Dr Janet Voke

Lasers and their use

in ophthalmology Part 2
Development of
photocoagulation
The intense light from the sun has been known
for centuries to cause ocular damage. The Roman
fleet are stated as having had solar power
directed at them at the Battle of Syracuse by
Archimedes in 212BC. From the beginning of this
century it was realised that eclipse blindness was
caused largely from the thermal component in
sunlight rather than the visible radiation. In
addition infrared radiation induces thermal
damage when viewing through any optical device.
American work in the late 70s showed that in
fact photochemical damage is the mechanism by
which visible light, particularly short wavelength
blue light, causes injury to the retina of the
unaided eye.
Data on the exposures necessary to produce
burns on retinal tissue come from studies of
victims of the atomic explosions at the end of
World War Two and about this time an
ophthalmologist called Meyer-Schwickerath began
to investigate how photocoagulation might be
used therapeutically for some retinal pathologies.
Using the sun as his light source, he induced
chorioretinal burns around retinal holes in the
first successful attempt to prevent a retinal
detachment in 1949.
In the early 50s commercial efforts were made
to extend such techniques throughout
ophthalmology with the production of the Zeiss
photocoagulator using a high pressure xenon-gas
source to generate the most intense, controlled,
man-made source available at this time.
Meyer-Schwickerath was probably the first
clinician to treat closed-angle glaucoma in the
mid 50s by this technique.
Xenon sources were not ideal for many
reasons. In spite of the relatively high intensity
of the beam which could be generated, it still
requires up to 1.5 seconds to produce an
acceptable burn and because of the pain, the
patient would typically move his eye; a
retrobulbar anaesthetic was thus needed. The
beam projected was too wide for optimum
manipulation. If the pupil could not be dilated to
its extreme the iris was liable to be struck by the
edge of the beam and accidentally burnt.
Controlling the exposure duration was very
hazardous with early instruments and
over-coagulation was typical because a timed
shutter delivering a known amount of energy
could not be incorporated. Instead the operator
had to judge the exposure length of each pulse.
Xenon gas emits across the spectrum from 400 to
1400nm and absorption in the eye is greatest
between 400-600nm and 900-1400nm.
The broad spectrum emission meant that it
was impossible to focus the beam into a small
spot, partly because of the chromatic aberration
of the eye. Treating macular lesions, which
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required very carefully placed small burns, was

therefore a problem. Lastly the most effective
retinal burns for treating pathology, occur
through absorption in the pigment epithelium of
the retina, the choroid and the haemoglobin in
blood vessels. The emission spectrum of xenon
does not coincide with the absorption spectrum
of any of these tissues and infrared primarily is
absorbed in the ocular media so that overheating
of the eye, in general, was a significant hazard.
Laser versus xenon gas instruments

Some Uses of Lasers

Micro-Welding and welding to ships,

aircraft, cars
Conservation of paintings
Paint Removal
Remote sensing
Surveying and Range finding
Material processing
Alignment of pipes and structures
Engraving of metals
eg, numbers or scales or threads to
brittle materials
General and eye surgery
Micro electronics
Monitoring pollution levels in
environment
Meterological applications
Communications and warfare
Planetariums, Discos

When the ruby laser was introduced in 1960, the

potential for its use in treating retinal disease,
replacing the xenon gas sources, was recognised
early. The ruby crystal contains chromium which,
when it absorbs light, brings about at the same
time, energy of a longer wavelength 694.3nm
emitted as the excited electrons return to their
ground or basic state. There is thus very little
absorption in the cornea and lens, which are
virtually protected from damage when the retina
is the focus of attention and there is limited
absorption in the blood vessels too. Melanin
pigment absorbs the red wavelengths well so that
retinal pigment (and some iris pigment too)
absorb well.

LASERS : An Introduction

The ruby laser

A laser beam is a single wavelength,

monochromatic, coherent parallel light
beam usually of high energy.

Wavelengths are measured in

nanometers (nm).
1nm = one thousand millionth of a
metre.

