Unit 11 Laser and its medical applications

1. Summary about atoms

• Atom is the smallest building block of matters, including body tissue and fluids,

• it is electrically neutral
• it contains three elementary
particles: the electron , the
proton, and the neutron. The
electron has a negative charge
(e=-1.6x10-19 C), the proton has a
positive charge (+e=-1.6x10-19 C),
the neutron is neutral.
• electrons make circular motion
around the nuclei in different level of orbits, called stationary orbits, they correspond to
different energy levels.
• the number of electrons is equals to the number of protons in an atom,
• a nucleus counts for vast majority of the atomic mass.
• The so-called atomic number (Z number) is the proton number (also electron number) in
an atom. Ions are formed when atoms obtained extra electrons or loose electrons.

2. Light emission
2.1 absorption and emission of light
From atomic model, we know that:
• These orbits differentiate them each other by different level of energy. The energy change
between orbits cannot be continued but rather quantized.
• We can display the these electron orbits schematically using an energy level diagram: energy
is plotted vertically with the lowest (n=1) , or ground stat, at the bottom and with exited
states (n=2, 3,4,…) above. n is called orbit number and can be only positive integer.

• The electron can absorb energy and promoted to a higher level, the process is called
excitation. A photon is emitted when an electron change from a higher orbit to a lower orbit
with a characteristic emission spectrum. This process is called de-excitation. The “Neon
light” is lights emitted in the glass tubes during an excitation and de-excitation processes:
the gases are excited by external electric energy and different color of lights are emitted
by de-excitation process.
• If an atom absorbs a photon, an electron jumps from a lower orbit to a higher orbit with a
characteristic absorption spectrum.

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• Atom will absorb and emit light photons at particular wavelength corresponding to the
energy differences between orbits. The wavelength λ of emitted or absorbed photon can be
obtained by the formula:
hc
∆E = = hf
λ
where E is the change in energy between the initial and final orbits. Every element has
its own characteristic pattern of frequencies, therefore atomic emission or absorption
spectra (atomic spectroscopy) are the fingerprint of the chemical element. A variety of
biological molecules have notable absorption spectra in the visible, IR, and UV. This has
many clinical applications, e.g. Oximeter.

3. How lasers work

3.1 Stimulated emission
The word "laser" stands for "light amplification by stimulated emission of radiation."

Lasers are possible because of the way light interacts with electrons. Electrons can be bumped
up to higher energy levels by the injection of energy-. The low orbit electrons can be excited to
higher orbit levels by the injection of energy-for example, by a flash of light, flow of electric
current.

An excited electron may gives off a photon and decay to the ground state by two processes, one
process called spontaneous emission. Examples: incandescent light bulb, they emit photons with
different energies and in all directions.

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 E2 E2 E2
Incoming
photon

E1 E1 E1 Emitted
photon

Absorption Spontaneous emission Stimulated emission

A second process: the excited atoms can interact with a pre-existing photon that just happens
to be passing by. If the incoming photon has the energy just equal to the energy difference
between two states, it induces the electron to decay and gives off a new photon. This process is
called stimulated emission.

3.2 Optical pumping

In order the second process prevails the first in an atom; many electrons must be previously
excited and held in an excited state without massive spontaneous emission: this is called
population inversion. The process is called optical pumping. The process of optical pumping is can
be illustrated by the example of a ruby laser.

The ruby laser was the first laser invented in 1960. Ruby is an aluminum oxide crystal in which
some of the aluminum atoms have been replaced with chromium atoms. Chromium gives ruby its
characteristic red color and is responsible for the lasing behavior of the crystal. Chromium
atoms absorb green and blue light and emit only red light.

In a ruby laser, a crystal of ruby is formed into a cylinder. A fully reflecting mirror is placed on
one end and a partially reflecting mirror on the other. A high-intensity flash lamp is spiraled
around the ruby cylinder to provide energy that triggers the laser action. The green and blue
wavelengths in the flash excite electrons in the chromium atoms to a higher energy level.

