Laser in Physics, Chemistry, Biology and Medicine

7.4 Medical uses of the laser

• Laser diagnosis
• Photo-medicine (phototherapy and photochemistry)
• Laser surgery

Figure 7.9. TPA example.

7.4.1 Laser diagnosis

The first stage in medical treatment is diagnosis. Laser diagnosis plays an important role in this today. The
holography is of particular importance for the three-dimensional representation of the important medical
data. A corresponding system is shown in Figure 7.10. The following Figure 7.11 shows as an example the
(three-dimensional) representation of the contour lines of electrical field strengths, as used in the diagnosis
of heart diseases.

Figure 7.10. Future diagnosis system including the use of laser holography for medical diagnosis and three-
dimensional representation of data.

Another important diagnostic method that relies on the use of a laser is the laser Doppler velocimeter
shown in Figure 7.12. This allows the speed of flowing liquids to be determined, e.g. the speed of blood in
the retina, as shown here. The measuring principle consists in the detection of the Doppler shift of the laser
light reflected from the flowing liquid particles. (Heterodyne spectroscopy).

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Figure 7.11. Display of a holograph of the contour lines of the electric field strength of a patient's chest.

Figure 7.12. Use of a laser Doppler velocimeter.

In heterodyne detection, the frequency component that occurs when two 𝐸-fields 𝜔% and 𝜔' with closely
adjacent wavelengths are superimposed is detected with the period (𝜔% − 𝜔' ).

The other applications of the laser (listed above) are based on the interaction of the laser radiation with
matter, which in this case is to be equated with the various types of biological tissue. Before we deal with
the two points further, let's look at this interaction a little.

7.4.2 Interaction of laser radiation with living tissue

The absorption of laser radiation by tissue shows a strong dependence on wavelength (Figure 6-21). The
different absorption maxima of different types of tissue (e.g. skin, blood, etc.) are important for practical
application, which enables different tissues to be influenced selectively by selecting the wavelength.

Laser radiation incident on tissue is partly reflected and partly absorbed in the tissue. A good indication of
the absorbed radiation to be expected in the tissue can be obtained from measurements of the reflection
of the laser radiation at the tissue surface. Figure 7.14 shows an example of such a measurement, in which
the reflection on normal skin is compared with the reflection on a port wine stain. In the case of a port wine
stain, there is an increased absorption of the laser radiation in the corresponding wavelength range.

Of course, the reflection can only give us a first indication of the possible absorbed power in the tissue. The
actual absorption in the tissue will again be strongly wavelength dependent. For this purpose, let us
consider in Figure 7.14 the measured absorption of the skin (dermis and epidermis) as a function of

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wavelength. This shows that increased absorption can be observed in the uppermost skin layers
(epidermis), compared with that of the dermis, due to pigments.

Figure 7.13. Wavelength dependence of the absorption coefficient (reflection coefficient) of different tissue types.

Figure 7.14. Wavelength-dependent reflection coefficient of laser radiation on normal skin and on a port wine stain on
skin

To increase the effectiveness of the laser radiation through increased absorption (or lower reflection
losses), the corresponding part of the skin can be dyed with a dye, for example. For demonstration
purposes, Figure 7.15 shows the irradiation of human skin with an argon ion laser. Small areas were stained
with the dye and an area of 9.5 ∙ 10$' 𝑐𝑚' was irradiated with 200𝑚𝑊 for 5, 10 and 15𝑠. The dyed areas
show strong reactions about 48 hours after irradiation, while the non-dyed areas show no reactions.

Figure 7.15. Skin irradiated with argon ion laser radiation. The dark spots show reactions caused by increased
absorption in coloured areas.

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This principle can be used, for example, to remove tattoos. The irradiation power can be dosed in such a
way that a reaction occurs only in the coloured (tattooed) areas, which can lead to the removal of the
tattoos. See Figure 7.16.

Figure 7.16. Selective reaction of laser radiation (ruby laser, pulsed, 1.5𝑚𝑠 pulse duration, 75𝐽/𝑐𝑚! , area shown: <<
2𝑐𝑚! ) with a tattoo.