Laser - Light amplification by

stimulated emission of radiation

Laser beams are produced by the

excitation of atoms to a higher than
usual energy state. Coherent
radiation is given out (emitted) as the
atoms return to their original energy
levels.

Continuous wave lasers can give

exposures from a few milliseconds to
several minutes

Q-switched lasers have an exposure

time of less than 100ns and produce
shock waves to the eye

IR pulsed lasers pose greatest threat

to sight being of very short duration
(less than 1ms) with the IR radiation
being invisible to the eye and the
damage often not felt as pain.

The ruby laser, in contrast to the xenon sources

previously used, had a narrow radiation beam so
that it could be directed at an angle through the
pupil with less risk than xenon presented of
damaging the iris.
The pulse length was controlled electrically in
the laser, another benefit over xenon sources.
Typical values of duration were 200-500s.
Patients were no longer able to feel pain with
such brief exposures and this could eliminate the

Diagram to show how a laser beam is transmitted through the transparent sensory
retina and absorbed by melanin pigment. The heat diffuses, burning the rods and cones
and the blood supply underneath

31

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Maximum permissible exposure values for industrial lasers
Laser Output

Exposure conditions +
laser pulse duration

MPE
Eye exposure

Excimer 248nm
(Krypton fluoride)

Single pulse
10 ns pulse duration

Excimer 248nm
(Krypton fluoride)
repetitively pulsed

Table 2
Ophthalmic uses of lasers
Condition

Laser Used

30 Jm
per pulse

Retinal hole, tear

detachment

3 x 104 sec exposure

100 Hz, 10 ns
duration

10 Jm-2
per pulse

Argon
Ruby
Krypton

Diabetic Retinopathy

Argon
Krypton

Helium-cadmium CW
(325nm)

3 104 sec exposure

10 Wm-2

Macular serous and

vascular changes

Argon
Krypton

Argon Ion CW
(514nm)

0.25 sec exposure

25 Wm-2

Rubeosis iridis

Argon
Krypton

Nd;YAG CW

10 sec continuous
exposure

51 Wm-2

Nd:YAG
(normal operation)

single pulse,
1ms duration

0.5 Jm
per pulse

Nd:YAG
(Q switched)

single pulse
0.1 s duration

0.05 Jm-2
per pulse

Nd:YAG Repetitively
pulsed
(mode locked)

3 104 sec exposure

100 Hz, 0.1s
duration

0.0012Jm-2
per pulse

Nd:YAG Repetitively
pulsed
(mode locked)

3 10 4 sec exposure
10kHz, 0.1s
duration

0.0004 Jm-2
per pulse

CO2 CW

10 sec continuous
exposure

1000 Wm-2

need for retrobulbar anaesthesia. The need to

immobilise the eye is still recognised, however,
because when treating retinal areas close to the
macula, any small movement could be
catastrophic, if central vision was damaged.
Ruby laser sources, with their highly
monochromatic beam, make possible destruction
of very small areas on the retina (of the order of
100m in diameter). The argon and krypton lasers
are perhaps more commonly used today, but the
ruby laser still has its place in ophthalmology,
particularly in the Q-switched mode, for example
in treating glaucoma. In the early 70s the
transcleral approach to laser photocoagulation of

-2

Maximum permissible exposure:

Summary
-2

The level of radiation to which under

normal circumstances, persons may be
exposed without suffering adverse effects.
International Standard IEC 825
The MPE is wavelength dependent
between 700nm and 1050 nm and
tends to increase with wavelength for a
given pulse duration.
Over pulse durations of less than about
50 microseconds within the wavelength
range, the MPE level is essentially
constant while, for longer pulse
lengths, the MPE increases as
thermal energy can diffuse out of the
area of power concentration