• Only those perpendicular to the

mirrors will be reflected back to
the active medium, They travel
together with incoming photons in
the same direction, this is the
directionality of the photon.

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• The second photon has the same energy, i.e. the same wavelength and color as the first –
laser has a pure color
• It travels in the same direction and exactly in the same step with the first photon – laser is
in phase or temporal coherence

Comparing to the conventional light, a laser is

differentiated by three characteristics. They
are:
• pure color,
• temporal coherence,
• directionality.

Directionality

Keep pace:
temporal
There are many types of lasers, including
coherencesolid-

state, gas, semiconductor, or liquid. The ruby laser is

a solid-state laser. Solid-state lasers provide the highest output power of all laser types.

3.3 Laser power and intensity

The amount of energy output by laser depends up both the power and intensity (or power
density) of a laser emission.

The power P is a measure of energy transfer rate; it depends on the energy carried by
each individual photon (given by wavelength) and the amount of photons emitted in a unit time.

Total energy output (J)

Power(W) =
exposurte time (s)

The total energy E during a exposure time TE can computed by E (J) = P(W) x TE(s),
where the unit of power is Joules/s or W.

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Sample problem: A 5 mW He-Ne laser outputs red light with wavelength at 633 nm. Calculated
the numbers of photons emitted per second.
Solution: Power is just energy per second of the radiation, so if we get the energy of the photon
from E=hc/λ , then we get the numbers of photons.
The energy of the photon with 633 nm wavelength is:
−9
E=hc/λ =(6.63x10-34 J-s x 3.0x108m/s)/λ =(6.63x10-34 J-s x 3.0x108m/s)/633x10 m=3.16x10-19J
0.005 J / s
So the number of photons per second is: −19
= 1.6 ×10 16 photons/s
3.16 ×10 J

The amount of photons encountered by a particular unit area in a unit time is measured by
the intensity (or power density). For an area illuminated, the relation between the power and
intensity can be expressed by:

Power (W)
Intensity (W/cm 2 ) =
spot area (cm 2 )

The directionality of laser beam offers a great advantage

over ordinary lights since it can be concentrate its energy
onto a very small spot area. This is because the laser rays
can be considered as almost parallel and confined to a well-
defined circular spot on a distant object. Thus even a small
power of laser can achieve high intensity.

Sample problem: we compare the intensity of the

light of a bulb of 10W and that of a laser with output
power of 1mW (10-3 W). For calculation, we consider an
imagery sphere of radius R of 1m for the light
spreading of the bulb, laser beams illuminate a spot of
circular area with radius r of 1mm. Then:
Pbulb 10W 10W
I bulb = = = = 8 ×10 −5W / cm 2
A 4πR 2
4π (100 cm ) 2

and
Plaser 10 −3W 10 −3W
I laser = = = = 3 ×10 −2 W / cm 2
A πr 2 π (0.1cm ) 2
I laser 3 ×10 −2W / cm 2
= ≈ 400
I bulb 8 ×10 −5W / cm 2

The intensity of a surgical laser determines how much light energy a body cell would encounter in
a unit time illuminated by the laser. This determines the laser‘s effectiveness for surgery or
therapy. On the other hand, Fluence, F is defined as the total energy delivered by a laser on a
unit area during an expose time TE,

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 F(J/cm2)=I(watts/cm2)xTE(s)

This can be thought as a dose of light energy delivered to region on a unit area.

Another advantage of the directionality of a laser is that laser light can be focused down to a
extremely small spot with a lens, this is because that a perfect parallel beam can be focused into
a single point at the focal point. So, extremely high intensity can be obtained with a laser beam.
Then away from the focal point, the laser light diverges and spreads out and corresponding
intensity decreases. This property can be used to vary the intensity of a laser by 100~10000
times.

f
Incoming
parallel ray

Focused spot
Diverged beam

3.4. CW laser vs. pulsed lasers

Laser has two modes of operations: continuous wave (CW) or pulsed mode. A CW laser has a
constant power output during whole operation time; while a pulsed laser emits light in strong
bursts, or pulses periodically with no light emitted in the intervals between bursts.

