Laser eye surgery

The invention: The first significant clinical ophthalmic application
of any laser system was the treatment of retinal tears with a
pulsed ruby laser.
The people behind the invention:
Charles J. Campbell (1926- ), an ophthalmologist
H. Christian Zweng (1925- ), an ophthalmologist
Milton M. Zaret (1927- ), an ophthalmologist
Theodore Harold Maiman (1927- ), the physicist who
developed the first laser
Monkeys and Rabbits
The term “laser” is an acronym for light amplification by the
stimulated emission of radiation. The development of the laser for
ophthalmic (eye surgery) surgery arose from the initial concentration
of conventional light by magnifying lenses.
Within a laser, atoms are highly energized. When one of these atoms
loses its energy in the form of light, it stimulates other atoms to
emit light of the same frequency and in the same direction. A cascade
of these identical light waves is soon produced, which then oscillate
back and forth between the mirrors in the laser cavity. One
mirror is only partially reflective, allowing some of the laser light to
pass through. This light can be concentrated further into a small
burst of high intensity.
On July 7, 1960, Theodore Harold Maiman made public his discovery
of the first laser—a ruby laser. Shortly thereafter, ophthalmologists
began using ruby lasers for medical purposes.
The first significant medical uses of the ruby laser occurred in
1961, with experiments on animals conducted by Charles J. Campbell
in New York, H. Christian Zweng, and Milton M. Zaret. Zaret and his
colleagues produced photocoagulation (a thickening or drawing together
of substances by use of light) of the eyes of rabbits by flashes
froma ruby laser. Sufficient energy was delivered to cause immediate
thermal injury to the retina and iris of the rabbit. The beam also was directed to the interior of the rabbit eye, resulting in retinal coagulations.
The team examined the retinal lesions and pointed out both
the possible advantages of laser as a tool for therapeutic photocoagulation
and the potential applications in medical research.
In 1962, Zweng, along with several of his associates, began experimenting
with laser photocoagulation on the eyes of monkeys
and rabbits in order to establish parameters for the use of lasers on
the human eye.
Reflected by Blood
The vitreous humor, a transparent jelly that usually fills the vitreous
cavity of the eyes of younger individuals, commonly shrinks with age,
with myopia, or with certain pathologic conditions. As these conditions
occur, the vitreous humor begins to separate from the adjacent
retina. In some patients, the separating vitreous humor produces a
traction (pulling), causing a retinal tear to form. Through this opening in
the retina, liquefied vitreous humor can pass to a site underneath the
retina, producing retinal detachment and loss of vision.
Alaser can be used to cause photocoagulation of a retinal tear. As a
result, an adhesive scar forms between the retina surrounding the
tear and the underlying layers so that, despite traction, the retina
does not detach. If more than a small area of retina has detached, the
laser often is ineffective and major retinal detachment surgery must
be performed. Thus, in the experiments of Campbell and Zweng, the
ruby laser was used to prevent, rather than treat, retinal detachment.
In subsequent experiments with humans, all patients were treated
with the experimental laser photocoagulator without anesthesia.
Although usually no attempt was made to seal holes or tears, the
diseased portions of the retina were walled off satisfactorily so that
no detachments occurred. One problem that arose involved microaneurysms.
A“microaneurysm” is a tiny aneurysm, or blood-filled
bubble extending from the wall of a blood vessel. When attempts to
obliterate microaneurysms were unsuccessful, the researchers postulated
that the color of the ruby pulse so resembled the red of blood
that the light was reflected rather than absorbed. They believed that
another lasing material emitting light in another part of the spectrum
might have performed more successfully.Previously, xenon-arc lamp photocoagulators had been used to
treat retinal tears. The long exposure time required of these systems,
combined with their broad spectral range emission (versus
the single wavelength output of a laser), however, made the retinal
spot on which the xenon-arc could be focused too large for many
applications. Focused laser spots on the retina could be as small as
50 microns.
Consequences
The first laser in ophthalmic use by Campbell, Zweng, and Zaret,
among others, was a solid laser—Maiman’s ruby laser. While the results
they achieved with this laser were more impressive than with
the previously used xenon-arc, in the decades following these experiments,
argon gas replaced ruby as the most frequently used material
in treating retinal tears.
Argon laser energy is delivered to the area around the retinal tear
through a slit lamp or by using an intraocular probe introduced directly
into the eye. The argon wavelength is transmitted through the
clear structures of the eye, such as the cornea, lens, and vitreous.
This beam is composed of blue-green light that can be effectively
aimed at the desired portion of the eye. Nevertheless, the beam can
be absorbed by cataracts and by vitreous or retinal blood, decreasing
its effectiveness.
Moreover, while the ruby laser was found to be highly effective
in producing an adhesive scar, it was not useful in the treatment of
vascular diseases of the eye. Aseries of laser sources, each with different
characteristics, was considered, investigated, and used clinically
for various durations during the period that followed Campbell
and Zweng’s experiments.
Other laser types that are being adapted for use in ophthalmology
are carbon dioxide lasers for scleral surgery (surgery on the
tough, white, fibrous membrane covering the entire eyeball except
the area covered by the cornea) and eye wall resection, dye lasers to
kill or slow the growth of tumors, eximer lasers for their ability to
break down corneal tissue without heating, and pulsed erbium lasers
used to cut intraocular membranes.