The prerequisite for the laser radiation to have an effect in the tissue is a finite absorption of the radiation
in the tissue. If the absorption or the intensity of the radiation used is relatively small, various processes are
triggered in the tissue which, as shown above, lead to a change in the tissue. This effect is used in photo-
medicine and phototherapy or biology. We have already discussed some examples of this above. Another
application is, for example, the stimulation of the production of various therapeutic chemicals. As an
example, vitamin D and the hormone prostaglandin. Further examples are discussed below.

When the laser power is increased or the absorption of the laser radiation is extremely high, in many cases
tissue is ablated by the energy input. This is referred to as laser ablation. While in the early days of laser
medicine 𝐶𝑂' lasers were mostly used for this purpose, today lasers with shorter wavelengths are
increasingly used for this purpose, whereby these are adapted to the specific problem and tissue to be
ablated.

For this purpose, one must visualize the following: Which processes lead to tissue ablation and how is the
non-ablated tissue affected (damaged!)? On the basis of the Figure 7.17 we want to illustrate different
possible situations of laser ablation, which can occur for different absorption coefficients and laser powers.
Some of the consequences for the "quality" of laser ablation can be derived directly from this.

Figure 7.17. Thermal, photochemical and explosive ablation.

The three most important lasers used in medicine are arranged in the diagram according to wavelength. It
is clear from the diagram that the various lasers offer different medical advantages. In general, the rule can
be applied that a thermal influence should be as small as possible. It follows from this that tissue ablation is
least damaging when the process of "photo-ablation" is instrumental in bringing about the ablation. This

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generally requires a short wavelength (high photon energy), as this is needed to break molecular bonds. An
important candidate for laser surgery is therefore the excimer laser, which delivers intense, short-
wavelength radiation.

In biological systems, such as human tissue, a detailed study and knowledge of the microscopic processes is
often very difficult and therefore often only partially understood. One way to obtain information about the
processes involved in laser ablation is to study the energy and power dependence (on the incident
radiation) of the ablation rate, the energy and time dependence, and the mass composition of the ablated
particles. The Figure 7.18 shows the dependence of the ablation rate (of human corneal tissue) on the laser
power for two wavelengths of incident radiation. In order to absorb the visible radiation at all, special
energy absorbers must be introduced into the tissue. A clearly visible threshold value can be seen, which
gives an indication of the mechanisms involved. Thus, we can associate a pronounced threshold with
"explosive desorption", while a small (or absent) threshold indicates a strong contribution of photo-
ablation. The resulting effect for ablation and the associated damage zone when corneal tissue is cut is
shown in Figure 7.19.

Figure 7.18. Ablation rate as a function of laser flux.

Figure 7.19. Damage zones during photochemical and explosive ablation.

Recently, femtosecond pulses offer another promising possibility for interference-free, non-thermal
ablation. On the one hand the short time and on the other hand the high intensity, which allows e.g. multi-
photon processes, are exploited. However, the processes are not really clarified and understood at the
present time.

In summary, we can use the following types of lasers for the problems in medicine due to their wavelengths
and the associated interaction and interaction properties with different types of tissue:

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• The argon ion laser is mainly absorbed by the blood. It is therefore particularly suitable for
coagulation. The argon laser is also characterized by low reflection from the skin.
• The CO2 laser is characterized by a high absorption of its radiation in the water of the tissue (90%
water). Therefore, it is suitable for cutting and vaporizing, provided that the associated high
thermal load of the tissue does not interfere.
• Excimer laser (193, 248, 308𝑛𝑚) for damage-free ablation of tissue.
• Various infrared lasers, such as the 𝐸𝑟-YAG (about 4𝜇), which are particularly well absorbed by
water and enable relatively damage-free ablation by means of "explosive desorption".
• The radiation of the 𝑁𝑑-YAG laser penetrates particularly deep into the tissue due to its relatively
low absorption. Due to the uniform distribution of the energy over a large tissue area, it is
particularly suitable for coagulation without unwanted ablation of the tissue.
• The dye laser is characterized by the fact that it covers a large wavelength range and can be
selectively tuned. This means that it can be used for a wide variety of tasks, but primarily for photo-
activation, where relatively low intensities are required.
• Femtosecond lasers of various wavelengths for effective, low-interference ablation.

