Volume 10, Issue 6 - Lasers in Ophthalmology

A method to determine the optimum laser parameters for maximizing laser induced refractive index change (LIRIC) while avoiding exceeding the damage threshold for different materials with high water content (in particular, polymers such as hydrogels or the human cornea) is proposed. The model is based upon two previous independent models for LIRIC and for laser induced optical breakdown (LIOB) threshold combined in a simple manner. This work provides qualitative and quantitative estimates for the parameters leading to a maximum LIRIC effect below the threshold of LIOB.

The cornea is a part of the anterior segment of the eye that plays an essential optical role in refracting the light rays on the retina. Cornea also preserves the shape of an eyeball and constitutes a mechanical barrier, protecting the eye against the factors of the external environment. The structure of the cornea influences its biomechanical properties and ensures appropriate mechanical load transfer (that depends on the external environment and the intraocular pressure) while maintaining its shape (to a certain extent) and its transparency. The assessment of the corneal biomechanics is important in clinical ophthalmology, e.g. in the diagnosis of ectatic corneal diseases, for precise planning of the refractive surgery, and in accurate determination of the intraocular pressure. A standard technique to determine corneal biomechanics requires the application of well-defined mechanical stimulus (e.g. air puff) and performing simultaneous imaging of the response of the tissue to the stimulus. A number of methods to assess the biomechanical properties of the cornea have been developed, including ultrasound, magnetic resonance imaging, and optical methods as visualization modalities. Commercially available methods include the ocular response analyzer (ORA) and corneal visualization scheimpflug technology (Corvis ST). Currently advanced research is conducted using optical coherence tomography (OCT). The extension of OCT called optical coherence elastography (OCE) possesses high clinical potential due to the imaging speed, noncontact character, and high resolution of images.

This review provides an overview of the historical development and modern applications of femtosecond (fs) lasers in ophthalmology, with a focus on the optical concepts involved. fs-Laser technology is unique because it allows very precise cutting inside the eye through optically transparent tissue, without a need for any mechanical openings. fs-Lasers were historically first used for refractive cornea surgery, later also for therapeutic cornea procedures and lens surgery. Further new areas of ophthalmic application are under development. The latest laser system concept is low pulse energy and high pulse frequency: by using larger numerical aperture focusing optics, the pulse energy required for optical breakdown decreases, and athermal tissue cutting with minimal side effects is enabled.

Smoother surfaces after laser vision correction have been widely accepted as a factor for improving visual recovery regardless of the used technique (PRK, LASIK, or even SMILE). We tested the impact of laser beam truncation, dithering (expressing a continuous profile on a basis of lower resolution causing pixels to round up/down the number of pulses to be placed), and jitter (a controlled random noise (up to ±20 µm in either direction) added to the theoretical scanner positions) on residual smoothness after Poly(methyl methacrylate) (PMMA) ablations, using a close-to-Gaussian beam profile. A modified SCHWIND AMARIS system has been used providing a beam profile with the following characteristics: close-to-Gaussian beam profile with full width at half maximum (FWHM) of 540 µm, 1050 Hz. Laser parameters have been optimized following Invest. Ophthalmol. Vis. Sci. , vol. 58, no. 4, pp. 2021–2037, 2017, the pulse energy has been optimized following Biomed. Opt. Express vol. 4, pp. 1422–1433, 2013. For the PMMA ablations, two configurations (with a 0.7 mm pinhole and 0.75 mJ and without pinhole and 0.9 mJ (for fluences of 329 mJ/cm 2 and 317 mJ/cm 2 and corneal spot volumes of 174 and 188 pl)) were considered, along with two types of lattices (with and without ordered dithering to select the optimum pulse positions), and two types of spot placement (with and without jitter). Real ablations on PMMA (ranging from −12D to +6D with and without astigmatism of up to 3D) completed the study setup. The effect of the 2 × 2 × 2 different configurations was analyzed based on the roughness in ablation estimated from the root mean square error in ablation. Truncation of the beam is negatively associated to a higher level of residual roughness; ordered dithering to select the optimum pulse positions is positively associated to a lower level of residual roughness; jitter is negatively associated to a higher level of residual roughness. The effect of dithering was the largest, followed by truncation, and jitter had the lowest impact on results. So that: Dithering approaches help to further minimize residual roughness after ablation; minimum (or no) truncation of the beam is essential to minimize residual roughness after ablation; and jitter shall be avoided to minimize residual roughness after ablation. The proposed model can be used for optimization of laser systems used for ablation processes at relatively low cost and would directly improve the quality of results. Minimum (or no) truncation of the beam is essential to minimize residual roughness after ablation. Ordered dithering without jitter helps to further minimize residual roughness after ablation. Other more complex dithering approaches may further contribute to minimize residual roughness after ablation.

Laser photocoagulation is one of the most frequently used treatment approaches in ophthalmology for a variety of retinal diseases. Depending on indication, treatment intensity varies from application of specific micro injuries down to gentle temperature increases without inducing cell damage. Especially for the latter, proper energy dosing is still a challenging issue, which mostly relies on the physician’s experience. Pulsed laser photoacoustic temperature measurement has already proven its ability for automated irradiation control during laser treatment but suffers from a comparatively high instrumental effort due to combination with a conventional continuous wave treatment laser. In this paper, a simplified setup with a single pulsed laser at 10 kHz repetition rate is presented. The setup combines the instrumentation for treatment as well as temperature measurement and control in a single device. In order to compare the solely pulsed heating with continuous wave (cw) tissue heating, pulse energies of 4 µJ were applied with a repetition rate of 1 kHz to probe the temperature rise, respectively. With the same average laser power of 60 mW an almost identical temporal temperature course was retrieved in both irradiation modes as expected. The ability to reach and maintain a chosen aim temperature of 41 °C is demonstrated by means of model predictive control (MPC) and extended Kalman filtering at a the measurement rate of 250 Hz with an accuracy of less than ±0.1 °C. A major advantage of optimization-based control techniques like MPC is their capability of rigorously ensuring constraints, e.g., temperature limits, and thus, realizing a more reliable and secure temperature control during retinal laser irradiation.

In this paper, we present a cornea deformation model based on the idea of extending the ‘neutral axis’ model to two-dimensional deformations. Considering this simple model, assuming the corneal tissue to behave like a continuous, isotropic and non-compressible material, we are able to partially describe, e.g., the observed deviation in refractive power after lenticule extraction treatments. The model provides many input parameters of the patient and the treatment itself, leading to an individual compensation ansatz for different setups. The model is analyzed for a reasonable range of various parameters. A semi-quantitative comparison to real patient data is performed.