a photosensitive dye effective as traditional laser trabeculoplasty but is easier to
(verteporfin), believed to localize within the choroidal perform as the laser spot is larger and only needs to be
neovascularization, is followed by treatment with a laser aimed at the whole trabecular meshwork
optimized for activation of the dye to cause thrombosis of
the abnormal vessels CYCLOPHOTOCOAGULATION

GLAUCOMA Glaucoma refractory can be controlled by direct destruction of

ANGLE CLOSURE GLAUCOMA the ciliary process
using a high-energy ruby laser, but is currently performed by
Primary angle closure glaucoma--. Aqueous flow through the pupil contact delivery through a fiberoptic probe with the thermal-
is blocked by contact of the lens with the posterior surface of the mode Nd:YAG laser or the diode laser
iris Good control is obtained but multiple treatments maybe required
Angle closure glaucoma can be determined only by examining the Side effects
anterior chamber angle by gonioscopy Pain
Most common type of glaucoma in Asian population and Inflammation
worldwide Reduction of vision
SURGICAL IRIDECTOMY
Standard treatment for decades LASER SUTURE LYSIS
Complications
Hemorrhage Trabeculectomy remains a popular method of glaucoma
Infection surgery
Anesthetic accidents increase the degree of drainage and perhaps achieve greater long-
Sympathetic opthalmia term reduction in intraocular pressure similar to that obtained
LASER IRIDOTOMY with the older full-thickness drainage procedures  laser of
more effective by the Abraham contact lens (with a 66- partial thickness scleral flaps sutures can be performed
diopter focusing button) and the Wise iridotomy-
sphincterotomy lens (103-diopter button) POSTERIOR AND ANTERIOR CAPSULOTOMY AFTER CATRACT SURGERY
Increase energy density and improve visualization of the iris.
often successful with either the argon laser or the Q- Modern cataract surgery uses phacoemulsification followed by
switched Nd:YAG laser posterior intraocular lens implantation
In laser iridotomy, the YAG laser is used to create a hole in If the posterior capsule supporting the intraocular lens later
the iris a new passage for fluid to exit from the posterior opacifies, vision can be restored by focusing Q-switched Nd:YAG
chamber of the eye laser pulses just posterior to the capsule to produce a central
When a cataract is removed, the posterior capsule serves to capsulotomy (thus avoiding further intraocular surgery).
support the lens implant. The YAG laser in YAG capsulotomy Capsulotomy side effects
is used to create an opening in the center of the membrane Increase risk of retinal holes
to restore the quality of vision Retinal detachment
When the cornea is to cloudy  argon laser iridoplasty can Anterior capsular fibrosis  may lead to contracture and
be attempted occlusion

OPEN ANGLE GLAUCOMA ANTERIOR VITREOLYSIS

Most common type of glaucoma in western countries Incomplete clearance of vitreous from the anterior chamber
Painless gradual reduction in trabecular meshwork function with during the management of vitreous loss secondary to trauma or
decreasing outflow, increasing intraocular pressure, progressive surgery may result in pupillary distortion, chronic uveitis, and
cupping of the optic nerve, and insidious loss of visual field, cystoid macular edema.
leading ultimately to blindness.
Topical Medical therapy is the standard approach VAPORIZATION OF LID TUMORS
TRABECULOPLASTY
Next approach if medical therapy is inadequte The carbon dioxide laser has been used to bloodlessly remove
spacing 100 or more nonperforating argon laser burns 360 both benign and malignant lid tumors.
degrees around the trabecular meshwork to shrink the However, because of scarring, lack of a histologic specimen, and
collagen in the tissues of the trabecular ring, reducing the inability to assess margins, laser treatment for this purpose
circumference and therefore the diameter of the trabecular appears inferior to surgery in most cases of malignant tumors

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 Principal use - to evaluate and follow glaucoma-induced changes
CORNEAL REFRACTIVE SURGERY in the optic nerve head, but other uses include macular, lens, and
corneal imaging.
Moderate myopic and Astigmatic refractive errors Laser interferometry is used to measure blood flow in the ciliary
can correct by controlled recontouring of the cornea body and retinal blood vessels.
(photorefractive keratectomy [PRK]) By using multiple Ocular coherence tomography can produce very high resolution
pulses and progressively changing spot size to evaporate optical sections of the cornea and retina to allow evaluation of
successive thin layers of the cornea diseases such as corneal dystrophies and macular edema.