7.4.3 Some examples

As just shown, the 𝐶𝑂' laser is suitable as a surgical cutting tool in many cases because it allows defined,
non-contact virtually bloodless cutting as the blood vessels are sealed by the heat generated.

Dermatology

As a first example of the application of the laser in dermatology, let us consider the removal of an ulcer
with the help of a 𝑁𝑑-YAG laser, as shown in Figure 68. A similar example would be the already mentioned
removal of tattoos, birthmarks, age spots or similar.

Figure 7.20. Removal of an ulcer (angioma) on the neck of a girl with 𝑁𝑑-YAG laser irradiation. An angioma is an ulcer
of the blood vessels.

Another example in dermatology is the treatment of herpes by laser irradiation. A krypton laser [𝜆 =
647𝑛𝑚] was used for this purpose. The power was 50𝑚𝑊/𝑐𝑚' and the beam diameter on the patient
was 3𝑐𝑚. The irradiation time was chosen to be 90𝑠 per irradiated field. Patients were irradiated with 6
fields each in the lip area for about 10 consecutive days. In almost all patients, the intervals between
eruptions were considerably prolonged. The healing of the eruptions by laser irradiation could be
accelerated. However, an exact explanation of the mode of action is not yet known at the present time.

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Finally, a relatively new application, "skin resurfacing" (Figure 7.21) using 𝐶𝑂' laser, should be mentioned.
Here, the effect is achieved from a combination of tissue ablation and shrinkage of collagen by raising the
temperature to about 52°𝐶.

Figure 7.21. "Skin resurfacing" using 𝐶𝑂! laser: effect from combination of tissue ablation and shrinkage of collagen
due to temperature increase to about 52°𝐶.

Ophthalmology

In ophthalmology, the use of the laser is particularly widespread and accepted. The share of lasers in
ophthalmology accounts for about 50% of medical laser sales.

Laser photocoagulation has been used for the treatment of retinal detachments for about 15 years already.
Here we will briefly consider two more recent applications, which are particularly interesting also with
respect to the spectroscopy of laser-tissue interaction. For this purpose, let us consider Figure 7.22.

Figure 7.22. New applications of the laser in ophthalmology.

In the upper part of the figure is a novel treatment method of the posterior capsule (a membrane behind
the lens of the eye), which can become fogged and cloudy, especially after certain oparative procedures
(cataracts).

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The highly focused 𝑁𝑑:YAG beam [10 − 50𝜇] can achieve power densities of 1011𝑊𝑐𝑚$' in the dielectric
medium. Thermal ion formation or multiphoton absorption and ionization create a plasma at this energy
density and a plasma breakdown occurs. Rapid acceleration of the resulting free electrons in the radiation
field causes rapid expansion of the plasma, resulting in a supersonic shock wave. This shock wave can be
used to form openings in the rear capsule.

The second treatment method in Figure 7.22 below uses an excimer laser to make a defined incision in the
cornea of the eye. The photochemical ablation discussed above is used for cutting purposes. The practically
non-existent thermal stress enables non-destructive tissue ablation. This feature is already used in practice
(on a trial basis) to correct refractive errors but also to remove pathological tissue (e.g. ulcers) from the
cornea.

The shape of the cornea can be changed by defined incisions in the cornea (radial keratomy), which can, for
example, reduce myopia and astigmatism. A more universal method is to remove corneal tissue from the
entire surface of the eye in order to change the refractive power.

Another method important for corneal surgery is the transplantation of donor corneas onto diseased eyes
to correct extreme refractive errors. Figure 7.23 shows some ways in which excimer laser radiation can be
used to produce such grafts. A computer-controlled device allows cutting and reworking of donor corneas
to a desired shape, which is then sewn onto the patient as a "living contact lens".

