PHYSICS
Basic principles of lasers
Daniel Haley
Oliver Pratt
Abstract
The theoretical basis for laser was first described by Einstein, 100
years ago. Lasers are now in widespread use and have an extensive
range of applications, including many within the field of medicine.
This article explores the properties of laser; its physical principles;
and the main components required to produce a laser beam. The spe-
cific properties of laser render it an extremely useful clinical tool in a
variety of circumstances. The application of laser also brings potential
hazards, which are discussed, along with the safety measures utilised
to minimize the associated risk.
Keywords Energy; fire; hazards; lasers; physics; principles; safety
Royal College of Anaesthetists CPD Matrix: 1A03, 2A06, 3A01, 3A02
The theoretical basis for laser light was first described in 1917 by
Albert Einstein, but it was more than 40 years later, in 1960,
when the first working laser was invented by an American en-
gineer and physicist named Theodore Maiman.1 The term
‘L.A.S.E.R.’ was coined by Gordon Gould, another American
physicist, as the acronym for ‘Light Amplification by Stimulated
Emission of Radiation’.
Properties of a laser
Laser differs from other forms of light due to several particular
properties:

Coherence: the photons (light particles) are emitted ‘in
phase’. Phase is the position of a point in time on a
waveform cycle. When the crest or trough of the wave
associated with one photon occurs at the same time as on
the wave associated with another photon they are said to
be in phase.

Collimation: the photons travel in parallel, and therefore
diverge very little as they propagate away from the laser
device. It is this collimation that results in the narrow
beam diameter of laser.

Monochromaticity: it consists of one specific wavelength
(a single colour) of light.

Uniform polarization: the electric field of the photons
usually (but not always) oscillates in a specific direction
perpendicular to the propagation direction of the laser
beam.
Daniel Haley MB ChB BSc MRCP FRCA is an ST7 in Anaesthesia and
Intensive Care Medicine at the University Hospital of South
Manchester, Wythenshawe, UK. Conflicts of interest: none declared.
Oliver Pratt MB BS FRCA is a Consultant Anaesthetist at Salford Royal
Hospital, Salford, UK. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 18:12
Learning objectives
After reading this article you should be able to:
C list the principal properties of a laser
C explain how a laser beam is produced
C identify the hazards of lasers and describe the safety
precautions employed whilst using them
Laser physics
Atomic physics describes an atom as possessing a central nucleus
of protons and neutrons, encircled by electrons contained in
distinct orbital shells. Following on from the earlier work of Max
Planck, a German theoretical physicist and subsequently Albert
Einstein, in 1913 the Danish physicist Niels Bohr theorized that if
a defined amount of energy is supplied to the atom, electrons can
jump from a low-energy orbital to a high-energy orbital further
from the nucleus. This defined amount of energy (E) came in the
form of a photon and was determined by the equation:
E ¼ hv
where h is Planck’s constant (6.63  1024 J/second) and v is the
photon frequency. This process, whereby atomic excitation oc-
curs due to the movement of an electron from its ground state to
a high-energy orbital is termed ‘absorption’.
Bohr also theorized that once moved to the high-energy orbital,
some electrons spontaneously return to the ground state, releasing
the difference in energy between the two states in the form of a
photon. This process is termed ‘spontaneous emission’. If this
photon then collides with another atom already in the excited
state, it can be stimulated to return to the ground state, in doing so
releasing a second photon identical to the first in its direction,
phase, polarization and energy. This process is termed ‘stimulated
emission’ and forms the basis of laser production.
Components of a laser
A laser consists of three main components (Figure 1):

A ‘pump’ or excitation source, which supplies the neces-
sary energy. There are many different types of pumps,
including optical (flash lamp, continuous arc lamp, light
from another laser), electrical or chemical.

A lasing medium or gain medium, which determines the
wavelength of the laser produced. It may be solid (crystals,
glasses, semiconductors), liquid (organic dyes or solvents),
or gas (e.g. argon, carbon dioxide). The lasing medium
present often determines the name of the type of laser.

