Editorial Comment on: Perceptions and Practice Patterns of Holmium Laser Goggles in Endourological Procedures: An Unnecessary Evil? by Paterson et al. (From: Paterson NR,Fitzpatrick R,Blew B,et al. J Endourol 2019;33:146–150;DOI: 10.1089/end.2018.0432)

When we perform an endoscopic holmium laser lithotripsy, which goggles should we be wearing? Prescription glasses, radiation safety glasses, holmium laser glasses, or all? Of course, there are prescription glasses available that protect us against radiation and holmium laser. However, they are expensive. Let us assume that we are willing to accept these expensive prescription glasses. The advantage of these glasses is that a single pair can help us see clearly in addition to protecting our eyes from radiation and holmium laser. Beside the expense, another disadvantage of these glasses is that once our eye prescription changes, then we would need to buy a new pair of glasses with radiation and holmium laser protection.

Another option is to use combination of radiation and holmium laser safety goggles over our prescription glasses. The advantage of this option is that it is cheaper to change the pair of prescription glasses should the prescription change. However, these over prescription radiation/holmium laser safety goggles impede peripheral vision. This was mentioned by 70% of respondents in the recent survey of Paterson et al. and it may have contributed to noncompliance because only a minority (40%) wore holmium laser safety goggles. ¹ This is slightly better than previously reported compliance of 17.2% with radiation safety goggles. ²

If we cannot find goggles that protect our eyes against both radiation and holmium laser, which protection is more important? Radiation or holmium laser? Recent in vivo experiments have shown that there was no corneal damage when the holmium laser was fired from a distance of ≥5 cm from the unprotected pig eyes for energies up to 20 W at 5 seconds. ³ In addition, prescription glasses were equally protective against holmium laser as holmium laser protection goggles. ³ Therefore, prescription glasses are adequate to protect against holmium laser. Given these results, 86% of current survey respondents would opt for prescription glasses/regular eye protection glasses rather than wearing holmium safety goggles. ¹ This study also confirms previously reported lack of documented eye injuries from holmium lasers. ⁴

If regular prescription glasses protect us from holmium lasers, do we still need to wear radiation protection goggles? I believe that for the practicing endourologist, protection from excessive radiation to the lenses of our eyes is more important than wearing holmium laser protection glasses especially when we already wear prescription glasses. This is because regular prescription glasses do not protect our eyes from radiation. Therefore, radiation protection goggles could be worn over prescription glasses.

Finally, another reason to use eye protection glasses during endourologic procedures is to protect our eyes from contamination with body fluids and irrigation fluid because these have been shown to occur in majority (67%) of transurethral cases even with the use of lens-mounted cameras. ⁵ To improve compliance with protective eyewear, future radiation safety/holmium laser safety goggles need to be cheaper, lighter, and well ventilated with improved peripheral vision.