Figure 7.23. Principle and equipment for computer-controlled laser corneal processing.

Urology

Another example of successful use of the laser as a surgical tool is the removal of bladder tumours. The
procedure is performed using endoscopic laser irradiation as shown in Figure 7.24. The bladder is filled with
water and rinsed to flush away any blood that may be released. This would absorb the laser beam at
undesirable points in the bladder. Figure 7.25 shows the carcinoma on the posterior wall of the bladder
before, immediately, 4 days and 6 weeks after 𝑁𝑑: YAG irradiation. After 6 weeks, an irritation-free scar has
formed.

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Figure 7.24. Realization and application of the ELCS system from Figure 7.23 and results in lenticular fabrication. The
low damage seen in the electron micrographs is characteristic of non-thermal ablation. This allows clear lenticels to be
produced for surgery.

Figure 7.25. Schematic representation of endoscopic laser irradiation. Papillary carcinoma at the posterior wall of the
bladder, about the size of a pea, is removed by 𝑁𝑑:YAG laser irradiation.

Photo-Radiation Therapy

In the first phase of the treatment of malignant tumours (cancerous tumours), it was thought that the
cancer cells could be eliminated by thermal action of the laser radiation. However, it has been shown that
although this could be eliminated, malignant cells can be carried by this vapour to other areas due to the
violent action of vaporization. Whether laser therapy is useful under these conditions will depend mainly
on the stage of the disease. Another approach has been recently adopted (Photo-Radiation Therapy, PRT).
Here, the malignant cells are first "stained" with pigments (e.g. HpD, a derivative of hematoporphyrin),
which are preferentially attached to the diseased tissue. The thus stained tissue is irradiated with intense
630𝑛𝑚 light (after a few days), which is absorbed by the HpD in the stained diseased cells. This results in
photochemical processes that destroy the diseased tissue.

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7.5 Some more supplementary examples

With the help of femtosecond spectroscopy, the movement of the nuclei during the oscillation and rotation
of a molecule can be followed directly, similar to how rapid periodic movements can be made visible with
stroboscopic illumination. This should be illustrated with an example.

The figure shows the potential curves of some of the electronic states of the 𝑁𝑎' molecule. If one excites
𝑁𝑎' molecules from the vibration level 𝑣 . = 02 in the 𝑋% 𝛴b` ground state with a short pulse of
duration ∆𝑡, then several vibration levels |𝑣/ > are coherently excited in the 𝑋% 𝛴b` +-state due to the
energy uncertainty ∆𝐸 = ℎ∆𝜈. The resulting wave packet (as a linear combination of the stationary
vibration wave functions with different phase factors oscillates spatially with the mean vibration
frequency 𝜔< , periodically back and forth between the reversal points. This wave packet oscillation
corresponds to the movement of the vibrating nuclei.

A second plioton from the same laser pulse stimulates the 𝑁𝑎' molecule further in oscillation levels of the
2% 𝛱b -state, which are also described by an oscillating wave packet.

If a second laser pulse (interrogation pulse) with a suitable wavelength 𝑋oHUJT and a variable time delay
compared to the first pulse is absorbed by the excited molecule, the final state of 𝑁𝑎' depends on the core
distance at which the wave packet is currently in the 2% 𝛱b -state. If it is at the inner turning point, a photon
from the second pulse can only excite the bound ground state of the Na + ion, because the repulsive ion
curve 2𝛴S is not reached. Therefore 𝑁𝑎'` molecule ions are formed.

If, on the other hand, it is excited from the outer reversal point, dissociation of the 𝑁𝑎'` can occur and
atomic 𝑁𝑎` ions can be observed. The desired end product can therefore be set by choosing the
appropriate delay time. This was demonstrated in many detailed experiments by G. Gerber and his group in
Würzbug. The figure shows the measured yields of 𝑁𝑎'` and 𝑁𝑎` ions as a function of the delay time
between the pump and ionization pulse.

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