the ciliary processes was first attempted with the

Q switched ruby laser.
The argon laser

The argon gas source, run as a continuous wave

laser, emits two wavelengths 514nm (green) and
488nm (blue). As such it became ideally suited
for retinal use, since there is good absorption in
the retinal pigment epithelium and the
haemoglobin of the blood. Blue radiation induces
photochemical damage to the retina and the
488nm wavelength can be reduced by
incorporating a green filter to the instrument.
The pigment epithelium is the main desired

site for absorption in diabetic eyes. Blood vessels

in the vicinity are coagulated indirectly through
heat transferred by conduction and radiation, so
that neovascular growth can be restricted and
controlled through this means, particularly in the
treatment of disciform lesions. The coagulation
of vessels occurs by means of the constricting
effect of shrinking scar tissue of the collagen in
and around the vessel walls. Heat is concentrated
in the retinas pigment epithelium and
transferred also to the overlying sensory retina
and the choriocapillaris of the choroid through
the thin membrane of Bruch. The damaged cells
swell as healing of the area sets in as glial cells

Accessible emission limit

Anterior and posterior eye procedures
involving lasers
Eye retinal, choroidal and
macular procedures

Anterior eye
procedures
Laser iridotomy

Retinal holes, tears and

detachments

Uses of laser photocoagulation in the Eye

A

Laser gonioplasty

Diabetic Retinopathy

Laser trabeculoplasty

Rubeosis iridis (panretinal ablation) Laser goniophotocoagulation

Macular serous and vascular
abnormalities

CO2 laser
tubeculostomy/trabeculoscelerostomy

Intraocular tumours

Laser cyclophotocoagulation

32

The maximum permitted level of accessible emitted

radiation for a particular class of laser.

June 29, 2001 OT

B
C

Heat shrinkage causing sealing and obliteration of

blood vessels such as those new vessels seen in
vascular retinopathies and re-shaping of tissue as
in laser gonioplasty or laser trabeculoplasty
Ablation of large areas of hypoxic retina which
might otherwise stimulate neovascular growth
Production of a burn scar which is used to unite
layers of retina and choroid which have
threatened to separate e.g., in retinal detachment.
Burning of holes as, for example, in laser
iridotomy to treat glaucoma

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Laser beam sent

into the eye
from an optical
fibre, focused at
the desired
position in the
patients eye.
Adjusting the
lens enables the
spot size to be
changed and
focused at
different depths.
Viewing lens held to the eye to neutralise the cornea and allow
viewing and positioning of the laser beam on the retina. Both the
peripheral and anterior areas of the retina can be accessed by
reflecting the laser beam from the appropriate mirror.
Absorption/transmission properties of ocular tissues as a function of wavelength
Wavelength range
>300nm
3000nm-1400nm
1400nm-400nm
400nm-300nm
<300nm

Dominant absorption

Partial transmission

Cornea
Lens
Retina
Lens
Cornea

Cornea
Lens, cornea
Cornea

are thought to play a role in filling in for the

damaged tissue. Gial cells help to form the
adhesion of the pigment epithelium to both
the photoreceptor layer of the retina and the
choroid.
Clinicians have to take into account known
anatomical variations in tissue as well as
likely random and largely unknown individual
variations between patients when using laser
sources for therapeutic purposes. One example
is in this retinal site since the retinal pigment
epithelium is not uniformly pigmented
throughout the retina. In the macular region,
the cells are longer and the layer is thicker
with more pigmented granules per cell; hence,
there is the potential for much greater
absorption of laser radiation here. Potentially
larger lesions will result from irradiating the
macula using a controlled power and size of
beam.
One of the disturbing side effects of an
argon source used for retinal problems is the
possibility that blood vessels supplying the
macular region may be unintentionally
destroyed in the process. A further, and this
time unique, potential hazard is important.
The yellow luteal pigment at the macula,
xanthophyll, absorbs the blue 488nm
radiation emitted by the argon source.
The krypton laser

Krypton laser sources emitting 647nm as a

continuous wave have found value to
overcome the absorption difficulties of argon
for retinal ablation. Krypton is poorly
absorbed by blood, because it is a red source,
so accidental coagulation of blood vessels can
be avoided.
Most of the radiation incident on the
pigment epithelium passes through into the
choroid with the luteal macular pigment
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taking little impact. Since long wavelengths

are scattered less than short wavelengths,
there is less overall scatter with krypton than
with an argan laser source. This is a
particularly important consideration where
considerable retinal oedema is present, or
where there are vitreous, corneal or lens
opacification in the eye which would
inevitably increase scatter.