TRANSCANALICULAR LASER ASSISTED DACRYOCYSTORHINOSTOMY

Surgical correction of nasolacrimal duct obstruction in which a

permanent fistula is formed between the lacrimal sac and the
nose
Used for patient with EIPHORA (excessive tearing) due to
blockage of nasolacrimal duct system.

LASIK (LASER IN SITU KERATOMILEUSIS)

use to preserve Bowman’s membrane

consists of cutting a hinged lamellar flap of cornea with a
mechanical keratome, performing the refractive laser ablation in
the corneal bed, and then replacing the flap
LASIK provides faster visual recovery and less discomfort than PRK
but carries a slightly higher risk of long-term complications.

MODERN EXCIMER LASER END

Have smaller spot size, an eye tracking system and a wavfront

custom ablation RED- BOOK
Improve accuracy of treatment and reduce the increase of GREEN- PREVOIUS TRANS
spherical aberration induced by corneal flaps BLACK- POWERPOINT

COSMETIC LASER EYELID SURGERY

Exposing wrinkled eyelid skin to repeated 1-ms pulses from the

carbon dioxide laser—obtained by rapid pulsing of the laser tube
or by computer-controlled rapid scanning of a continuous small
laser beam—evaporates the epidermis and induces collagen
contraction in the dermis.
Green laser can also be used to remove xanthalesma. It is very
effective but can cause depigmentation and should be avoided in
darkly pigmented skin.
Techniques are more precise than older methods such as
dermoabrasion or chemical peels
Complications
Keloid scarring
Hyperpigmentation
Herpes virus infection

LASER DIAGNOSTIC IMAGING

Confocal imaging is a video method that uses a rapidly scanning

tiny laser spot whose reflected light is imaged through a pinhole
upon a detector, thus suppressing all reflections except those
from the focal plane.

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 LASER IN OPTHALMOLOGY

Laser In Opthalmology
Opthalmology – Dr. Alejo
• What we can only see is the visible light from 400-700nm.
“LASER” is an acronym for:
LASER VS. LIGHT
• L – Light
• A – Amplification by LASER LIGHT
• S – Stimulated
Stimulated emission Spontaneous emission
• E – Emission of
Monochromatic Polychromatic
• R – Radiation
Highly energized Poorly energized
• Gordon Gould – Physicist
Parallelism Highly Divergent (kumakalat)
INTRODUCTION Coherence Not Coherent
Can sharply be focused Can’t be sharply focused
• 1917 – Einstein hypothesized that a stimulated atom would release a
packet of light known as ‘photon’. PRINCIPLE OF LASER
− Established the foundation of Laser
• 1958 – C. H. Townes, A. L. Schalow: Theoretical basis of lasers
• 1960 – Theodore Maiman: 1st laser using ruby crystal
• 1963 – C. Zweng: 1st medical laser trial (Retinal Coagulation)
• 1965 – W.Z. Yarn: 1st clinical laser surgery
• 1970 – Excimer laser was invented by Nikolai Basov
• 1971 – Neodymium yttrium aluminum garnet (Nd:YAG) and Krypton
laser were developed.

LASER APPLICATIONS

• Common consumer products – DVD players, laser printers, barcode

scanners
• Medicine – laser surgery, skin treatments
• Industry – cutting, welding materials
• Military and Law enforcement – marking targets and measuring range The principle of laser is that you release a photon that’s why you have
• Entertainment – laser isotopes for lighting the space stimulated emission.
CHARACTERISTICS: TISSUE OPTICS
• Monochromaticity • Laser when it hits an object or our tissue it can be:
− Only 1 wavelength or sometimes a combination of several o Reflected
wavelengths. o Refracted
− This pure monochromatic beam is obtained by combining § Scattered
sometimes different wavelengths or one wave length. § Absorbed
• Directionality o Transmitted
− Laser is also unidirectional. LASER TISSUE INTERACTION
− Emit a narrow beam that spreads very slowly
• Coherent (in phase) – It removes focusing characteristics ü Thermal Effect – Photocoagulation, Photodisruption &
(Again, LASER is unidirectional, monochromatic, and coherent.) Photovaporization
ü Photochemical Effect – Photoradiation & Photoablation
LIGHT – (Spectrum of different wavelengths so it move all the colors) ü Ionizing Effect

