EXCIMER LASER BASICS

Original Author: Professor Theo Seiler Universittsaugenklinik Dresden Dresden, Germany

The Excimer Laser

Laser Fundamentals

The Excimer Laser

193 nm (ArF) ultraviolet Laser Primarily Non-Thermal
10 - 20 Degree C Temperature Rise

No Collateral Tissue Damage Submicron precision

Laser Ablation Of A Human Hair

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The Excimer Laser

Ablative Photodecomposition
High Energy (6.4 eV) Irradiance
Fluence Measure Of Energy Density

Tissue Ablation Threshold

50 mJ/cm2 Plume After Impact
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The Photoablation Process

laser light hits tissue 10 psec collegen molecule undergoes conformal change bound water heats up 10 nsec molecules break 2 sec fragments are expelled as plasma
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Physical Side Effects

Thermal Damage
*heat diffusion *condensation

Mechanical Damage
*direct damage *repulsive forces

Actinic Damage
*primary radiation *secondary radiation
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Thermal Damages
The travel time of a heat front for 1 micron in corneal tissue is approximately 5 sec Expellation of the 500 C hot ablation products is completed after approximately 1 sec

The excimer laser is a cold laser

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Thermal Damages
The 500 C hot ablation may condensate at the ablation edges and form the pseudomembrane

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Physical Side Effects

Thermal Damage
*heat diffusion *condensation

Mechanical Damage
*direct damage *repulsive forces

Actinic Damage
*primary radiation *secondary radiation
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Mechanical Damages

Direct Damage
Photoablation leads to keatocyte loss (cell death and apoptosis) 100m deep. Repopulation within 6 weeks.

Repulsive Forces
Photoablation products leave the corneal surface with suprasonic speed

Repulsive Forces
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Mechanical Damages

Fast Effects of Repulsion

Pressure transients of up to 100 bar travel through the eye and orbit

Slow Effects of Repulsion

Trampolin oscillations of the cornea may lead to central steep islands

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 Thermal Damage *heat diffusion

*condensation *repulsive forces

Physical Side Effects

Mechanical Damage *direct damage Actinic Damage

*primary radiation *secondary radiation
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Actinic Damages

Primary Radiation
Due to the small penetration depth the 193 nm-light can not reach the cell nucleus (cytoplasmatic shielding)

Secondary Radiation
Secondary radiation has longer wavelengths that can reach the DNA

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Actinic Damages
Due to enzymatic repair the threshold of

mutagenicity of UV-radiation is approximately 10 W/cm2

During a standard PRK, the secondary radiation reaches a level of

approximately 5 W/cm2

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Excimer Laser
Beam Profile
Fluence
Homogeneous Versus Gaussian

Hot Spots

Homogeneous

Gaussian
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Excimer Laser
Broadbeam Lasers

Energy Distribution
Masks, Diaphragms, Rotating Mirrors Smoothness Optical Zones - 2mm To 7mm

0.25 Micron Steps

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Excimer Laser Scanning Lasers

1-2 mm spot Computer controlled delivery Active/Passive tracking Myopic, astigmatic, hyperopic, patterns Custom patterns (topography linked)
Irregular corneas Wavefront guided Prolate ablations
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Excimer Lasers

Summit Apex Plus

VISX Star S2

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Excimer Lasers Scanning

Nidek EC 5000

LaserSight LSX

Autonomous

Technolas 217

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Munnerlyns Formula
Depth (mM)=Diopters/3 x O.Z. Squared As Optical Zone forcreases for Diameter, The Depth Of The Ablation Is Greater To Achieve Any Given Correction
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Excimer Laser
Ablative Depth
Diameter & Depth Per Diopter Diameter 3.00 mm 4.00 mm 5.00 mm 6.00 mm 7.00 mm 8.00 mm Depth 3.0 microns 5.3 microns 8.3 microns 11.9 microns 16.2 microns 21.2 microns
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Excimer Laser
Ablative Depth
6 mm

Depth Versus Correction

100 90 80 Center Depth 70 60 Microns 50 40 30 20 10 0 0 -1 -2 5 mm 4 mm 3 mm

-3 -4 -5 -6 -7 -8 Correction (Diopters)

-9

-10

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Common LASIK Surgeons Error: The excimer is a simple, reliable trouble-free device

Although relatively simple from the outside, the excimer laser is an extremely complex device

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Excimer Laser
Naturally produces dirty beam
requires extensive cleaning

Optical elements damaged by far UV Can cause cold spots, other calibration problems

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Excimer Calibration
Calibration extremely critical
crude assay surgeon needs to know technique

Affected by gas mixture, state of optics, energy level, environment (humidity, temp, perfumes)
Control OR environment

Remember that the refractive results are produced by the laser (the actual refractive surgeon)

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Common Error #2 Instrument Reliability Know the instrument Participate in calibration

multi-user center: good working relationship with laser technician

Standardize environmental conditions in OR Prepare yourself, patient, family for possible cancellation (Bataan Death March) Monitor your results (overRx, Fast Track to LASIK ISRS GLORY

Conclusions
None of the physical side effects of excimer photoablation of the cornea is really dangerous. Endothelial cell damage due to pressure transients as well as resonance oscillations of the eye need to be further investigated.

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Thank you for your kind attention!!!

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