Femtosecond-Laser Assisted Surgery of the Eye: Overview and Impact of the Low-Energy Concept

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Femtosecond-Laser Assisted Surgery of the Eye: Overview and Impact of the Low-Energy Concept micromachines Review Femtosecond-Laser Assisted Surgery of the Eye: Overview and Impact of the Low-Energy Concept Catharina Latz 1,* , Thomas Asshauer 2, Christian Rathjen 2 and Alireza Mirshahi 1 1 Dardenne Eye Hospital, D-53173 Bonn, Germany; [email protected] 2 Ziemer Ophthalmic Systems, CH-2562 Port, Switzerland; [email protected] (T.A.); [email protected] (C.R.) * Correspondence: [email protected] Abstract: This article provides an overview of both established and innovative applications of femtosecond (fs)-laser-assisted surgical techniques in ophthalmology. Fs-laser technology is unique because it allows cutting tissue at very high precision inside the eye. Fs lasers are mainly used for surgery of the human cornea and lens. New areas of application in ophthalmology are on the horizon. The latest improvement is the high pulse frequency, low-energy concept; by enlarging the numerical aperture of the focusing optics, the pulse energy threshold for optical breakdown decreases, and cutting with practically no side effects is enabled. Keywords: femtosecond laser; fs-assisted cataract surgery; laser-assisted ophthalmic surgery; high pulse frequency; low energy Citation: Latz, C.; Asshauer, T.; 1. Introduction Rathjen, C.; Mirshahi, A. Laser technology and ophthalmic surgery have shaped each other over the past Femtosecond-Laser Assisted Surgery 40 years. The optically transparent structures of the eye, namely cornea, lens, and vitreous of the Eye: Overview and Impact of body, allow for delivery of the laser energy at different focal depths, thereby giving access the Low-Energy Concept. to surgical interventions without having to open or mechanically enter the eye (Figure1). Micromachines 2021, 12, 122. Other types of lasers, with various wavelengths, pulse durations, and power levels, interact https://doi.org/10.3390/mi12020122 with eye tissues in a range of different ways. For continuous laser irradiation of low to moderate average power (mW range), photochemical and thermal effects induced by the Academic Editor: Rebeca Martínez absorbed light are the dominant laser–tissue interactions. Depending on the wavelengths Vázquez used, specific types of molecules can be optically excited to trigger chemical reactions, or Received: 15 December 2020 local heating of specific tissue can be achieved. If temperatures above 60 ◦C are reached, Accepted: 18 January 2021 7 Published: 24 January 2021 tissue coagulation will occur. When pulsed laser light with intensities between 10 and 109 W/cm2 interacts with strongly absorbing tissue, near-surface material can be removed Publisher’s Note: MDPI stays neutral explosively. This effect is called “photoablation”. In ophthalmology, it is applied to change with regard to jurisdictional claims in the curvature of the cornea with pulsed UV light from excimer lasers. For shorter pulse 11 2 published maps and institutional affil- durations in the ps to fs range and even higher intensities above 10 W/cm , more exotic iations. interactions can be achieved, as will be explained in detail below. A more comprehensive general overview of laser–tissue interaction mechanisms can be found in excellent quality in several text books [1,2]. The first reported ophthalmic use of short pulse lasers at near-infrared wavelengths was in 1979 by Aron-Rosa, who treated posterior capsule opacification (PCO) after cataract Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. surgery [3]. In 1989, Stern et al. demonstrated that by decreasing pulse width of ultrashort- −9 −15 This article is an open access article pulsed lasers from nano- to femtoseconds (ns: 10 s, fs: 10 s), ablation profiles showed distributed under the terms and higher precision and less collateral damage [4]. At the same time, optical coherence conditions of the Creative Commons tomography developed and provided noninvasive three-dimensional (3D) in vivo imaging Attribution (CC BY) license (https:// with fine resolution in both lateral and axial dimensions at a micrometer level [5]. These creativecommons.org/licenses/by/ developments offered ophthalmic surgeons a tool for high precision cutting and visual 4.0/). control through imaging, and ultimately allowed a gamut of treatment applications for Micromachines 2021, 12, 122. https://doi.org/10.3390/mi12020122 https://www.mdpi.com/journal/micromachines Micromachines 2021, 12, x 2 of 22 Micromachines 2021, 12, 122 2 of 21 cutting and visual control through imaging, and ultimately allowed a gamut of treatment theseapplications lasers within for these the field lasers of ophthalmology.within the field Recent of ophthalmology. changes in the Recent numerical changes aperture in the of thenumerical laser focusing aperture optics of the and laser the focusing repetition optics rate of and the the laser repetition sources haverate of further the laser decreased sources collateralhave further damage decreased while collateral increasing damage precision. while This increasing review articleprecision. gives This an review overview article of thegives technical an overview backgrounds of the te ofchnical femtosecond backgrounds lasers of and femtos OCTecond imaging lasers as and well OCT as imaging clinical applicationsas well as clinical in ophthalmic applications surgery in ophthalmic today. surgery today. FigureFigure 1. 