Optic nerve sheath fenestration using a Raman-shifted alexandrite laser.

BACKGROUND AND OBJECTIVE: Optic nerve sheath fenestration is an established procedure for relief of potentially damaging overpressure on the optic nerve resulting from idiopathic intracranial hypertension. Prior work showed that a mid-IR free-electron laser could be delivered endoscopically and used to produce an effective fenestration. This study evaluates the efficacy of fenestration using a table-top mid-IR source based on a Raman-shifted alexandrite (RSA) laser. STUDY DESIGN/MATERIALS AND METHODS: Porcine optic nerves were ablated using light from an RSA laser at wavelengths of 6.09, 6.27, and 6.43 µm and pulse energies up to 3 mJ using both free-space and endoscopic beam delivery through 250-µm I.D. hollow-glass waveguides. Waveguide transmission was characterized, ablation thresholds and etch rates were measured, and the efficacy of endoscopic fenestration was evaluated for ex vivo exposures using both optical coherence tomography and histological analysis. RESULTS: Using endoscopic delivery, the RSA laser can effectively fenestrate porcine optic nerves. Performance was optimized at a wavelength of 6.09 µm and delivered pulse energies of 0.5-0.8 mJ (requiring 1.5-2.5 mJ to be incident on the waveguide). Under these conditions, the ablation threshold fluence was 0.8 ± 0.2 J/cm(2) , the ablation rate was 1-4 µm/pulse, and the margins of ablation craters showed little evidence of thermal or mechanical damage. Nonetheless, nominally identical exposures yielded highly variable ablation rates. This led to fenestrations that ranged from too deep to too shallow-either damaging the underlying optic nerve or requiring additional exposure to cut fully through the sheath. Of 48 excised nerves subjected to fenestration at 6.09 µm, 16 ex vivo fenestrations were judged as good, 23 as too deep, and 9 as too shallow. CONCLUSIONS: Mid-IR pulses from the RSA laser, propagated through a flexible hollow waveguide, are capable of cutting through porcine optic nerve sheaths in surgically relevant times with reasonable accuracy and low collateral damage. This can be accomplished at wavelengths of 6.09 or 6.27 µm, with 6.09 µm slightly preferred. The depth of ex vivo fenestrations was difficult to control, but excised nerves lack a sufficient layer of cerebrospinal fluid that would provide an additional margin of safety in actual patients.

Miniature forward-imaging B-scan optical coherence tomography probe to guide real-time laser ablation.

BACKGROUND AND OBJECTIVE: Investigations have shown that pulsed lasers tuned to 6.1 µm in wavelength are capable of ablating ocular and neural tissue with minimal collateral damage. This study investigated whether a miniature B-scan forward-imaging optical coherence tomography (OCT) probe can be combined with the laser to provide real-time visual feedback during laser incisions. STUDY DESIGN/METHODS AND MATERIALS: A miniature 25-gauge B-scan forward-imaging OCT probe was developed and combined with a 250 µm hollow-glass waveguide to permit delivery of 6.1 µm laser energy. A gelatin mixture and both porcine corneal and retinal tissues were simultaneously imaged and lased (6.1 µm, 10 Hz, 0.4-0.7 mJ) through air. The ablation studies were observed and recorded in real time. The crater dimensions were measured using OCT imaging software (Bioptigen, Durham, NC). Histological analysis was performed on the ocular tissues. RESULTS: The combined miniature forward-imaging OCT and mid-infrared laser-delivery probe successfully imaged real-time tissue ablation in gelatin, corneal tissue, and retinal tissue. Application of a constant number of 60 pulses at 0.5 mJ/pulse to the gelatin resulted in a mean crater depth of 123 ± 15 µm. For the corneal tissue, there was a significant correlation between the number of pulses used and depth of the lased hole (Pearson correlation coefficient = 0.82; P = 0.0002). Histological analysis of the cornea and retina tissues showed discrete holes with minimal thermal damage. CONCLUSIONS: A combined miniature OCT and laser-delivery probe can monitor real-time tissue laser ablation. With additional testing and improvements, this novel instrument has the future possibility of effectively guiding surgeries by simultaneously imaging and ablating tissue.

Efficacy and predictability of soft tissue ablation using a prototype Raman-shifted alexandrite laser.