An optical resonator, which contains the lasing medium
with two parallel mirrors on either side, thus causing the
photons to pass repeatedly back and forth between the
two. One of the mirrors is partially transparent, allowing
some of the photons to exit the device to form the laser
beam. This is termed the ‘output coupler’.
Clinical use of laser
Lasers can be utilised to create targeted tissue damage and it is
the absorption of the laser by the tissues that allows it to exert its
648 Ó 2017 Elsevier Ltd. All rights reserved.
 PHYSICS

When irradiated by light of a specific wavelength, this

Components of a laser
Pump source
Lasing medium Laser
Pump source
Highly
Partially
mirror Optical resonator
mirror
Figure 1
effects. Some examples of the clinical uses of laser are displayed
in Table 1. The interaction between laser and tissues and thus the
extent of the damage, is determined by the irradiance or power
density of the laser, its wavelength, the exposure time and the
optical properties of the tissues themselves. There are therefore
several different mechanisms by which lasers produce tissue
damage:

Photoacoustic or photomechanical: a brief but intense
pulse of laser results in thermal expansion. An example of
this is the holmium:YAG laser used in lithotripsy, which
fragments calculi by heating the water within them.

Photodissociation: the absorption of light within the ultra-
violet range produces non-thermal breakdown of covalent
bonds within proteins. An example is laser-assisted in-situ
keratomileusis using excimer (ArF) laser.

Photodynamic: a non-toxic, light-sensitive chemical
compound is administered topically or intravenously.
photosensitizer enables production of reactive oxygen
compounds that cause selective lysis of targeted cells.

Photothermal: a localized, rapid increase in temperature
causes tissue coagulation, vaporisation or both. The cut-
ting and haemostatic effects of the CO2 laser are produced
in this manner.
Laser safety
The specific characteristics of laser mean that it is potentially
much more hazardous than other forms of light. For example,
since laser is collimated the beam diverges very little as it propa-
gates, therefore resulting in a similar degree of hazard regardless
of distance from the laser origin. Public Health England has pub-
lished guidance on the use of lasers with relevant safety advice.2
The British Standard on laser safety (BS EN 60825-1:2014) sets
out eight different classes of laser, based on the maximum
permissible exposure (MPE) levels, measured at the skin or
cornea.3 The presence of ‘M’ in Classes 1M and 2M is derived from
the requirement to avoid the use of magnifying optical viewing
instruments. The ‘C’ in Class 1C relates to the emission of laser
radiation above the accessible emission limit (AEL) of Class 1
products only when the device is in contact with (or very close to)
the skin or internal body tissue. The ‘R’ in Class 3R is derived from
reduced, or relaxed, safety requirements for both the manufac-
turer and the user, due to the risk of injury being relatively limited.
Finally, the ‘B’ for Class 3B has historical origins. The lasers used
in medical devices are predominantly from Class 4 (Table 2).
It is important for everyone involved in the use of lasers in
clinical practice to be aware of the associated dangers,

Commonly used lasers in medicine

Name Wavelength (nm) Medium type Applications

Excimer (ArF) 193 Gas Ophthalmic surgery

Argon 488 Gas Coagulation, ophthalmic surgery, dermatology

KTP 532 Gas Coagulation

Dye 390e640 Liquid Photodynamic therapy (PDT)

