Mechanisms of corneal intrastromal laser dissection for refractive surgery: ultra-high-speed photographic investigation at up to 50 million frames per second

Every year, more than a million refractive eye surgeries using femtosecond lasers are performed but the intrastromal cutting process remains an area of development. We investigated the mechanisms of laser dissection in cornea by ultra-high-speed photography. We found that the intrastromal bubble forms multiple lobes along the elongated laser plasma and the overlying lobes expand along the corneal lamellae. Videography demonstrated that the cutting process relies on crack propagation in the stroma along the bubble lobes with the crack originating from the pre-existing bubble layer. These insights are important for further improvement of the cutting mechanisms in refractive surgery.

Optical Vortex Beam for Gentle and Ultraprecise Intrastromal Corneal Dissection in Refractive Surgery

Purpose

We introduce a novel focus shaping concept for intrastromal corneal dissection that facilitates cleavage along corneal lamellae, and we analyze laser-tissue interactions governing cutting effectiveness and mechanical side effects.

Methods

Focus shaping was achieved by a spiral phase plate that converts an incident Gaussian beam into a Laguerre-Gaussian beam with a helical phase. Such vortex beams have zero intensity at their center, are propagation invariant, and possess a ring focus equal in length to the Gaussian focus but with a larger diameter. Cutting precision and the required absorbed energy for flap dissection were compared for Gaussian and vortex beams on ex vivo porcine corneal specimens at pulse durations between 480 fs and 9 ps. Cutting quality and bubble formation were characterized by scanning electron microscopy and macro photography.

Results

With the vortex beam, the cuts were much smoother. Bubble formation was markedly reduced because cutting can be performed close to the bubble threshold, whereas with the Gaussian beam energies well above threshold are needed. Although the incident energy at the flap dissection threshold was slightly larger for the vortex beam, the absorbed energy was much smaller and contributed more effectively to cutting. This reduced plasma-induced pressure more than sevenfold.

Conclusions

The vortex beam approach for corneal dissection is a simple, versatile, and cost-effective way of improving the precision of refractive surgery while reducing bubble formation and pressure-related mechanical side effects.

Translational Relevance

Phase plates for propagation invariant vortex beams are easily implemented in the beam path of next-generation clinical devices.

Development of a Noninvasive, Laser-Assisted Experimental Model of Corneal Endothelial Cell Loss

Nd:YAG lasers have been used to perform noninvasive intraocular surgery, such as capsulotomy for several decades now. The incisive effect relies on the optical breakdown at the laser focus. Acoustic shock waves and cavitation bubbles are generated, causing tissue rupture. Bubble sizes and pressure amplitudes vary with pulse energy and position of the focal point. In this study, enucleated porcine eyes were positioned in front of a commercially available Nd:YAG laser. Variable pulse energies as well as different positions of the focal spots posterior to the cornea were tested. Resulting lesions were evaluated by two-photon microscopy and histology to determine the best parameters for an exclusive detachment of corneal endothelial cells (CEC) with minimum collateral damage. The advantages of this method are the precise ablation of CEC, reduced collateral damage, and above all, the non-contact treatment.

Correction of hyperopia by intrastromal cutting and liquid filler injection

Correction of hyperopia requires an increase of the refractive power by steepening of the corneal surface. Present refractive surgical techniques based on corneal ablation (LASIK) or intrastromal lenticule extraction (SMILE) are problematic due to epithelial regrowth. Recently, it was shown that correction of low hyperopia can be achieved by implanting intracorneal inlays or allogeneic lenticules. We demonstrate a steepening of the anterior corneal surface after injection of a transparent, liquid filler material into a laser-dissected intrastromal pocket. We performed the study on ex-vivo porcine eyes. The increase of the refractive power was evaluated by optical coherence tomography (OCT). For a circular pocket, injection of 1 μl filler material increased the refractive power by +4.5 diopters. An astigmatism correction is possible when ellipsoidal intrastromal pockets are created. Injection of 2 μl filler material into an ellipsoidal pocket increased the refractive power by +10.9  dpt on the short and +5.1  dpt on the long axis. OCT will enable to monitor the refractive change during filler injection and is thus a promising technique for real-time dosimetry.