THERMAL EFFECT
• Photocoagulation
o Laser à target tissue à generate heat à denatures
proteins (coagulation) – tissue coagulation
o Rise in temperature of about 10-20 degree celcius will case
coagulation
o E.G. Pan Retinal Photocoagulation (PRP) – used diabetic
• Visible light refers to the visible portion of the electromagnetic spectrum patients
at region of about 400-700nm (nanometers) in wavelength. • Photodisruption
o Mechanical effect of laser light à acoustic shockwaves à SD
WAVELENGTHS OF LIGHT tissue damage
o E.G. Laser Capsulotomy, Laser Darcryocystorhinoscopy
LDC
(DCR)
SECTION B
Batch2020 – OPTHALMOLOGY 1
 LASER IN OPTHALMOLOGY

• Photovaporization • Laser light will reflect to the mirror to the target tissue
o Vaporization of tissue to CO2 & H2O occurs when its • We often use the contact lens or the lens
temperature rise 60-100 degree celcius CONTROL – can be manipulated
o Commonly used CO2 à absorbed by water of cells à • Laser Parameters
visible vapor o Spot size – different sizes for lase light (larger area of effect)
o Heat – E.G. Cauterization o Duration – how long it hits the target (exposure of target
o Cell disintegration – incision cells)
o E.G. Femtosecond Laser o Energy – how high the enery is
PHOTOCHEMICAL EFFECT LASER LENS (ACCESSORY)
• Photoablation
o Breaks the chemical bonds that hold tissue
o E.G. Photorefractive Keratectomy (PRK), Argon Flouride
(ArF) Excimer Laser
• Photoradiation
o A.K.A. Photodynamic theraphy
o Treatment of ocular tumors of choroidal neovascularizations
OPTHALMIC LASER
3 basic Elements:
1. Active medium – used to EMIT the coherent radiation
2. Energy Input – PUMPS the energy to the medium
3. Optical feedback – CONCENTRATES the photon to produce the • This is the example lens put on top of the cornea. A 3 mirror lens
output beam where in you can focus a particular part of the eye.
• These particular type of lens used for glaucoma and also for doing
laser at the periphery of the retina.

ARGON LASER FOR PHOTOCOAGULATION

TYPES OF LASERS – (based on active medium)

ü Gas – Argon & Krypton

ü Liquid – Dye
ü Solid – Nd: YAG
ü Semiconductor – Diode
COMPONENTS • Uses a slit lamp delivery system
• Laser Source – builds up the laser power • Gas type
• Delivery system • Used in photocoagulation for proliferative diabetic retinopathy
o Ophthalmoscope • Argon laser to the macula should be sufficient to produce only light
o Treatment Probe burns, as laser scars can expand and affect vision.
o Telescope
SLIT LAMP DELIVERY SYSTEM DIODE LASER FOR PHOTOCOAGULATION

• Semiconductor
Also used for photocoagulation same thing with argon laser also
•
used for diabetic retinopathy and glaucoma.
SD
LDC
SECTION B
Batch2020 – OPTHALMOLOGY 2
 LASER IN OPTHALMOLOGY

Nd: YAG LASER FOR PHTODISRUPTION • Refractive procedure in which we change the totally flattened
surface of the eye to produce a different refraction to correct the
errors of refraction.
• In myopic patients, this is used to flattened the surface of the eye.

• Neodymium: Yttrium aluminum garnet. Used for posterior capsule

opacification due to cataract surgery. Remember when you have
cataract extraction you put the lens on the capsule sometimes its
opacify. So the YAG Laser is being used for photodisruption.
• In the past upto 50% of eyes developed opacification of the
posterior capsule (“after cataract”) after uncomplicated adult
extracapsular cataract extraction.
• ND: YAG laser provides noninvasive method for discussion of the
posterior capsule
• Pulses of laser energy cause small explosion in target tissue à
creating an opening in the posterior capsule in the pupillary axis
• Complication of this technique
o Transient rise in IOP
o Damage to the intraocular lens LASIK – Compared to PRK, Lasik uses flap then you flatten the surface then
o Rupture of the anterior hyaloid face à re-attach the flap.
rhegamtogenous detachment or crystalloid macular − Laser In-Situ Kertatomileusis
edema − Creation of FLAP!
PRK – Ablate the surface
INDIRECT LASER OPTHALMOSCOPE LASIK – Uses a flap