Typical
thresholds
for laser
exposure
Exposure
duration

Lowest
energy/
power
entering the
eye for
observed
damage

8.6J

Energy/
power
entering
the eye
for 50%
probability
for damage

22J

Q-switched ruby

10ns

Long-pulsed ruby

200ls
1.7ms
1.7ms

Q-switched
neodymium

30 ns

1.60J

280J

Long-pulsed
neodymium

600ls

3mJ

4.7mJ

13.5ms
80ms

17mW
14mW

23mW
18mW

He-Ne gas

0.048mJ 0.08mJ
0.5mJ
1.1mJ
0.42mJ 0.5mJ

Anatomical effects

Histolopathological studies demonstrate that

both retinal blood vessels and nerve fibres
adjacent to the vascular tissue in the retina
are damaged with argon laser beams. This is
reduced for krypton sources, although there
is some concomitant destruction of photoreceptor cells as a consequence with the
krypton beams, which is thought to be the
result of absorption by the underlying retinal
pigment epithelium. Within the foveal area
damage to the inner layers of the retina was
considerable with argon beams, while with
krypton only the pigment epithelium showed
damage. Both types of laser cause heat
diffusion to penetrate to the choriocapillaris
producing changes. Damage to the choroid is
noted with krypton beams, unlike argon, and
this is thought to be the cause of reports of
pain which patients often mention following
peripheral ablation in diabetic retinopathy.
It is thought that the yellow line of
krypton at 568nm may also have a valuable
role to play in the clinical photocoagulation
of the retina. It is absorbed by the pigment
epithelium melanin and is well absorbed by
haemoglobin in the blood. However, unlike
the argon laser light, the yellow krypton line
is transmitted well through the macula lutea
pigment and also through the crystalline lens
yellowed by age.

Some typically encountered lasers with

their wavelengths of hazard
Producing blue light hazard to eyes
(400-500nm)
Helium cadmium vapour, krypton
ionised,helium selenium, xenon, cadmium
sulphide, copper vapour.
Emitting IR radiation (700-1000nm)
Cadmium telluride, argon-oxygen, gallium
arsenide, indium phosphide
Emitting IR radiation (1000-2000nm)
Neodymium YAG helium-neon, iodine, heliumcarbon dioxide, erbium, thulium, xenon.
Emitting IR radiation (2000-3500nm)
Xenon, holmium, uranium, helium-neon
Emitting IR radiation beyond 4500nm
Carbon monoxide, carbon-dioxide, helium,
nitrogen-oxide
Emitting UV radiation
Xenon, argon-fluoride excimer, ruby, neonionized, krypton-fluoride excimer, neodymium,
argon-nitrogen, krypton-ionised, argon-ionised

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Pulsed lasers have another feature built into
their aiming system, which is a beam of increased
vergence to reduce damage to tissues that are not
in the plane of focus. This is brought about by
making the beam cone shaped; it is wide as it
leaves the slit-lamp microscope, converging to
about 50m at the point of focus, and thereafter
diverges.
Exposure or pulse lengths

normal iris
and lens

narrow angle of
filtration due to
lens being moved
forward

aqueous movement through

the pupil is impaired causing
iris to buckle forward,
closing drainage channel

surgery to produce a
hole in the iris results
in normal OP
drainage

Laser treatment to the iris to allow better outflow of aqueous

before treatment

After treatment

Corrective laser surgery to open the trabecular meshwork.