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The energy emitted in each bursts, Epulse, and the pulse width tw, are known for each laser. The
instantaneous power Pi can be calculated as
E pulse
Pi =
tw

The tw may vary from milliseconds (1ms=10-3 s) to femtoseconds (1fs=10-15s), but typically at
nanoseconds (1ns=10-9s).

In pulsed lasers energy is stored up and emitted in a very short time, this results in a very high
power during a brief time tw. Two ways to achieve this energy storage and delivery:
• Q-switching: an optical technique to compress the laser output into 10 to 20 ns.
• Mode-locking: a technique further compress the laser into a shorter pulse of 10 to 40 ps
(1ps=10-12s).

In fact the average power delivered by a pulsed laser is very low because in between pulses no
energy emitted. The average power Pave can be obtained by

E pulse
Pave == E pulse ( J ) × R ( Hz )
T
Where R is the repetition rate, i.e. the number of pulses per second, so the repetition rate is
related to the pulse period by R=1/T.

Examples: A pulsed laser emits 1 milliJoule (1mJ=10-3J) energy that lasts for 1 ns, if the
repetition rate R is 5 Hz, comparing their instantaneous power and average power.
E 1mlliJoule 10 −3 J
Pi = pulse = = −9 = 10 6W
tw 1ns 10 s
E pulse
Pave = = E pulse ( J ) × R ( Hz ) = 10 −3 J × 5 Hz = 5 ×10 −3W
T

The instantaneous power determines the intensity for heating during instance, while average
density determines the fluence during a total time of operation.

4. Mechanisms of laser interaction with human tissues

In order to understand how to choose correctly a laser for application purpose, we need to
understand further how laser light interacts with body tissue.

When a beam of laser projected to a body tissue, basically fives phenomena happens, they are
reflection, transmission, scattering, re-emission, and absorption.

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When a laser beam hits the target, it may be
(a) absorbed, reflected and scattered or
(b) transmitted, re-emitted

Laser light interacts with tissue and

transfers energy of photons to tissue
because absorption occurs.

In most cases, the photons energy of laser light is

transferred to blood, tissues or bone in the form of
heat.

4.1 Photocoagulation
A slow heating of muscle and other tissues is like a cooking of meat in everyday life. The heating
induced the destabilization of the proteins, enzymes, etc. This is also called coagulation. Like
egg whites coagulate when cooked, red meat turns gray because coagulation during cooking.
Proteins are body’s most important structural and functional chemicals. They form the muscles,
connecting tissues and blood vessels, they transport oxygen necessary for the metabolism. When
temperature is much higher than the body temperature, proteins are destabilized: their complex
structures begin to uncoil and losing their natural order and forming dense tangled network.

A Laser heating above 50 oC but below 100oC induces disordering of proteins and other bio-
molecules, this process is called photocoagulation.

When lasers are used to photocoagulate tissues during surgery, tissues essentially becomes
cooked: they shrink in mass because water is expelled, the heated region change color and loses
its mechanical integrity and can be moved or pull out, cells in the photocoagulated region die and
a region of dead tissue called photocoagulation burn develops.

Application: destroy tumors, treating various eye conditions like retinal disorders caused by
diabetes. Photocoagulation also accounts for laser surgery’s excellent hemostatic property -
blood less incision, excision, due to its ability to stop bleeding during surgery. A blood vessel
subjected to photocoagulation develops a pinched point due to shrinkage of proteins in the
vessel’s wall. This coagulation restriction helps seal off the flow, while damaged cell initiate
clotting.

4.2 photo- vaporization

With very high power densities, instead of cooking, lasers will quickly heat the tissues to above
100o C , water within the tissues boils and evaporates. Since 70% of the body tissue is water,
the boiling change the tissue into a gas. This phenomenon is called photo-vaporization.
Photo- vaporization results in complete removal of the tissue, making incision or complete
removal of thin layer of tissue possible. Due to coagulation around the edges of the heated
tissue, bloodless operation is possible.