HeeNe 630 Gas Barcode scanners

Ruby 694 Solid Tattoo removal, hair removal

Alexandrite 700e830 Solid Tattoo removal, lithotripsy, mole removal

Diode semiconductor 805e1000 Solid PDT, percutaneous laser disc decompression

Nd:YAG 1064 Solid Urological surgery, gynaecological surgery, ophthalmic surgery

Ho:YAG 2100 Solid Ophthalmic surgery

CO2 10,600 Gas ENT surgery, neurosurgery

Table 1

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 PHYSICS

British Standards Institution classification of laser products

Class Product description

1 Safe during use, including long-term direct intra-beam viewing, even when exposure occurs while using telescopic optics
(e.g. binoculars). Also includes fully enclosed high power lasers so that no potentially hazardous radiation is accessible
during use (embedded laser product). The term ‘eye-safe’ may only be used for Class 1 laser products
1M Laser products that are safe for viewing with the naked (unaided) eye, including long-term direct intra-beam viewing.
The maximum permissible exposure (MPE) can be exceeded following exposure with telescopic optics,
therefore resulting in eye injury
1C Intended for direct application of laser radiation to the skin or internal body tissues for medical, diagnostic,
therapeutic or cosmetic procedures such as hair removal, skin wrinkle reduction, treatment of acne
2 Emit visible laser beams and are safe for momentary eye exposures, but can be hazardous following deliberate
staring into the beam. The use of optical instruments does not increase the risk of ocular injury
2M Like Class 2 products, they are safe for short time exposure with the unaided eye. However, the MPE can be exceeded
whilst using telescopic optics and eye injury may occur
3R Emit radiation that can exceed the MPE under direct intra-beam viewing, but the risk of injury in most cases is relatively low
3B Laser products that are normally hazardous when intra-beam ocular exposure occurs including accidental short time exposure.
Viewing diffuse reflections is usually safe. May produce minor skin injuries or even pose a risk of igniting flammable materials,
however this is only likely if the beam has a small diameter or is focussed
4 Intra-beam viewing and skin exposure is hazardous and the viewing of diffuse reflections may also be hazardous.
These lasers also often represent a fire hazard

Table 2
particularly in the presence of an anaesthetized patient. Potential
hazards of lasers from medical devices include:

Tissue injury: this can be due either to application of the
laser at a site other than that intended, or accidental expo-
sure to the eye resulting in damage to the cornea or retina.

Fire: due to the thermal energy generated by lasers, there
is an increased risk of fire, particularly in an oxygen-
enriched environment such as theatres.

Inhalational injury: the use of laser can generate toxic by-
products, which have the potential to cause secondary
injury if the resultant smoke particles are inhaled.
Safety measures to minimize hazards
Each hospital trust should have an established safety programme
in place, governing the safe use of medical device lasers and the
steps taken to limit the potential associated hazards. The main
features can be considered in terms of three areas and should
include the following.
General considerations

A laser protection advisor (LPA) responsible for initial
assessment of risk and determining of hazards, as well
as proposing any necessary protective controls and
procedures.

A laser protection supervisor (LPS) to ensure the safe and
appropriate use of lasers.

A well-defined laser-controlled area with locked doors,
covered windows and appropriate warning signs, to pre-
vent exposure of those outside this area.

Protection eyewear for use by staff and patients, appro-
priate for the specific laser in use.

Extraction systems in place to minimize the risk of smoke
inhalation.

Immediate availability of an appropriate fire extinguisher.
Surgical considerations

The use of non-reflective surgical instruments to minimize
reflection of the laser beam.

The use of a guidance beam for lasers of non-visible
wavelengths.

Protection of surrounding tissue with wet swabs and
avoidance of combustible drapes and spirit-based cleaning
solutions.
Anaesthetic considerations

Utilising a low fraction of inspired oxygen, thus reducing
the concentration of oxidising agent present.

Avoidance of nitrous oxide, which although not flam-
mable, does support combustion more vigorously than
air.

The use of ‘laser resistant’, non-flammable endotracheal
tubes. The tube cuff is also vulnerable to damage by the
laser and can be filled with saline to dissipate the thermal
energy from the laser, as well as aiding recognition in in-
stances of inadvertent rupture. Laser-resistant endotra-
cheal tubes with two distal cuffs are also available, to
prevent airway soiling in the event of this occurring.

Application of aqueous lubricating gel to any exposed
facial hair, to minimize risk of combustion. A
REFERENCES
1 Maiman TH. Stimulated optical radiation in ruby. Nature 1960; 187:
493e4.
2 Laser radiation: safety advice. 2017. Public Health England, https://
www.gov.uk/government/publications/laser-radiation-safety-
advice/laser-radiation-safety-advice. [Accessed 1 November 2017].
3 BS EN 60825-1: 2014. Safety of laser products: Part 1. Equipment
classification and requirements. London: British Standards Insti-
tution; 2014.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 18:12 650 Ó 2017 Elsevier Ltd. All rights reserved.