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Ultrashort pulse laser surgery of the cornea and the sclera

The strongly localized interaction process of ultrashort laser pulses with tissue makes femtosecond lasers a powerful tool for eye surgery. These lasers are now routinely used in refractive surgery and other forms of surgery of the anterior segment of the eye. Several clinical laser systems also offer options for corneal grafting and the potential use of ultrashort pulse lasers in glaucoma surgery has been the object of several recent studies which have shown promising results. While devices aimed for interventions in clear tissue may be based on available solid state or fibre laser technology, the development of tools for surgery in more strongly scattering tissue has to account for the compromised tissular transparency and requires the development of optimized laser sources. The present paper focuses on surgery of clear and pathological cornea as well as sclera. It aims to give an overview over typical medical indications for ultrashort pulse laser surgery, the optics of the tissues involved, the available laser technology, the laser–tissue interaction process, and possible future developments.

In situ monitoring of second-harmonic generation in human corneas to compensate for femtosecond laser pulse attenuation in keratoplasty

The application of femtosecond lasers in corneal transplant surgery requires high pulse energies to compensate for the strong optical scattering in pathological corneas. However, excessive energies deteriorate the quality of the incisions. The aim of this study is to demonstrate the dependence of side effects on local radiant exposure, numerical aperture, and tissue properties, to quantify the penetration depth of the laser for individual corneas, and to provide a method for optimizing the energy in the volume of the cornea. We examine histological and ultrastructural sections of clear and edematous corneas with perforating and lamellar incisions performed at different pulse energies. We demonstrate that the augmented energies in edematous corneas may result in unwanted side effects even when using high numerical apertures. The dependence of the laser beam penetration depth on pulse energy is evaluated by histology and an exponential decrease is observed. We show that the penetration length can be determined by evaluating the backscattered second-harmonic emission associated with the nonlinear optical properties of the tissue. This approach represents a noninvasive method for the in situ quantification of the laser beam attenuation, enabling us to adapt the pulse energy accordingly. Experiments using adapted energies show that the side effects are minimized.

Interaction dynamics of spatially separated cavitation bubbles in water

We present a high-speed photographic analysis of the interaction of cavitation bubbles generated in two spatially separated regions by femtosecond laser-induced optical breakdown in water. Depending on the relative energies of the femtosecond laser pulses and their spatial separation, different kinds of interactions, such as a flattening and deformation of the bubbles, asymmetric water flows, and jet formation were observed. The results presented have a strong impact on understanding and optimizing the cutting effect of modern femtosecond lasers with high repetition rates (>1 MHz).

Self-focusing and spherical aberrations in corneal tissue during photodisruption by femtosecond laser

The use of ultrashort pulse lasers is current in refractive surgery and has recently been extended to corneal grafting (keratoplasty). When performing keratoplasty, however, permanent degradation of the optical properties of the patients cornea compromises the penetration depth of the laser and the quality of the incisions, therefore causing unwanted secondary effects. Additionally, corneal grafting needs considerably higher penetration depths than refractive surgery. Little data are available about the interaction processes of the femtosecond pulses in the volume of pathological corneas-i.e., in the presence of spherical aberrations and optical scattering. We investigate the influence of the focusing numerical aperture on the laser-tissue interaction. We point out that at low numerical apertures (NAs), tissue damage is produced below and above the focal region. We attribute this phenomenon to nonlinear self-focusing effects. On the other hand, at high NAs, spherical aberrations become significant when focusing at high depths for posterior surgeries, which also limit the cutting efficiency. As high NAs are advisable for reducing unwanted nonlinear effects and ensure accurate cutting, particular attention should be paid to aberration management when developing clinical femtosecond lasers.