LASER IRIDOTOMY IN GLAUCOMA

• Doesn’t use opthalmoscope

• Wet mounted light source on the lens
• Instead of using a contact lens in the eye the doctor hold a lens to
focus the posterior eye. • Mechanism of Acute Angle Closure Glaucoma: fluid accumulates
in the posterior chamber of the eye. Na-iipon yung intraocular
pressure sa eye.
• Laser Iridotomy – will relieve the pupillary flap by making a fistula
OPTHALMIC LASER APPLICATIONS
so that the aqueous fluid that accumulates will pass through to the
anterior of the eye.
• PRK, LASIK – for EOR
• Laser Iridotomy – 1st line: Closed Angle Glaucoma
− Refractive surgery
• Yag Capsulotomy – (POSTERIOR) “Post-cataract procedure” YAG CAPSULOTOMY
− For POST. CAPSULARITY OPACITY
• Panretinal Photocoagulation (PRP) – Diabetic patients
• Focal Photocoagulation – Diabetic patients
• Transcleral Photocoagulation – Diabetic or patients with uncontrolled
IOP
• Endolaser Photocoagulation – heat PROBES inserted
• Laser DCR
SD
PRK LDC
• Photorefractive Keratectomy SECTION B
Batch2020 – OPTHALMOLOGY 3
 LASER IN OPTHALMOLOGY

VITRECTOMY SURGERY FOR DIABETIC RETINOPATHY WITH

ENDOLASER TREATMENT

• Laser is also used in capsulotomy procedures to sure opacification

happens in post cataract procedures.
• We direct laser to the posterior capsule so that light can pass through.
• Laser procedures are also used as an adjunct for vitrectomy
POST LASER IRIDOTOMY procedures
• We do an endolaser treatment – probes are inserted to target the
tissue for photocoagulation.
• After cleaning the vitreous from TB or fibrovascular proliferation,
there can be retinal detachment, laser is also used.

FOCAL PHOTOCOAGULOPATION IN RETINOPATHY OF

PREMATURITY
− The goal is to destroy the tissues to prevent production of
abnormal blood vessels. (Prevent Neovascularization)

SEVERE NON-PROLIFERATIVE DIABETIC RETINOPATHY

• We also do laser – (PRP) – we destroy cells so that oxygen can

pass through.
• So when you do your laser you are decreasing the need for
FOCAL PHOTOCOAGULOPATION IN BRANCH RETINAL VEIN
oxygen preventing from forming new blood vessels by
OCCLUSION (Prevent Neovascularization)
tearing/tripping the part of retina.
− blockage of small veins in the retina

LASER PANRETINAL PHOTOCOAGULATION

− Typically YELLOW GREEN or RED Laser is used.

− Temp by 20-30oc (denatures proteins) SD
− decrease VEGF à prevent neovascularization LDC
SECTION B
Batch2020 – OPTHALMOLOGY 4
 LASER IN OPTHALMOLOGY

TRANCANALICULAR LASER ASSISTED

DARCRYOCYSTORHINOSTOMY

• In patient with nasolacrimal duct obstruction.

• In old procedures, to produce a fistula from bone, we need to do it
manually by grafting the bone but now we can do it through laser
treatment to produce a fistula.

