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SPECIAL FIBER FOR MEDICAL LASER APPLICATIONS

INTRODUCTION Many lasers, such as the argon-ion, excimer, carbon dioxide and Nd: YAG, are used for therapeutic applications. Two others, the Er: YAG and Er: YSSG lasers, are unique in that they operate close to the water absorption band of 2.9 um and can precisely ablate tissue at near the cellular level with minimal thermal damage to adjacent healthy tissue. The precision of these lasers, which are used for medical procedures in dermatology, dentistry and ophthalmology, has benefited application such as skin resurfacing, preparation of dental cavities and retinal surgery. The requirements for the erbium laser and optical fiber delivery system vary with each applications In dentistry, high-power delivery is required to efficiently ablate hard tissues (e.g., dentin and enamel). For ophthalmology, precision laser surgery of delicate tissues requires minimal thermal and mechanical damage to surrounding ocular structures. Cosmetic applications requires both high power and high-repetition-rate delivery of laser radiation for rapid skin resurfacing of large facial areas. Delivery systems For lasers operating in the visible and near-infrared, conventional silica optical fibers are a small, flexible and inexpensive means of performing minimally invasive surgery via small openings in the body. However, radiation from mid IR lasers, such as the Er: YAG (2.94um) and Er: YSGG (2.79um), cannot be transmitted through these fibers because of their high absorption at these wavelengths. Although for some erbium medical applications, large, rigid articulated arms consisting of a series of rotating mirrors are sufficient for power delivery, a small, flexible optical fiber delivery system expands the lasers applications. Specialty IR fibers made www.Fullinterview.com

www.Fullinterview.com from materials such as germanium-Oxide glass, fluoride glass, sapphire and hollow waveguide fibers can deliver mid-IR radiation. A typical fiber delivery system for the Er: YAG laser consists of an approximately 2-m-long trunk fiber to deliver the laser power to the patient. The distal end of the fiber is attached to a probe terminated with a reusable or disposable tip that is custom-made from sapphire or low-OH silica for the specific medical procedure of interest.

Fig. 1 The graph plots the losses exhibited by germanium fibers and the wavelengths of various medical lasers Each type of specially optical fiber has advantages and disadvantages in delivery systems. Fluoride glass fibers have the best transmission at 2.94 micro meter, but they not only are weak and sensitive to moisture, but also can degrade with time and generate toxic gases such as fluorine and hydrogen fluoride when damaged. Sapphire fiber is biocompatible tips that come in direct contact with the tissue. But it has a relatively high absorption at 2.9 micro meter because it lacks a core / clad structure, and is not the best choice for the long trunk fiber because of the limited flexibility and long-term mechanical degradation related to its crystalline structure. Hollow waveguides can handle power, but their transmission fluctuates greatly during use because of bending induced losses.

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www.Fullinterview.com An IR fiber optimized for use with mid-IR lasers such as Er: YSGG and Er: YAG has been developed based on germanium oxide glass, which exhibits higher thermal stability and melting temperature than fluoride glass. Germanium- oxide fiber is stronger, can handle more power and is more chemically durable than fluoride fibers. Unlike the sapphire fiber and hollow waveguide, it has an optical eladding that minimizes bending losses. Fiber transmission losses are very low (Less than 0.7 dB/M at 2.94um and 0.25 dB/m at 2.79um) with power handling over 20 W for a 450-um-core fiber (Figure 1) The realization of a robust and reliable IR fiber, such as the germanium oxide, has played an important role in the establishement of the market for Ef: YAG medical lasers and has stimulated study of new medical procedure and laser types. A number of Er: YAG and Er: YSGG laster systems are commercially available, in-cluding dental lasers from Biolase and kavo; aesthetic lasers form asclepion laser, fotona and Scition; and ophthalimic lasers from Austrian laser and Inpro. Other systems are in development. In dentistry, the Ef: YAG and Er: YSGG laser have proved unique in their ability to cut dentin and enamel in a precise and char-free manner for applications such a s cavity preparation and caries removal, usually without the need for an anesthetic. These lasers are also being used in endodontics for sterilization and drying of the root canal, in peirodntics for closed curettage with removalof subgigival concrement, in dental surgery for incisions and excisions, impacted wisdom teeth and removal of hepes, and in tooth etching and sealing fissures. The Er: YAG is being used in dermatology for skin resurfacing, removal fo warts and lesions, hair removal, and the smoothing of scars, blemishes and wrinkles. Several ophthalmic application are being investigated, such as cataract removal, capsulorrhexis, capsulotomy, sclerostomy and photorefractive keratotomy. At the Institute for Medical Lasers in Germany, is investigating a system that uses Er: YAG lasers and germanium-oxide glass fibers for the surgical treatment of carpal tunnel syndrome. They have developed a surgical www.Fullinterview.com

www.Fullinterview.com procedure to decrease the rate of recurrence by using the laser to ablate a small amount of the carpal ligament land to denature its ends with this system, 11 carpal ligament dissections have been performed without complications in the follow up period . All patients were free of pain and recurrence.

