Laser pointers and the human eye: a clinicopathologic study

Presumed Sertraline-Associated Maculopathy: A Case Series

Purpose

To report findings of maculopathy after treatment with sertraline in three patients.

Methods

This case series includes three patients who presented with reduced visual acuity after treatment with sertraline for various psychiatric indications. All patients had been treated with sertraline for varying periods of time between 4 weeks and 5 years.

Results

Data were collected from three patients (age range, 27–68 years). All three patients were white females, with both eyes being affected in all cases. The range of presenting visual acuities was between 20/30 and 20/100 after presentation with central visual disturbance. All patients underwent comprehensive ocular examination and imaging with the main ocular findings being outer retinal layer and retinal pigment epithelial disruption. The follow-up period was between 1 and 9 months with final visual acuities between 20/25 and 20/100. Patients showed objective clinical evidence of phenotypically similar maculopathy supported by appropriate imaging

Conclusion

In this cohort, we report the possible association of sertraline use and associated maculopathy in three patients. This is potentially significant, given the large numbers of patients treated with sertraline currently; however, further evidence is required to both quantify how common this association is and establish a possible causative mechanism.

Multimodal imaging in phototoxic maculopathy: description of findings in a series of 12 patients

OBJECTIVE

To study the differences between solar retinopathy (SR) and the maculopathy produced by laser pointer (LPM) using multimodal imaging.

METHOD

A retrospective series is presented of 20 eyes of 12 patients with injuries associated with light, 7 with SR-compatible injuries, and 5 with LPM. At diagnosis, a complete ophthalmological examination was performed, including visual acuity (VA), retinography, and spectral domain optical coherence tomography (OCT). The patients were followed-up for a mean period of 20 months.

RESULTS

LPM is common in paediatrics (mean age 15.60±1.5years), and SR affects patients of all ages (mean age 47.56±1.51years). VA at diagnosis in LPM is greater, and recovery is more complete than in solar retinopathy. In conventional retinography, SR is shown as a single lesion in the macular area (100% of cases), while LPM usually presents as multifocal lesions (86% of cases). Infrared reflectance makes this difference clearer. The main sign in OCT is the disruption of the ellipsoid layer and interdigitation zone. This sign is maintained over time, and its size is greater in the SR than in the LPM. Hyper-reflective columns and hyper-reflective reaction of the retinal pigment epithelium are associated with the acute phase.

CONCLUSIONS

LPM and SR show significant differences in the type of patient affected, as well as in the signs in multimodal imaging, as well as in functional impairment and their evolution.

Optical coherence tomography angiography findings of choroidal neovascularization secondary to laser injury: A case report

Purpose

To report a case of choroidal neovascularization (CNV) secondary to laser injury imaged by optical coherence tomography angiography (OCTA) and treated by intravitreal anti-vascular endothelial growth factor (VEGF).

Observations

A 14-year-old boy presented with vision loss and central scotoma in the right eye (RE) in the last month, after having stared at the beam of a laser pointer. At presentation, his best-corrected visual acuity (BCVA) in the RE was 20/40 and spectral-domain OCT (SD-OCT) showed an interruption of ellipsoid zone and the presence of an hyperrelfective lesion in subfoveal region. OCTA examination revealed the presence of a high-flow lesion on both outer retina to choriocapillaris (ORCC) and choriocapillaris segmentations. The patient was treated by one anti-VEGF injection: at one month follow-up his BCVA in the RE was 15/20. SD-OCT revealed the complete resolution of hyperreflective lesion and no detectable flow on OCTA.

Conclusions and Importance

Retinal laser injury may be complicated by CNV. OCTA may non-invasively assess the presence of CNV, as well as treatment-response.

Non-Therapeutic Laser Retinal Injury

BACKGROUND:

As lasers have become an increasingly important component of commercial, industrial, military, and medical applications, reported incidents of non-therapeutic laser eye injuries have increased. The retina is particularly vulnerable due to the focusing power and optical transparency of the eye. Continued innovations in laser technology will likely mean that lasers will play an increasingly important and ubiquitous role throughout the world. Critical evaluation should thus be paid to ensure that non-therapeutic injuries are minimized, recognized, and treated appropriately.

METHODS:

A comprehensive literature review on the PubMed database was conducted to present case reports and case series representative of the variety of laser eye injuries in different injury circumstances, tissue types, and biological damage mechanisms.

RESULTS:

A general summary of non-therapeutic laser retina injuries is presented, including information about growth of the industry, increasingly accessible online markets, inconsistent international regulation, laser classifications, laser wavelengths, and laser power, mechanisms of tissue injury, and a demonstration of the variety of settings in which injury may occur. Finally, 68 cases found in the literature are summarized to illustrate the presentations and outcomes of these patients.

CONCLUSIONS:

As non-therapeutic laser eye injuries increase in frequency, there is a greater need for public health, policy, diagnosis, and treatment of these types of injuries.

Green laser induced foveal cyst sustained in a recreational laser light show

We report the case of a 9-year-old boy complained of visual loss in his right eye after watching green laser light show being hit by a ray of a laser at shopping center before five days ago. The laser had a maximum power rating of 30 mW (US Food and Drug Administration class IIIB). Best-corrected visual acuity in his right eye was 0.2 with Snellen at 5 days after the injury. Dilated fundoscopic examination demonstrated a macular hole appearance in the right eye. Spectral domain optical coherence tomography (OCT, Spectralis, Heidelberg Engineering, Heidelberg, Germany) demonstrates a steep fovea contour, a thickening of the macular edges, intraretinal cysts, disruption of the photoreceptor inner segment/outer segment layer and macular pseudohole formation. Central foveal thickness (515 µm) was increased. Two months after the injury, the patient's visual acuity improved to 0.9 in the right eye without any ocular treatment. Spectral domain OCT revealed the closure of the macular hole with the resolution of the cystic spaces. At 6-months follow-up, visual function had fully recovered and macular assessment was normal.