A ring of laser shots facilitates outflow of aqueous

The red wavelength lasers, neodymium-YAG,

ruby and krypton, have an advantage of very low
absorption in the cornea and lens, which helps to
avoid damage to those structures. Melanin
pigment absorbs the wavelengths well and so
these lasers have their maximal effect on the iris
and retinal pigment.
Delivering the beam

To send a laser beam into the eye it might be

suggested that all that is needed to focus laser
light onto the retina is to direct the parallel laser
beam at the relaxed eye, which, being
accommodated to infinity, would refract the light
onto a fine spot in the target area. This
arrangement, however, provides for no control of
the size of the spot on the retina, and myopic
eyes would be unable to focus parallel light.
Instead, early laser coagulators tended to be
built in with ophthalmoscopes and the laser
beam was transmitted through one or more
lenses which allowed the operator control of the
focusing.
Nowadays the laser light is coupled by an
optical fibre to a binocular microscope, or the
slit lamp. The laser is usually housed in a
separate box beside the slit lamp and delivered
to the slit lamp by a fibre optic bundle or
articulated arm with mirrors at each joint.
The laser beams may be allowed into the
instrument by positioning a highly reflecting
mirror at 45 between the two microscope
objectives. Fine adjustment may be provided by a

34

June 29, 2001 OT

joy-stick connected to a mirror, which can direct

the beam as required. The laser beam converges
to a focus generally in the plane of examination,
but the spot size on the target may be increased
by defocusing the beam. When examining and
treating the posterior segment of the eye it is
necessary to neutralise the refracting power of
the cornea with a negative lens, and one type
commonly used is the Goldmann three-mirror
contact lens. This is held by the operator in
contact with the anaesthetised eye and various
regions of the retina may be imaged and treated
by utilising the different parts of the lens. The
most posterior region of the retina is viewed and
treated through the centre of the lens. The
peripheral retina and more anterior regions are
reached by reflection from the appropriately
inclined mirror.
The laser produces an attenuated beam for
aiming and, at the command of a foot pedal,
produces a flash of higher energy at the duration
and intensity that had been pre-set by the
operator.
The lasers which are invisible at the infra-red
end of the spectrum, and all the pulsed lasers,
require a separate continuous wave laser for
aiming. The aiming laser should not be too
different in wavelength to reduce errors of
different focal distances caused by chromatic
aberration in the optics of the eye. The
Neodymium-YAG laser uses a helium-neon aiming
beam exactly coaxial with the path along which
the YAG will flash.

Exposure duration is obviously a highly critical

feature affecting the resulting damage and to
some extent how the damage occurs.
Exposure durations range from the exceedingly
brief 10 nanosecond pulse of the neodymium-YAG
to an exposure as long as half a second with a
continuous wave laser, although an exposure of
200 milliseconds is more typically used with
continuous wave systems.
Pulsed lasers, such as the neodymium-YAG
beam, produce an explosive effect which when
photographed by high speed techniques indicates
that shock waves are often generated. On impact
the tissue molecules are broken down to form a
plasma which emits light and UV radiation. Of
course it is not ideal that the effects should
extend to neighbouring areas but, in practice,
this is avoidable.
Damage to the corneal endothelium has been
shown when the YAG laser has been used on the
iris or lens capsule. An accurately focused pulse
of YAG laser energy can produce sufficiently
intense energy concentration to cause plasma
formation and disruption in completely
non-pigmented tissues, such as the lens capsule,
where it is frequently used for capsulotomy in
patients with intraocular lens implants where the
subsequent opacity of the capsule often occurs.
In this case, the capsule ruptures dramatically
and presumably there is some inevitable damage
to the implanted lens material.
Burn sizes

