This article provides an overview of both established and innovative applications of femtosecond (fs)-laser-assisted surgical techniques in ophthalmology. Fs-laser technology is unique because it allows cutting tissue at very high precision inside the eye. Fs lasers are mainly used for surgery of the human cornea and lens. New areas of application in ophthalmology are on the horizon. The latest improvement is the high pulse frequency, low-energy concept; by enlarging the numerical aperture of the focusing optics, the pulse energy threshold for optical breakdown decreases, and cutting with practically no side effects is enabled.

This review provides an overview of the historical development and modern applications of femtosecond (fs) lasers in ophthalmology, with a focus on the optical concepts involved. fs-Laser technology is unique because it allows very precise cutting inside the eye through optically transparent tissue, without a need for any mechanical openings. fs-Lasers were historically first used for refractive cornea surgery, later also for therapeutic cornea procedures and lens surgery. Further new areas of ophthalmic application are under development. The latest laser system concept is low pulse energy and high pulse frequency: by using larger numerical aperture focusing optics, the pulse energy required for optical breakdown decreases, and athermal tissue cutting with minimal side effects is enabled.

The power density of femtosecond lasers and exposure time to the tissue are crucial for a successful procedure in terms of safety and precision. The reduction of the pulse duration allows reducing the quantity of the energy to be delivered to the tissue for disruption with strongly diminished mechanical and thermal collateral damage. The cutting effect of ultra-short pulses is very precise, minimally traumatic, safe, and predictable. Future developments will lead to further energy reductions to achieve optical breakdowns. However, the pulse length cannot be shortened arbitrarily because below 100 fs nonlinear effects can change the process in an unfavorable way. Compared to manual-conventional cataract surgery, femtosecond laser-assisted cataract surgery (FLACS) shows many advantages in clinical application, especially with regard to precision and tissue protection. The femtosecond laser has become particularly important and has made the overall procedure safer when we deal with complex cataract cases such as subluxated lenses. We provide an overview of the evolution of femtosecond laser technology for use in refractive and cataract surgeries. This article describes the advantages of available laser platforms with ultrashort pulses and mainly focuses on the technical and physical backgrounds of ophthalmic surgery technologies.

In the early 2000s, solid-state lasers emerged as an alternative technology to excimer systems in refractive surgery. Despite some technological limits at the time, good clinical results could be achieved with solid-state laser systems. This prospective case series reports clinical outcomes of five eyes treated with a newly developed solid-state laser system (AquariuZ) in three patients. Patients underwent preoperative examination, including corneal topo-and tomography, aberrometry, and confocal microscopy. All patients received a femtosecond LASIK with the Ziemer LDV Z8, a refractive treatment with the AquariuZ solid-state ablation laser, and were then followed up for a period of up to 12 months. The applied aspheric optimized profiles did not induce higher-order aberrations nor spherical aberration in any of these operated subjects. No eye lost BCVA lines throughout the duration of the follow-up. Six months after surgery, the safety index of patient 1 was 5, and for patients 2 and 3, it equaled 1. Confocal laser microscopy imaging findings were comparable to those seen typically for excimer lasers. The obtained results are encouraging and confirm that the new solid-state laser system is safe.

. Significance: Refractive surgery in ophthalmology uses pulsed lasers at 193, 210, or 213 nm. The reason is that most molecular constituents of cornea absorb strongly in this wavelength range. Precise refractive surgery via ablation requires an accurate knowledge of the absorption coefficient at the relevant wavelengths. Yet, the absorption coefficients of corneal tissue reported in literature vary by almost an order of magnitude; moreover, they were measured mostly at the wavelengths mentioned earlier. Aim: By measuring the corneal absorption coefficient of intact eyeballs stored at different environmental conditions, prepared by following different procedures, and as a function of postmortem time, we determine the absorption coefficient for the entire wavelength range between 185 and 250 nm for as close as possible to in-vivo conditions. Approach: We use a specially designed UV ellipsometer to measure refractive index and absorption coefficient. Specifically, we investigate the temporal evolution of refractive index and absorption coefficient after enucleation of the eyeballs under different environmental conditions and preparation procedures. Results: Our measurements provide accurate values for refractive index as well as absorption coefficient of cornea in the wavelength range between 185 and 250 nm. We find that the absorption coefficient decreases with time and that neither storage conditions nor preparation procedures but a continuous degeneration of the cornea is responsible for the observed time evolution. We use the measured time evolution to extrapolate refractive index and absorption coefficient to in-vivo conditions. Conclusion: Our measurements of the close to in-vivo absorption coefficient of cornea between 185 and 250 nm allow for a better understanding and modeling of refractive cornea surgery, also at other than the three commonly used wavelengths. In the future, this may be relevant when new pulsed laser sources with other wavelengths become available.