Laser parameters, focusing optics, and side effects in femtosecond laser corneal surgery

Nowadays, femtosecond lasers are routinely used in refractive eye surgery. Until recently, commercialised clinical systems were exclusively based on ytterbium or neodymium-doped solid state lasers emitting sub-picosecond pulses at a wavelength of about 1 μm and repetition rates of a few 10 kHz. These systems use pulse energies in the μJ range and focussing optics of NA = 0.3 to 0.5. Recent developments have provided a variety of alternative and equally viable approaches: systems are now available using nJ pulses at high numerical apertures and MHz repetition rates - an approach so far only used for femtosecond cell surgery - and fibre laser technology is now being used for femtosecond laser corneal surgery. Recent research has also provided more insight in side effects occurring in present systems: self focusing phenomena and so far unexplained periodical structures have been observed even at high numerical apertures (NA >> 0.5) and moderate pulse energies. The interaction of femtosecond laser pulses with strongly scattering tissue has been studied in view of extending the application of femtosecond lasers to keratoplasty for opaque corneas and to glaucoma surgery. The use of new laser wavelengths and adaptive optics has been proposed. Despite the reputation of femtosecond surgical systems for their precision, repeatability and the absence of secondary effects or complications, a closer examination reveals the presence of subtle phenomena which merit further investigation. We present three of these phenomena: the influence of optical aberration on the quality of the incision, the occurrence of filamentation effects, and the deposit of microscopic glass fragments when performing penetrating incisions.

Dynamic and interaction of fs-laser induced cavitation bubbles for analyzing the cutting effect

A prominent laser based treatment in ophthalmology is the LASIK procedure which nowadays includes a cutting of the corneal tissue based on ultra short pulses. Focusing an ultra short laser pulse below the surface of biological tissue an optical breakdown is caused and hence a dissection is obtained. The laser energy of the laser pulses is absorbed by nonlinear processes. As a result a cavitation bubble expands and ruptures the tissue. Hence positioning of several optical breakdowns side by side generates an incision. Due to a reduction of the duration of the treatment the current development of ultra short laser systems points to higher repetition rates in the range of hundreds of KHz or even MHz instead of tens of kHz. This in turn results in a probable occurrence of interaction between different optical breakdowns and respectively cavitation bubbles of adjacent optical breakdowns. While the interaction of one single laser pulse with biological tissue is analyzed reasonably well experimentally and theoretically, the interaction of several spatial and temporal following pulses is scarcely determined yet. Thus the aim of this study is to analyse the dynamic and interaction of two cavitation bubbles by using high speed photography. The applied laser pulse energy, the energy ratio and the spot distance between different cavitation bubbles were varied. Depending on a change of these parameters different kinds of interactions such as a flattening and deformation of bubble shape or jet formation are observed. Based on these results a further research seems to be inevitable to comprehend and optimize the cutting effect of ultra short pulse laser systems with high (> 1 MHz) repetition rates.

Ultrashort-pulse laser eye surgery uses fiber technology at 1.6 microns

New, compact, and wavelength-optimized ultrashort-pulse laser systems may facilitate corneal grafting and enable new forms of glaucoma surgery.

Femtosecond laser corneal surgery with in-situ determination of the laser attenuation and ablation threshold by second harmonic generation

Femtosecond lasers start to be routinely used in refractive eye surgery. Current research focuses on their application to glaucoma and cataract surgery as well as cornea transplant procedures. To avoid unwanted tissue damage during the surgical intervention it is of utmost importance to maintain a working energy just above the ablation threshold and maintain the laser energy at this working point independently of the local and global tissue properties. To quantify the attenuation of the laser power density in the tissue by absorption, scattering and modification of the point spread function we monitor the second harmonic radiation generated in the collagen matrix of the cornea when exposed to ultrashort laser pulses. We use a CPA system with a regenerative amplifier delivering pulses at a wavelength of 1.06 &mgr;m, pulse durations of 400 fs and a maximum energy of 60 &mgr;J. The repetition rate is adjustable from single shot up to 10 kHz. The experiments are performed on human corneas provided by the French Eye bank. To capture the SHG radiation we use a photomultiplier tube connected to a lockin amplifier tuned to the laser repetition rate. The measured data indicates an exponential decay of the laser beam intensity in the volume of the sample and allows for the quantification of the attenuation coefficient and its correlation with the optical properties of the cornea. Complementary analyses were performed on the samples by ultrastructural histology.