Producing a satisfactory laser burn usually

involves beginning with a low power setting and
judging the power required from observing the
reaction of the retina. The appearance of the burn
will depend upon the degree of pigmentation of
the pigment epithelium and choroid; generally
burns are mild, with a colour varying from yellow
to grey with increasing pigmentation. A white
burn is too intense for most purposes. Spot size
settings can usually be selected from the range
50 to 100m, and are controlled by diverging the
beam with an appropriate lens. This means that
the power should usually be reduced when using
small diameters of burn, otherwise the intensity
of burn may be too great.
As a rule, laser burns are created around
500m (micron) in diameter in the periphery and
smaller in the macular region, say 200m. The
smallest sizes of 50 to 100m may be used for
treating subretinal vessels near the fovea, when
opacities such as haemorrhage in the vitreous
may attenuate the beam. Care must be taken with
spot sizes of less than 200m if power settings of
more than 500mW are used, because there is then
a danger of damage to the cornea since the beam
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diameter, as it passes through the cornea, will be

small and so the corneal irradiance will be
correspondingly high.

Retinal uses of lasers

Tears, holes or detachment

The retina is vulnerable to developing a small tear

or hole in the periphery, since the pigment
epithelium layer of the retina and the sensory
part containing the photoreceptors have a
potential space between them. Any force that
might tend to separate them, such as head
trauma or even refractive dynamics, in extreme
cases, can be a potential cause. Often a small
area of degenerating retina in the periphery can
progress towards a hole or tear and fluid may
accumulate in this area. This sequence of events
does not make separation or detachment
inevitable, but if the vitreous humour drags on
the torn retina when the eye moves as a normal
course of events, more fluid can seep in and
detachment is more probable.
The patient may not, at first, experience any
great change to vision, for the detached retina
may be nourished sufficiently by the underlying
fluid to function reasonable well for a time.
However, if untreated, the detachment eventually
becomes total, and blindness is inevitable.
Surgery can now be avoided by prophylactic
treatment of holes or tears or obvious peripheral
retinal degeneration which requires setting up an
adhesive scar between the pigment epithelium
and the sensory retina. The scar may also involve
the choroid. The hole or tear is encircled with a
ring of interrupted laser lesions, placed in the
normal retina around the break. This seals off the
threatening tear and prevents separation from
extending.
Generally the laser lesions are created several
rows wide to ensure good adhesion. Typically
their size will be between 500 and 1000m
(microns). While this may seem alarmingly large,
one must remember that this is the peripheral
retina and vision will not be greatly compromised.
The usual power is 500mW for exposure durations
of 0.2-0.5s.
When the treatment area is in the peripheral
retina, pigmentation will be lower than towards
the posterior, and a correspondingly greater level
of power will be needed for effective lesions.
Provided that treatment is given early, the
prognosis for laser treatment of retinal holes and
tears is good. If the tear has proceeded to retinal
detachment, the detachment should be
completely walled off to the ora serrata with
photocoagulation spots.
Diabetic retinopathy

Degenerative changes in the retinal capillaries

result as a consequence of well established
diabetes mellitus. Most commonly, the blood
vessels are liable to leak, haemorrhage and/or
develop microaneurysms. A smaller proportion of
diabetics have proliferative changes which involve
new blood vessel formation, usually at the optic
disc and in the peripheral retina. It is thought
that low retinal oxygen tension might contribute
to this proliferation as existing vessels dilate.

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The danger is then of massive haemorrhage of