Fig. 2 The shielded fiber and sterilizable handpiece Also at the University of Ulm, Dr. R. Hibst has used the Er. YAG laser with a germanium oxide fiber delivery system for ear, nose and throat surgery. Beginning in 1989, the benefit of different lasers for tympanoplasty and stapedotomy was investigated. The Er. YAG laser was found to be optimum for operating on the eardrum, along the ossicles as far as the foot plate without carbonization, and with sharpedged, 0.2- mm diameter canals drilled through the bone2. Using this technique, children with mucotympanon could have their eardrums reopened in the doctors office without the need for drain tubes. Initial experimental studies conducted in collaboration with Johns Hopkins Medical School in Baltimore also show that hybrid optical fibers consisting of a germanium trunk fiber and a low OH silica tip can transmit upto 180 mj of Er : YAG power for applications requiring contact issue ablation through a flexible endoscope.3. This pulse energy is more than sufficient for ablation of avariety of hard and soft tissues. In urology, germanium fibers are being tested for use with flexible endoscopes for precise Er : YAG laser Incision of urethral, bladder neck that www.Fullinterview.com

www.Fullinterview.com may result in recalcitrant scarring and urinary incontinence. A significant number of patients undergoing surgery for benign or malignant prostate cancer suffer from bladder neck strictures, and there is no simple and effective minimally invasive treatment. An Er : YAG lase can ablate soft tissue approximately 15 to 30 times better then a HO : YAG laser, which is the laser of choice in urology.

Fig.3 As seen in a stained histological cross section of a pig bladder neck, at Day 0, a clean incision is made with a freerunning Er: YAG laser with no significant thermal damage (left). At day 14, the incision has almost completely healed, with only a narrow zone of scar tissue present (right)

After surviving premature birth and a semi-orphand childhood and escaping the bubonic plague, Sir Issac Newton succumbed to a kidney stone in 1727. The National Institute of Diabetes and Digestive and Kidney Diseases estimates that 10 percent of the US population will have nephrolithiasis, or kidney stone disease, during their life-time, for an annual incidence of more than 1 million cases. This disease accounts for up to 1 million cases. This disease accounts for up to 1 percent of all hospital admissions, and billions of dollars are spent on evaluation and treatment each year. Kidney stones most commonly occur between the ages of 20 and 40, with recurrence or serious complications in as many as 50 percent of cases, according to the institute. Lases offer a minimally invasive surgical option that has become attractive to many urologists when surgical intervention is indicated. One of the first uses of lasers in surgery was for stone fragmentation (lithotripsy), but www.Fullinterview.com

www.Fullinterview.com because early alexandrite lasers proved to be too application-specific, costly and unreliable, the technique fell into disfavor. With the advent of the Ho:YAG, which produces short pulses of energy at 2.1) m, laser lithotripsy is faster and more reliable, and is quickly becoming the most popular minimally invasive procedure for kidney stones. Kidney stones are typically formed of hydrated calcium salts and other insoluble metabolic wastes. Early claims by laser manufactures indicated that sonic shock waves produced by the laser fragmented the kidney stones, but infrared lasers actually ablate stones piecemeal. output of 2.1 m. They Although the stones compositions can vary markedly, most absorb fairly strongly at the Ho:YAGS absorb even more strongly at the Er:YAG

wavelength (2.9 m ), but no effective fiber optic delivery system compatible with this energy and surgical conditions has been developed. Research is proceeding at a frenetic pace because the erbium laser could shorten surgical sessions by an order of magnitude, reducing costs and improving outcomes. Today, holmium lasers producing up to 100 W of average power are available. However, these highly effective lasers present new problems in the design of fiber optic energy delivery devices. To ensure safety and efficacy for surgical use, laser lithotripsy fibers must be made to couple to lasers with high efficiency and reliability, to operate well at moderate peak energy and high average power, to perform for many hours and to transmit energy to the fiber tip while withstanding greater degrees of bending than those typically considered as the physical and optical limits. They also should use only biocompatible materials, maintain a low cost for relatively low production volumes and accommodate the reality of routine reprocessing and reuse of single use only devices.