SD
LDC
SECTION B

Batch2020 – OPTHALMOLOGY 5
LASERS IN OPHTHALMOLOGY – DR. KARLO ALEJO

LASER  Monochromaticity
 Only 1 wavelength or
 LIGHT AMPLIFICATION by
sometimes a
STIMULATED EMISSION of
combination of
RADIATION
several wavelengths
 Gordon Gould - physicist
 This pure
INTRODUCTION monochromatic beam
is obtained by
 1917 – Einstein hypothesized that a
combining sometimes
stimulated atom would release a
different wavelengths
packet of light known as a “photon”
or one wave length.
- Established the foundation of laser
 Directionality
 1958 – C.H. Townes, A.L. Schawlow:
 Laser is also
theoretical basis for lasers
unidirectional.
 1960 – Theodore Maiman: 1st laser
using ruby crystal  Emit a narrow beam
 1963 – C. Zweng: 1st medical laser that spreads very
trial (retinal coagulation) slowly
 1965 – W.Z. Yarn: 1st clinical laser  Coherent (in phase)
surgery  It improves focusing
 1970 – Excimer laser was invented characteristics
by Nikolai Basov (Again, LASER is unidirectional,
 1971 – Neodymium yttrium monochromatic, and coherent.)
aluminum garnet (Nd:YAG) and
Krypton laser were developed LIGHT

LASER APPLICATIONS
 Common consumer products – DVD
players, laser printers, barcode
scanners
 Medicine – laser surgery, skin
treatments
 Industry – cutting, welding materials
 Military and law enforcement –
marking targets and measuring
range
 Entertainment – laser isotopes for  Visible light refers to the visible
lighting the space portion of the electromagnetic
LASER spectrum at the region of about
400-700 nm (nanometers) in
 CHARACTERISTICS: wavelength.
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LASERS IN OPHTHALMOLOGY – DR. KARLO ALEJO

WAVELENGTHS OF LIGHT sinabi nya ba ay VERTICAL AXIS) – it

emits the Photon
 The light is amplified in a (di ko
maintindihan ung word) graph
system
 Those photons are collected to
 What we can only see is the visible produce a stimulated emission.
light from 400-700nm. Tissue Optics
LASER vs LIGHT  Lasers when it hits an object or our
LASER LIGHT tissues it can be:
Simulated emission Spontaneous  Reflected
emission  Refracted
Monochromatic Polychromatic  Scattered
Highly energized Poorly energized  Absorbed
Parallelism Highly divergent  Transmitted
Coherence Not coherent
Can sharply be Can’t be sharply
focused focused

PRINCIPLE OF LASER

LASER TISSUE INTERACTION

 Thermal Effect
 Photocoagulation
 Photodisruption
 Photovaporization
 Photochemical Effect
 In simplified sequence, the energy  Photoradiation
source excites the atoms in the  Photoablation
active medium to a higher state and  Ionizing Effect
(di ko maintindihan si doc kung ang

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LASERS IN OPHTHALMOLOGY – DR. KARLO ALEJO

THERMAL EFFECT  Treatment of ocular tumors

of choroidal
 Photocoagulation
neovascularizations
 Laser light → target tissue →
generate heat → denatures OPHTHALMIC LASER
proteins (coagulation) –
 3 Basic Elements
tissue coagulation
 Active medium – used to
 Rise in temperature of about
emit the coherent radiation
10 – 20 degree Celsius will
 Energy input – pumps the
cause coagulation
energy to the medium
 E.G. Pan retinal
 Optical feedback –
photocoagulation (PRP) –
concentrates the photon to
used for diabetic patients
produce the output beam
 Photodisruption
 Mechanical effect of laser
light → acoustic shockwaves
→ tissue damage
 E.G. Laser capsulotomy, laser
DCR
 Photovaporization
 Vaporization of tissue to CO2
& H2O occurs when its
temperature rise 60 – 100
degree Celsius
 Commonly used CO2 →
absorbed by water of cells →
LASER
visible vapor
 Heat – e.g. cauterization  TYPES OF LASERS
 Cell disintegration – incision  Gas
e.g. femtosecond laser  Argon
PHOTOCHEMICAL EFFECT  Krypton
 Liquid
 Photoablation  Dye
 Breaks the chemical bonds  Solid
that hold tissue  Nd: YAG
 E.G. photorefractive  Semiconductor
keratectomy (PRK), Argon  Diode
Flouride (ArF) Excimer Laser
 Photoradiation
 A.K.A. Photodynamic therapy

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LASERS IN OPHTHALMOLOGY – DR. KARLO ALEJO

COMPONENTS LASER LENS (ACCESSORY)

 Laser source
 Delivery system
 Ophthalmoscope
 Treatment probe
 Telescope
SLIT LAMP DELIVERY SYSTEM
ARGON LASER FOR PHOTOCOAGULATION