these poorly formed, fragile vessels, and possibly
traction on the vessels by the vitreous body,
leading to retinal detachment.
Originally, proliferative retinopathy was
treated by coagulating the new vessels directly,
but this carries with it the risk of haemorrhage
and vitreo-retinal traction.
About forty years ago a new technique was
explored to treat this problem using widespread
laser ablation (panretinal) of a large area except
the macular, optic nerve and the far peripheral
anterior region. This followed observations that
diabetic retinas frequently escape neovascular
changes if they have already experienced an
unrelated degenerative change. The result did
reduce the tendency towards neovascular changes.
While originally attempts were made to ablate
the retinas with just a few hundred laser burns, to
err on the side of caution, the approach recently
is to make several thousand lesions per eye.
Treatment is best spread over several sessions
some days apart for optimum result. Typically the
burns are around 200m in diameter near the
posterior pole and up to 500m further out in the
peripheral retina. Ideally they should almost
touch each other and be of moderate intensity.
Lasers of between 100 and 400mW are used,
ablating for 0.1 to 0.2 seconds. The skill of
knowing how much and for how long lies largely
in the degree of local pigmentation observed, but
ease of viewing will obviously depend on how
easy it is for the clinician to see through the
ocular media. Normally abnormal vessels are not
attached directly, at least first. These vessels will
normally reduce once a dose of laser treatment
has begun. At a second session, however,
macroaneurysms, neovascularisations and grossly
leaking blood vessels in the paramacular region
can be directly ablated.
Surprisingly, perhaps, the effect on vision of
such widespread coagulation is relatively slight,
probably because the mild burns leave the inner
nerve layers of the retina undamaged. Usually only
a general, mild constriction of the field of vision is
found, along with a decrease in night vision and a
loss of vividness in colour vision. In the light of
the considerable success of panretinal
photocoagulation for diabetic retinopathy, such
side effects must surely be an acceptable
consequence of treatment.
Patients with non-proliferative diabetic
retinopathy usually undergo focal photocoagulation
to seal leaking capillaries or even destroy them
completely. Intraretinal oedema can also be helped
with this technique. Where panretinal treatment in
proliferative cases has not given the desired result
this approach can also be useful. It is always
important to ensure that in the macular region
laser shots are aimed further out than half a disc
diameter from the fovea.
Rubeosis iridis

This condition often accompanies an ischaemic

retina where retinal vein occlusion may have
occurred, for example. Panretinal ablation using
the argon, krypton red and yellow or dye lasers
can be helpful, otherwise there is a threat to the

blood supply to the trabecular meshwork and

glaucoma as a consequence. Regression of vessels
in the surface of the iris and in the angle of the
anterior chamber occurs.
Macular serous and
vascular abnormalities

Photocoagulation using the argon, krypton red

and yellow wavelengths or dye laser is helpful in
cases of serous detachment of the pigment
epithelium or the photosensitive sensory layer of
the retina containing the rods and cones.
The choriocapillaris shows abnormalities and
fluid can gain entry and accumulate between
either the pigment epithelium and Bruchs
membrane, or between the pigment epithelium
and the sensory retina, or both.
Where the area is small, say, of less than two
disc diameters, coagulation will not usually be
attended. For larger detachments though, vascular
changes can occur and laser photocoagulation is
a valuable means of therapy. Serous detachment
is usually corrected by using spot sizes of 200m
from each other, providing they are not close to
the fovea. Typical intensities are between 100
and 200mW for durations of 0.1 seconds.
Clinicians are aware that in cases of central
serous retinopathy where the sensory retinal layer
has become detached from the pigment
epithelium recovery often occurs naturally
without treatment after six to eight weeks.
Treatment would only normally be attempted if
there is obvious leakage of fluid or the problem
does not readily resolve of its own accord. Low
intensity burns of around 50-200m might then
be used. Leakage probably occurs as a
combination of the swelling of the pigment
epithelial cells and scar production as a result of
damage to the choriocapillaris. Absorption of the
remaining fluid will normally follow quickly and
visual acuity is largely restored.
Where there is no evidence of structural
retinal damage and VA is 6/12 or better it is
often not necessary to ablate since there is no
evidence that laser photocoagulation helps.
Using argon laser treatment to improve
patients with vascular disciform macular lesions
has not always been useful and complications
such as a fibrosis of the retinal layer can occur.
The choice of laser for vascular disciform
macular lesions is the krypton red laser. This
beam is transmitted well to the choroid and so
the choroidal blood vessels are effectively sealed.
Argon blue-green beams do not penetrate so well.
Haemoglobin present in the red blood cells means
that accidental damage to a vein or arteriole are
unlikely since there is low absorption of the red
wavelengths. The yellow luteal pigment in the
macular region also transmits the krypton beam.
Other vascular retinopathies, which may be
treated by laser, include Eales disease and sickle
cell retinopathy (using argon, krypton and yellow
and dye lasers), where peripheral new vessels can
be obliterated directly with few complications
because of their location. Some retinal conditions
exhibit exudative characteristics where yellowwhite deposits are found, as in Coats disease,
and these may threaten vision. These areas may