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Two conditions must be met in order that photo-
vaporization possible,
1. the tissue must be heated quickly to above
the boiling point of the water, this require
very high intensity lasers,
2. a very short exposure time T , so no time for
E

heat to flow away while delivering enough

energy,

For condition 1, the advantage of lasers over other

light sources is their highly spatial coherence
(directionality) and can provide higher intensities
over conventional lamp.

In practice, we can either vary the laser spot size

or the laser power to change the intensity of the
laser to achieve various laser intensities.

Powers density (intensity) required for different

processes.

Power density (W/cm2) Results

Low (<10) General heating
Moderate (10 – 100) Photocoagulation
High (>100) Photo-vaporization

For condition 2, a short exposure time TE is important because during heating, a competing
process called thermal relaxation also occurred. The thermal relaxation time TR is the time for
thermal energy flow away from heated region. In order to control the heating within the
targeted area, TE should be smaller than TR, while sufficient energy should be supplied by the
laser within a short time. This can be achieved only with high power density pulsed lasers.

4.3 Photochemical ablation

When using high power lasers of ultraviolet wavelength, some chemical bonds can be broken
while without causing local heating; this process is called photo-chemical ablation.

The photo-chemical ablation results in clean-cut incision. The thermal component is relatively
small and the zone of thermal interaction is limited in the incision wall.

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5. Selective absorption of laser light by human tissues
Selective absorption occurs when a given color of light is strongly absorbed by one type of
tissue, while transmitted by another. Lasers’ pure color is responsible for its selective
absorption by body tissues. This selectivity provides a handle for laser surgery and therapy.

Each type of tissue has its specific absorption characteristics depending on its components, and
the main absorbing components of tissues are:
• Hemoglobin (in blood): the blood’s oxygen carrying protein, absorption of UV and
blue and green light,
• Melanin (a pigment in skin, hair, moles, etc): absorption in visible and near IR light
(400nm – 1000nm),
• Water (in tissues): transparent to visible light but strong absorption of UV light
below 300nm and IR over 1300nm

Absorption spectrum for

hemoglobin and melanin.

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6. Applications of lasers

6.1 General purpose: surgery: incision, ablation, coagulation

• CO2 laser operating at 10.6 mm in the far – infrared region, most effective for
incision while minimizing bleeding.
• Tissue at the focus plane of the laser is subject to high irradiance and being ablated
for incision, while by defocusing, coagulation can be made.
• The Nd:YAG laser operates at 1.064mm in the near infrared and employed where
heavy tissue coagulate is desired, electrocautery is replaced by laser now.

6.2 Lasers in beauty therapy

• Skin rejuvenation: IR lasers are used to remove extremely thin layer of skin (<0.1
mm). In the absence of pigment in general, they take advantage of the presence of water
in the skin to provide an ability to remove skin and body tissue.
• Hair removal: here selective absorption with absorbing component being melanin
pigment in hair and follicle, it is best worked with a red light ruby laser. White hair can
not be treated with any laser due to the lack of absorbing component.
• Port-wine stains: this is made with a yellow dye pulsed laser 585nm. It corresponds
to the peak absorption of the hemoglobin.

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 • Tattoo Removal: tattoo can be removed with variety of laser depending on the
absorption of the ink in the tattoo.
All these applications are based on the selective absorption and photo-vaporization of the
treated components and in general pulsed lasers are used.

6.3 Lasers in ophthalmology

Visible light is transparent to the cornea and crystalline lens, and can be focused with eye’s
lens on the retina. So for retina operation, visible laser can be used. The most popular visible
laser is the green argon laser.

• Treatment of glaucoma: due to excess pressure builds up. Argon laser is focused
externally on iris to make incision, creating drainage holes for excess aqueous humors
• Diabetic retinopathy: inadequate blood supply to the retina due to diabetes. Small
photocoagulation burn by green argon laser to repair the retina due to vessels leakage.
• Retina tear: photocoagulation burn to repair retina tears due to trauma to the head.

UV light emitted by the excimer laser is strongly absorbed by water and proteins, so their
energy can be absorbed by transparent cornea and lens, permitting laser surgery on these
areas.