Probing the immune and healing response of murine intestinal mucosa by time-lapse 2-photon microscopy of laser-induced lesions with real-time dosimetry

Gut mucosa is an important interface between body and environment. Immune response and healing processes of murine small intestinal mucosa were investigated by intravital time-lapse two-photon excited autofluorescence microscopy of the response to localized laser-induced damage. Epithelial lesions were created by 355-nm, 500-ps pulses from a microchip laser that produced minute cavitation bubbles. Size and dynamics of these bubbles were monitored using a novel interferometric backscattering technique with 80 nm resolution. Small bubbles (< 2.5 µm maximum radius) merely resulted in autofluorescence loss of the target cell. Larger bubbles (7-25 µm) affected several cells and provoked immigration of immune cells (polymorphonuclear leucocytes). Damaged cells were expelled into the lumen, and the epithelium healed within 2 hours by stretching and migration of adjacent epithelial cells.

[Alternatives to femtosecond laser technology: subnanosecond UV pulse and ring foci for creation of LASIK flaps]

BACKGROUND

In refractive corneal surgery femtosecond (fs) lasers are used for creating LASIK flaps, dissecting lenticules and for astigmatism correction by limbal incisions.

OBJECTIVES

Femtosecond laser systems are complex and expensive and cutting precision is compromised by the large focal length associated with the commonly used infrared (IR) wavelengths. Based on investigations of the cutting dynamics, novel approaches for corneal dissection using ultraviolet A (UVA) picosecond (ps) pulses and ring foci from vortex beams are presented.

METHODS

Laser-induced bubble formation in corneal stroma was investigated by high-speed photography at 1-50 million frames/s. Using Gaussian and vortex beams of UVA pulses with durations between 200 and 850 ps the laser energy needed for easy removal of flaps created in porcine corneas was determined and the quality of the cuts by scanning electron microscopy was documented. Cutting parameters for 850 ps are reported also for rabbit eyes. The UV-induced and mechanical stress were evaluated for Gaussian and vortex beams.

RESULTS

The results show that UVA picosecond lasers provide better cutting precision than IR femtosecond lasers, with similar processing times. Cutting energy decreases by >50 % when the laser pulse duration is reduced to 200 ps. Vortex beams produce a short, donut-shaped focus allowing efficient and precise dissection along the corneal lamellae which results in a dramatic reduction of the absorbed energy needed for cutting and of mechanical side effects as well as in less bubble formation in the cutting plane.

CONCLUSION

A combination of novel approaches for corneal dissection provides the option to replace femtosecond lasers by compact UVA microchip laser technology. Ring foci are also of interest for femtosecond laser surgery, especially for improved lenticule excision.

Femtosecond-laser-induced nanocavitation in water: implications for optical breakdown threshold and cell surgery

We determined the bubble radius R_(max) for femtosecond optical breakdown in water at 347, 520, and 1040 nm with an unprecedented accuracy (+/-10 nm). At threshold, R_(max) was smaller than the diffraction-limited focus radius and ranged from 190 nm to 320 nm. The increase of R_(max) with laser energy E_(L) is slowest at 347 nm, providing optimum control of cell surgery. Experimental results agree with a model of bubble formation in heated and thermoelastically stretched liquids. Theory predicts a threshold temperature T_(th) approximately equal to 168 degrees C. For T>300 degrees C, a phase explosion sets in, and R_(max) increases rapidly with E_(L).

Sensitive high-resolution white-light Schlieren technique with a large dynamic range for the investigation of ablation dynamics

We developed a modified Hoffman contrast technique with a 12 ns pulsed incoherent extended white-light source that enables an easily interpretable visualization of ablation plumes with high resolution, a large dynamic range, and color information. By comparison, a conventional dark-field setup with a slitlike laser light source provides large sensitivity but a small dynamic range, and it is difficult to interpret the filtered images.