[Classification of laser irradiation and safety measures]

The use of lasers in medicine and especially surgery is rapidly expanding in many disciplines from clinical laboratory to the office practice and operating room. It is essential that users of this powerful tool have knowledge of their potential hazards and the measures to protect patients and personnel against injuries or undesired effects. Below, we have included information about the way lasers are classified; the development of protective standards; the current status of protection standards that apply to lasers, especially those used in medicine/surgery; the specific kinds of hazards associated with medical/surgical applications; and the measures by which hazards have been controlled. Since laser technology is still a young field, it is likely that problems unknown at present will occur and methodologies for controlling hazards will evolve. The American National Standards Committee produced the first consensus standard Z136.1 in 1973. The Standard was revised in 1976 to accommodate differences in biological effects for different wavelengths in the visible spectrum. The ANSI Standard has been revised again in 1980, and currently (1984) there are two additional standards in preparation, Z136.2 and 136.3, which treat the safe use of light-emitting diodes and the safe use of lasers in the health care environment, respectively. Most surgical and medical lasers are Class III or IV. Some lasers have a Class IV therapy level beam plus a Class I or II alignment beam. When using lasers, it is possible to generate incandescence or fluorescence in an irradiated object. This can occur even with protective eyewear, because the correlated radiations are usually of a different wavelength. Generally, this should not be a problem when beams are directed at biological material. However, hazard could be caused by lasers designed to produce fluorescence. Control of correlative radiation in a laser system is required in the federal regulations. Hazards of lasers may be grouped as those to the eye, skin and associated hazards, fire, x-rays, electrical, fumes, toxic materials, etc. Effects on tissue are governed by the following factors:--the energy or power density of the beam;--the absorption in tissue at the laser wavelength;--the time the beam is held at a given area.;--the protective effects of heat removal by thermal conduction and by circulation. Eye hazards include thermal burns or acoustical disruption (shock waves) from high-powered or high-energy beams in the visible and near infrared wavelengths. Direct beam exposure or specular or diffuse reflaction from these very high-power lasers can also cause injuries to other parts of the retina. For example, beams can directly penetrate through the sclera and cause retinal injury. Near ultraviolet (less than 400 hm) and far infrared (.3000 hm including CO2 lasers) can cause moderate to severe corneal burns. Far ultraviolet (200-315 nm), mid infrared (1400-3000 nanometers) can cause welders' flash or snow blindness and chronic exposure could cause cataract, and exposure to ultraviolet rays may be carcinogenic. For CO2 lasers, the far infrared radiation is attenuated by plastic goggles, or by glasses, or quartz. Other eyewear with special filters is used for different lasers. The whole personnel who may be exposed to direct beams, specular reflections, and many times diffuse reflections must wear protective eyewear. In all cases the surgeon and others viewing the procedure through the endoscope need glasses or suitable protective lenses installed in the endoscope. Persons who are not viewing the beam may not need to wear protective glasses with the same level of optical density. Glasses may be selected to provide protection for lasers operating in the visible wavelength to the point where the normal aversion response could protect the individual.