• Cataracts: a milky structure in the lens of the eye. Photo-vaporization by using UV laser
to remove the obaque regions.
• Correction of myopia: over focusing of the lens. Excimer laser removal of surface of
cornea to make it flatten.

7. Laser hazards and protections

7.1 Hazards to the eye
The retina
The directionality of a laser beam permits the ray to be focused to an extremely small spot on
the retina. A collimated laser will be concentrated by a factor of 100,000 when passing from
cornea to retina. So Visible or near IR lasers (400 nm to 1400nm) are particularly dangerous
to the retina and always requires eye-protection when working with these kind of lasers.

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The cornea and lens
• Cornea is accessible to danger of UV and most of IR lasers,
• UV-A, UV-B (between 295nm and 320 nm) and IR-A (between 1 to 2 mm) are dangerous
for lens,
• 308-nm (UV-B) excimer XeCl laser is particular dangerous because of it can
simultaneously damage the lens, the cornea and the retina.

Eye protection
Eyewear (goggles) is the most common laser protective measure, especially for open laser beams.
It should be good design with all around shielding and adequate visible light transmission.

Identification of the eyewear : All laser protective eyewear shall be clearly labelled with
information adequate to ensure the proper choice of eyewear with particular lasers.
Required optical density (OD)

7.2 Hazards to the skin

Unless for high power laser, the skin is less vulnerable to laser hazards than is the eye, because
that skin is rarely at the focal point of the laser spot.
Skin protection
•Skin protection is normally not required with the use of most non-UV lasers
•With the use of UV lasers, ordinary street -wear or surgical gowns would normally provide a
protective factor of 1000,
•Gloves will provide sufficient protection too.

7.3 Laser classification

Class I -Exempt from laser control measures
Lasers are incapable of producing damaging radiation levels, no control measures are required,
including the use of warning labels, Good practice and good common sense dictate that
unnecessary and prolonged gazing at the laser beam must be avoided.

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Class II - Low power laser
CW Lasers of output less than 1 mW, incapable of causing eye injury accidentally, but can
produce retinal injury with continuous intra-beam viewing.
Control measures:
• avoid staring at the beam for a long time.
• "caution" label should be placed prominently on the laser housing and/or control panel.
Class III (a) - Medium Power laser
CW Laser (visible) of output up to 5 mW, incapable of injuring the eye within the duration of the
blink or aversion response (0.25 second). Injury is, however, possible using binoculars or similar
optical devices, or by continued staring at the beam.
Control measures:
•warning label should be placed prominently on the laser housing and/or control panel.
•suitable engineering controls should be adopted.
•suitable administrative controls should be adopted.
•wearing protective eyewear and introduction of the laser control area are advisable.
Class III b - Medium Power laser
Lasers output in any part of spectrum (200nm to 1mm), CW power up to 500mW. Capable of
causing accidental injury to the eye if the beam is viewed directly from a specular reflection.

Control measures:
•warning label should be placed prominently on the laser housing and/or control panel.
•suitable engineering controls should be adopted. .
•Suitable administrative controls should be adopted.
•Wearing protective eyewear and introduction of the laser control area are advisable

Class IV – High power lasers : CW power > 0.5 W

All viewing is hazardous. Risk of skin burns. Extreme caution essential.

Most of medical lasers are class 4 lasers.

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 Optional reading : Oxymetry

A oximeter displays the percentage of arterial

hemoglobin in the oxyhemoglobin configuration.
Acceptable normal ranges are from 95 to 100
percent.

A pulse oximeter is a particularly convenient non-

invasive measurement instrument. Typically it has
a pair of small light-emitting diodes facing a
photodiode through a translucent part of the
patient's body, usually a fingertip or an earlobe.
One LED is red, with wavelength of 660 nm, and
the other is infrared, 910 nm. Absorption at these wavelengths differs significantly
between oxyhemoglobin and its deoxygenated form, therefore from the ratio of
the absorption of the red and infrared light the oxy/deoxyhemoglobin ratio can be
calculated.

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