Biophysical considerations for optimizing energy delivery during Erbium:YAG laser vitreoretinal surgery

Er:YAG laser-mediated tissue disruption and removal results from both direct ablation and the acousto-mechanical sequelae of explosive vaporization of the tissue water. We investigated the scaling laws for photoablative and photodisruptive interactions, and interpret these results towards optimizing energy delivery for vitreoretinal surgical maneuvers. Experimental studies were performed with a free-running Er:YAG laser (100 - 300 microseconds FWHM, 0.5 - 20 mJ, 1 - 30 Hz). Energy was delivered by fiberoptic to a custom-made handpiece with a 75 - 600 micrometer quartz tip, and applied to excised, en bloc samples of bovine vitreous or model systems of saline solution. Sample temperature was measured with 33 gauge copper- constantan thermocouples. Expansion and collapse of the bubble following explosive vaporization of tissue water was optically detected. The bubble size was calculated from the period of the bubble oscillation and known material properties. A model for bubble expansion is presented based on energy principles and adiabatic gas expansion. Pressure transients associated with bubble dynamics are estimated following available experimental and analytical data. The temperature rise in vitreous and model systems depends on the pulse energy and repetition rate, but is independent of the probe-tip diameter at constant laser power; at moderate repetition rates, the temperature rise depends only on the total energy (mJ) delivered. The maximum bubble diameter increases as the cube root of the pulse energy with a reverberation period of 110 microseconds and a maximum bubble diameter of 1.2 mm following one mJ delivery to saline through a 100 micrometer tip. Our modeling studies generate predictions similar to experimental data and predicts that the maximum bubble diameter increases as the cube root of the pulse energy. We demonstrate that tissue ablation depends on radiant exposure (J/cm ²), while temperature rise, bubble size, and pressure depends on total pulse energy. Further, we show that mechanical injury should be minimized by delivering low pulse energy, through small diameter probe tips, at high repetition rates. These results allow for optimization strategies relevant to achieving vitreoretinal surgical goals while minimizing the potential for unintentional injury.