Previous research showed that mid-infrared free-electron lasers could reproducibly ablate soft tissue with little collateral damage. The potential for surgical applications motivated searches for alternative tabletop lasers providing thermally confined pulses in the 6- to-7-µm wavelength range with sufficient pulse energy, stability, and reliability. Here, we evaluate a prototype Raman-shifted alexandrite laser. We measure ablation thresholds, etch rates, and collateral damage in gelatin and cornea as a function of laser wavelength (6.09, 6.27, or 6.43 µm), pulse energy (up to 3 mJ/pulse), and spot diameter (100 to 600 µm). We find modest wavelength dependence for ablation thresholds and collateral damage, with the lowest thresholds and least damage for 6.09 µm. We find a strong spot-size dependence for all metrics. When the beam is tightly focused (~100-µm diameter), ablation requires more energy, is highly variable and less efficient, and can yield large zones of mechanical damage (for pulse energies>1 mJ). When the beam is softly focused (~300-µm diameter), ablation proceeded at surgically relevant etch rates, with reasonable reproducibility (5% to 12% within a single sample), and little collateral damage. With improvements in pulse-energy stability, this prototype laser may have significant potential for soft-tissue surgical applications.

Endoscopic free electron laser technique development for minimally invasive optic nerve sheath fenestration.

PURPOSE: This study proposed to develop a technique for efficiently accessing the posterior orbital space using endoscopy and attempted application of free electron laser (FEL) energy, biopsy forceps, electrocautery, and CO(2) insufflation to posterior orbital tissues. METHODS: Through an inferior transconjunctival incision, access to the posterior orbital space was attempted in 14 eyes of 7 non-survival pigs. FEL energy (6.1 microm, 30 Hz, delivered via 250 microm hollow-glass waveguide), biopsy forceps, and monopolar electrocautery application were endoscopically attempted in the posterior orbit. CO(2) gas insufflation effects were assessed by analyzing arterial blood gases at 30-minute intervals for 1.5 hours. RESULTS: The posterior orbit was accessed in 13 of 14 eyes, the optic nerve was encountered, and FEL energy was applied in 8 of 14 eyes. Use of biopsy forceps and electrocautery were successful. Although ANOVA results for arterial blood gas changes were not statistically significant, visibility was adequate without CO(2) insufflation. CONCLUSIONS: The posterior orbit was endoscopically accessed and the optic nerve was exposed and successfully treated with FEL energy. CO(2) insufflation did not alter blood gases, but did not further enhance visibility in this study.

Optic nerve sheath fenestration with endoscopic accessory instruments versus the free electron laser (FEL).

BACKGROUND AND OBJECTIVE: The free electron laser (FEL) can efficiently produce an optic nerve sheath fenestration using an endoscopic approach. To develop a surgical protocol, this study compared effectiveness of available accessory endoscopic instruments to endoscopic FEL delivery effectiveness in producing optic nerve sheath fenestrations. STUDY DESIGN/MATERIALS AND METHODS: An endoscope was used to perform optic nerve sheath fenestrations on goat optic nerves. Accessory endoscopic instruments and glass-hollow waveguides (250 and 320 microm in diameter) were inserted into the instrument channel for comparison. FEL energy (6.45 microm, 30 Hz) was delivered to the tissue through the waveguides and histological analysis was performed. RESULTS: The endoscopic instruments alone were unable to incise the optic nerve sheath. The FEL successfully incised the sheath and the biopsy forceps extricated the circular flap. CONCLUSIONS: Endoscopic optic nerve sheath fenestration using FEL energy followed by biopsy forceps for sheath extrication produced good results, thereby creating a feasible protocol for optic nerve sheath fenestration.

Chronic and acute analysis of optic nerve sheath fenestration with the free electron laser in monkeys.

BACKGROUND AND OBJECTIVES: The Amide II wavelength (6.45 microm) produced by the free electron laser (FEL) can efficiently create an optic nerve sheath fenestration in rabbits. We wished to determine if it would be equally successful in macaque monkeys and to determine the histopathologic changes between traditional scissors or knife optic nerve sheath fenestration to FEL fenestration. STUDY DESIGN/MATERIALS AND METHODS: Optic nerve sheath fenestration was performed using either the FEL (6.45 microm, 30 Hz, 2-3 mJ, 325-microm spot size) through a hollow waveguide probe in 12 eyes or with a scissors or a knife in 6 eyes. The monkeys survived 1 month with the fellow optic nerve operated acutely just prior to sacrifice. Optic nerves were evaluated histologically. RESULTS: Less tissue manipulation was required using the FEL surgical probe. Electroretinograms showed minimal or no change. Tissue responses using either method were similar following chronic or acute incisions. Mild upregulation of vimentin and glial fibrillary acid protein (GFAP) was seen in astrocytes adjacent to the fenestration, but no change in S100 beta was evident. CONCLUSIONS: The FEL energy at 6.45 microm delivered through a hollow waveguide appears capable of efficiently and safely producing an optic nerve sheath fenestration in monkeys. This innovative surgical technique should be considered for human use.