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Fig. 4 In this drawing of the human renal system, stones are shown in red in the lower pole of the kidney (A) and in the ureter (B) By passing a small-core fiber through a highly flexible endoscope, even urinary calculi deep within the lower pole of the kidney are accessible without incision (Figure 1). A continuous saline solution flow flushes out tiny stone fragments and keeps the field of view clear of debris during surgery. The 2.1- m radiation produced by Ho:YAG lasers is close to the longwavelength limit for silica and thus challenges fused silica fiber significantly. Commercially available polymer-clad silica fiber is unsuitable for use with Ho:YAG lasers because the laser light interacts and the polymer causes light loss of ~ 10 percent per meter on first exposure as the polymer degrades. Flourine-doped silica is far more transparent than polymers for Ho:YAG energy, and doped silica-clad fiber transmits 97-99 percent of holmium laser energy per meter of fiber (neglecting Fresnel reflection losses.) Aspects of the surgery itself and the design of the surgical laser systems cause several problems that fiber manufacturing. Must deal with. Samll, fledxible endoscopes Wont deflect fully, and saline irrigation cant flow sufficiently if large, stiff fibers fill the working channel. A 200-um-core fiber is the practical maximum for retaining good endoscope performance, but most holmiu8m surgical lasers have focal spot diameters ranging from ~ 275 to ~ 500 um, with maximum focal angles corresponding to ~0.18 and ~ 0.12 NA, respectively. Thus, for optimum surgery in flexible scopes, the laser,

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www.Fullinterview.com beam must be coupled into an optical fiber of significantly smaller diameter than the light source focal spot. During surgery, small fibers are often required to bend to radif smaller than the recommended minimum short term physical radius, where optical osses can become significant. To contain the escaping light, fiber is usually coated with the same low-refractive-index polymers used to clad silica fiber. Overreliance on this secondary containment leads to failure because the laser light gradually degrades the polymer. Keeping the initial angular fill of the fiber core to a minimum will reduce the amount of High contained by the secondary polymer cladding. Several factors can cause problems in alignment between the laser and the fiber optics. For one, surgical laser are fully mobile. In fact, amny are rente and transported to surgical centers only as needed. The stainless steel port that accommodate fiber assemblies on most holmium lasers are not always manufactured with precise dimensions, and they wear with repeated use. Also, surgical sessions can last many hours, particularly if large stones. Are ablated using small fibers, which can lead to a variable beam quality as optical elements heat and cool.

Fig. 5 A typical holmium surgical laser focal spot profile illustrates the indistinct edge and irregular energy density distribution. Off-the-shelf connectors for fiber optics do a very good job of placing the fiber axis parallel to the laser axis and of centering the fiber face in the laser focus, but standard connectors fail in surgical applications because high www.Fullinterview.com

www.Fullinterview.com power laser foci are far from perfect. The focal Spots do not have sharp edges, and enrgy density is not uniformly distributed within (Figure 2), so some laser energy invariably strikes outside the fiber ore. Any laser labile materials that are in focal plane are vapor ized: adhesive, fiber coating or even the steel connector body. Several simple modifications of standard connectors are made for coupling to surgical lasers. Although generally successful, many of these alterations result in other subtle, but serious, performance flaws. The air well is the most common high power strategy used in lser lighotripsy fiber designs because of its low cost and simplicity. Air-well connectors reduce the core overfill problem by ensureing that laser labile materials do not lie in the plane of focus. The portion of the connector tha normally falls in the laser focus is simply removed by enlarging the connector before for a few millimeters behind the focus. References : 1. D. Russ etal (2003). Er : YAG laser for the surgical treatment of the carpal tunnel syndrome. Therapeutic laser applications and laser tissue interactions Proc. SPIE, Vol 5142, p.76-81. 2. R. Pflaz, R. Hibst and N. Bald (1995). Suitability of different lasers for operations ranging from the tympanic membrane to the base of the stapes. Advances in Oto-Rhino Laryngology vol. 49, pp 87-94. 3. C.A. Chaney, Y. Yang and N.M. Fried . Hybrid germanium / silica optical fibers for endoscopic delivery of erbium ; YAG laser radiation. LASERS IN SURGERY AND MEDICINE , vol. 34 pp. 5-11 4. N.M. Fried et al (2003) Optimization of the erbium : YAG laser for precise incision of ureteral and urethral tissue ; in vitro and in vivo results, Lasers in surgery and Medicine Vol. 33, pp. 108-114. 5. N.M. Fried at Transmission of free running and Q-switched erbium : YAG laser radiation through sapphire and germanium fibers. Proc. SPIE, optical Fibers and Sensors of Medical Applications IV. In Press.

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