 Uses a slit lamp delivery system

 Gas type
DIODE LASER FOR PHOTOCOAGULATION

 Laser light will reflect to the mirror

to the target tissue
 We often use the contact lens or the
lens
CONTROL – can be manipulated
 Laser Parameters
 Spot size – different sizes for
laser light
 Duration – how long it hits
the target  semiconductor
 Energy – how high the
energy is

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LASERS IN OPHTHALMOLOGY – DR. KARLO ALEJO

Nd: YAG LASER FOR PHOTODISRUPTION PRK

 Photorefractive Keratectomy
 Refractive procedure in which we
change the totally flattened surface
of the eye to produce a different
refraction to correct the errors of
refraction.
 In myopic patients, this is used to
flatten the surface of the eye.

INDIRECT LASER OPHTHALMOSCOPE

 Doesn’t use ophthalmoscope

 Wet mounted light source on the
lens
OPHTHALMIC LASER APPLICATIONS
 PRK, LASIK
 Laser Iridotomy – refractive surgery
on glaucoma
LASIK
 Yag Capsulotomy– post cataract
procedure
 Panretinal Photocoagulation –
diabetic patients
 Focal Photocoagulation – diabetic
patients
 Transcleral Photocoagulation –
diabetic or patients with
uncontrolled IOP
 Endolaser Photocoagulation
 Laser DCR

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LASERS IN OPHTHALMOLOGY – DR. KARLO ALEJO

 Compared to PRK, Lasik uses a flap

then you flatten the surface then
you re-attach the flap.
PRK – ablate the surface
LASIK – uses a flap
LASER IRIDOTOMY IN GLAUCOMA  Laser is also used in capsulotomy
procedures to sure opacification
happens in post cataract
procedures.
 We direct laser to the posterior
capsule to somehow destroy the
posterior capsule so that light can
pass through.
POST-LASER IRIDOTOMY

 Mechanism of Acute angle closure

SEVERE NON-PROLIFERATIVE DIABETIC
glaucoma: fluid accumulates in the
RETINOPATHY
posterior chamber of the eye. Na-
iipon ung intraocular pressure sa
eye.
 Laser iridotomy – will relieve the
pupillary flap by making a fistula so
that the aqueous fluid that
accumulates will pass through to the
anterior of the eye.
YAG CAPSULOTOMY
 We also do Laser - Panretinal
photocoagulation – we destroy cells
so that oxygen can pass through.
 So when you do your laser you are
decreasing the need for oxygen
preventing from forming new blood
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LASERS IN OPHTHALMOLOGY – DR. KARLO ALEJO

vessels by tearing/ tripping the

peripheral part of the retina
LASER PANRETINAL PHOTOCOAGULATION

FOCAL PHOTOCOAGULATION IN BRANCH

RETINAL VEIN OCCLUSION

VITRECTOMY SURGERY FOR DIABETIC

RETINOPATHY WITH ENDOLASER
TREATMENT
 Laser procedures are also used as an
adjunct for vitrectomy procedures
 We do an endolaser treatment –
probes are inserted to target the TRANSCANALICULAR LASER ASSISTED
tissue for photocoagulation. DACRYOCYSTORHINOSTOMY
 After cleaning the vitreous from TB
or fibrovascular proliferation, there
can be retinal detachment, laser is
also used.

 In patients with nasolacrimal duct

FOCAL PHOTOCOAGULATION IN obstruction.
RETINOPATHY OF PREMATURITY – the goal  In old procedures, to produce a
is to destroy the tissues to prevent fistula from the bone, we need to do
production of abnormal blood vessels. it manually by grafting the bone but
now we can do it through laser
treatment to produce a fistula.
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LASERS IN OPHTHALMOLOGY – DR. KARLO ALEJO

Questions:
1. What does LASER stand for?
2. It is known as the packet of light
which established the foundation of
laser?
3. What are the 3 characteristics of
laser?
4. What is the range of the visible light
in the spectrum?
5. In the ophthalmic laser what
element is used to emit the
coherent radiation?
6. What procedure ablates the eye
surface?
7. What procedure uses a flap to
flatten the eye surface?
8. What condition arises when the
aqueous humor accumulates in the
posterior chamber?
9. Treatment that uses probes to
target the tissues for
photocoagulation?
10. Treatment procedure used in
patients with nasolacrimal duct
obstruction?

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