35

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t
be tackled by laser coagulation (argon, krypton
yellow, dye) not directly, because of the high
reflectivity of the exudate, but by treating the
surrounding retina.
Parasitic infections and tumours

The potential exists to seal off an area of the

retina infiltrated by a parasitic infection or a
retinal melanoma confining the area of pathology
to prevent spreading and infiltrating further. Very
early retinoblastomas, malignant melanomas and
certain secondary metastatic tumours of the
choroid can benefit from this technique,
frequently reducing the need for surgery or
resorting to enunciation.
Often though, established intraocular
tumours are not usually helped by argon laser
photocoagulation. Xenon arc photocoagulation is
often more successful. Argon laser treatment can
be of some use in obliterating the blood supply
to the tumour by placing intense spots around
the tumour border. One rare, benign tumour
against which laser treatment can be effective is
a choroidal haemangioma. Xenon arc therapy is
often preferred because of the deeper
penetration of the red and infrared radiation
compared with the argon wavelengths. Once the
haemangioma has been separated from a
malignant melanoma, the leaking tumour is
isolated from its surroundings rather like a
peripheral retinal hole is treated by walling it off
from the healthy retina around it. Generally
though surgery, or radiotherapy is needed to
tackle these tumours.

36

June 29, 2001 OT

Retinal vein occlusion

Laser photocoagulation has a role to play in

other more isolated and often acute, retinal
conditions. The most common of this range is
retinal vein occlusion. The cause may be a
thrombosis, or external compression perhaps
from a nearby diseased artery or damage to the
retinal vein itself. When the central retinal vein
is involved all the veins leading into it are
affected and oedema, haemorrhage and
ischaemia usually occur with the patient noticing
considerable central visual loss. It is following
this sequence of events that neovascularisations
may arise, and rubeosis iridis could follow as the
new vessels affect the arterior chamber of the
eye and the outflow of aqueous is compromised.
This can be a precursor for an acute attack of
glaucoma. Although argon or krypton red or
yellow or dye laser treatment to the peripheral
retina will not usually bring back vision, it may
nevertheless reduce the likelihood of rubeosis
iridis and a very painful eye.
Prognosis may be better if only a branch vein
of the central vein has become occluded. In this
case, retinal oedema can be helped by placing
laser spots close to the fovea with 200m size
shots to prevent new vessels forming.
Unwanted retinal damage from lasers

Finally it is worth considering the effects of

inadvertent damage to the retina from laser
exposures, which arise in situations involving
industrial exposures when suitable eye protectors
are not worn.

Damage to the retina from UV laser exposure

produces most changes to the outer retinal layers
with only minimal or moderate retinal pigment
epithelial change. Photoreceptors are thinned
initially and eventually destroyed over a period of
weeks following the exposure. There is clearly a
latent period over which damage occurs. In a
study by Schmidt and Zuclich (1980), it took a
high exposure level of 3.8J/cm2 for four seconds
for damage to be seen just one hour later. The
inner segments of the photoreceptors showed
most change. In the monkey the lowest energy
which caused a lesion seen with the light
microscope was 0.15J/cm2 for 0.8 seconds.
Damage was seen in the inner and outer
segments of the photoreceptors and their nuclei
and over this period a dark pigmented picture
builds up in the retina, when viewed with the
ophthalmoscope. The exact cause of this change
is not well understood. It could be that the loss
of retinal tissue eroded by the laser but retention
of most of the pigment epithelium highlights this
appearance; the damage is wavelength related.

About the author

Janet Voke PhD is a visual scientist who
has played an active part in industrial
vision in recent years.

Part 3
Part 3 of this series will be published on July 27.

www.optometry.co.uk