1.Cross-section Cross-section of of the the eye. eye. Cornea, Cornea, crystalline crystalline lens, lens, and and vitreous vitreous body body are are transparent transparent in in the the healthy eye. healthy eye. 2.2. LaserLaser TechnologyTechnology 2.1.2.1. Solid-StateSolid-State LasersLasers inin OphthalmologyOphthalmology 2.1.1. Nd:YAG Laser with Ns Pulse Durations 2.1.1. Nd:YAG Laser with Ns Pulse Durations The first type of short-pulsed laser at near-infrared wavelengths successfully used in The first type of short-pulsed laser at near-infrared wavelengths successfully used in ophthalmology was the Q-switched Nd:YAG solid-state laser. Its wavelength of 1064 nm is ophthalmology was the Q-switched Nd:YAG solid-state laser. Its wavelength of 1064 nm transmitted by all the visually transparent structures in the eye (cornea, lens, and vitreous is transmitted by all the visually transparent structures in the eye (cornea, lens, and body). Their pulse durations are a few nanoseconds (ns), and for ophthalmic applications, vitreous body). Their pulse durations are a few nanoseconds (ns), and for ophthalmic pulse energies in the range of 0.3–10 mJ are typically used [6]. applications, pulse energies in the range of 0.3–10 mJ are typically used [6]. When Nd:YAG laser pulses are strongly focused at a location inside the eye, to spot When Nd:YAG laser pulses are strongly focused at a location inside the eye, to spot sizes in the order of a few microns, the combination of short pulse duration focusing sizes in the order of a few microns, the combination of short pulse duration focusing to to minimal spot sizes creates very high intensities at the laser focus, above 1011 W/cm2. minimal spot sizes creates very high intensities at the laser focus, above 1011 W/cm2. Under Under these conditions, a phenomenon called “optical breakdown” occurs. In the first step,these multiphoton conditions, absorptiona phenomenon leads called to ionization ”optical of breakdown” some tissue molecules,occurs. In the creating first freestep, electrons.multiphoton In the absorption subsequent leads second to step,ionization these “seed” of some electrons tissue absorb molecules, photon creating energy andfree areelectrons. thus accelerated. In the subsequent After repeated second photon step, th absorptions,ese ”seed” electrons electrons absorb reach photon a sufficiently energy high and kineticare thus energy accelerated. to ionize After themselves repeated morephoton molecules absorptions, by impact electrons ionization, reach a sufficiently creating more high freekinetic electrons. energy Ifto the ionize laser themselves irradiation more is intense molecules enough by impact to overcome ionization, electron creating losses, more an avalanchefree electrons. effect If occurs the laser [2]. irradiation is intense enough to overcome electron losses, an avalancheWhen effect the extremely occurs [2]. fast rising electron density exceeds values of approximately 1020/cmWhen3, a “plasmathe extremely state of fast matter” rising (cloud electron of ions density and free exceeds electrons) values is created of approximately at the laser focus1020/cm [2].3, Thisa ”plasma plasma state is highly of matter” absorbing (cloud forof ions photons and free of all electrons) wavelengths. is created Therefore, at the laser the restfocus of [2]. the laserThis plasma pulse is is directly highly absorbedabsorbing by fo ther photons plasma, of increasingall wavelengths. its temperature Therefore, and the energyrest of densitythe laser (Figure pulse 2is). directly absorbed by the plasma, increasing its temperature and energyThe density hot plasma (Figure cloud 2). rapidly recombines to a hot gas, with a thermalization time of the energy initially carried by free electrons of a few picoseconds to tens of ps [7]. This time is much shorter than the acoustic transit time from the center of the focus to the periphery Micromachines 2021, 12, x 3 of 22 The hot plasma cloud rapidly recombines to a hot gas, with a thermalization time of Micromachines 2021, 12, 122 the energy initially carried by free electrons of a few picoseconds to tens of ps [7].3 This of 21 time is much shorter than the acoustic transit time
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