Optical Coherence Tomography Angiography Findings in Laser Maculopathy

Purpose

Handheld laser pointer thermal injury affects primarily the retinal pigment epithelium (RPE). However, so far no study has reported on the possible effects of laser pointers in the deeper layers, beneath the RPE. Here, we describe the spectral-domain optical coherence tomography angiography findings in the choriocapillaris of a patient with laser maculopathy.

Methods

A 13-year-old boy presented to our department with decreased vision in the left eye 12 hours after having stared at the beam of a laser pointer.

Results

Structural optical coherence tomography (OCT) showed 2 focal hyperreflective columns at the fovea extending from the RPE, involving all outer retinal layers, and terminating at the outer plexiform layer. The patient also underwent OCT angiography (OCT-A), which in the choriocapillary segmentation revealed 2 hypointense lesions in correspondence of the focal hyperreflectivities detected on structural OCT. We hypothesize that the OCT-A findings could represent a rarefaction of the choriocapillaris. However, the choriocapillary OCT-A findings could also represent artifacts due to the overlaying hyperreflective lesions.

Conclusions

It is known that the RPE is primarily damaged by the laser injury. Our findings suggest that the thermal injury could involve also the choriocapillaris, and thus not limited to the RPE. Multimodal imaging in laser maculopathy including OCT-A may lead to a better comprehension of the pathogenesis of laser retinal damages.

Retinal Injury Secondary to Laser Pointers in Pediatric Patients

This case report describes 4 male children (age, 9-16) who had laser-related retinal injury to the macula of 1 eye or both eyes due to the mishandling of the laser pointer devices at a single vitreoretinal clinical practice. The presenting symptoms associated with laser pointer injury include central vision loss, central scotoma, and metamorphopsia. Clinical findings of laser-related retinal injury include reduced visual acuity, disruption of the photoreceptor ellipsoid zone, retinal pigment epithelium atrophy, and choroidal neovascular membrane formation. Disruption of the foveal ellipsoid zone (photoreceptor inner segment/outer segment layer) is the most common finding on optical coherence tomography imaging. Three patients had potential irreversible vision loss. Laser pointers are readily available and appropriate use of laser pointers in the pediatric population must be emphasized due to the potential irreversible retinal injury. Health professionals, school teachers, and parents should raise public awareness of this emerging public health issue by educating children about the dangers of laser pointers. Laser pointer devices among children should be discouraged and limited due to the possibility of permanent harm to themselves and others. Legislation and laws may be required to better control the sale and use of these devices.

Laser-Induced Photic Injury Phenocopies Macular Dystrophy

OBJECTIVE

To describe the phenotypes associated with laser-induced retinal damage in children.

METHODS

Five patients with maculopathy and reduced visual acuity associated with laser pointer use were evaluated. Best-corrected visual acuity, retinal structure, and function were monitored with color fundus, infrared (IR), and red-free images, fundus autofluorescence (AF), spectral domain-optical coherence tomography (SD-OCT), and full-field electroretinography (ERG).

RESULTS

All five laser pointer injury patients had retinal lesions resembling a macular dystrophy (one bilateral and four unilateral). These lesions were irregular in shape but all had a characteristic dendritic appearance with linear streaks radiating from the lesion. Photoreceptor damage was present in all patients, but serial OCT monitoring showed that subsequent photoreceptor recovery occurred over time in the eyes of at least four patients. One patient also had bilateral pigment epithelial detachments (PED). Both hyper- and hypoautofluorecence were observed in the laser damage area.

CONCLUSIONS

In general, OCT and IR images are quite useful to diagnose laser damage, but AF is not as sensitive. Laser pointer damage in children can occasionally be misdiagnosed as a macular dystrophy disease, but the distinctive lesions and OCT features are helpful for differentiating laser damage from other conditions.

Green-laser induced maculopathy in a 15-year-old boy

We report the case a 15-year-old boy who presented with retinopathy caused by a green-diode (class IIIB) laser. The patient was followed over a period of 8 weeks. Visual acuity on day 1 was 6/7.5, with central scotoma in the right eye, and 6/5 in the left eye. Macular optical coherence tomography of the right eye day 1 showed focal subfoveal disruption of the photoreceptor ellipsoid and myoid zones extending through the external limiting membrane to the outer nuclear layer. At week 8, visual acuity was 6/6 right eye and 6/5 in the left eye. Disruption of the ellipsoid and myoid layers, though still present, had improved.

Spectral-domain optical coherence tomography and fundus autofluorescence findings in a case of laser pointer-induced maculopathy

PURPOSE

To describe the spectral-domain optical coherence tomography and fundus autofluorescence findings in a case of laser pointer-induced maculopathy.

METHODS

Observational case report of a patient with bilateral decreased visual acuity after exposure to a handheld green laser pointer.

RESULTS

A 15-year-old boy presented with decreased vision after exposure to a green laser pointer. Fundoscopy revealed gray and yellowish round spots in the foveal area of both eyes. Fundus autofluorescence imaging revealed subtle changes of the normal background macular autofluorescence of the right eye, with hyperautofluorescence dots in the fovea of the left eye. Spectral-domain optical coherence tomography showed a variety of changes of the outer retina and retinal pigment epithelium, with disruption of the external limiting membrane, the photoreceptor ellipsoid zone of the inner segments, and the interdigitation zone in the foveal region in both eyes. Six months after laser exposure, fundoscopic examination showed persistent alterations at the level of the retinal pigment epithelium in the fovea in both eyes. Fundus autofluorescence revealed mild but persistent changes of the normal autofluorescent macular background in both eyes. Spectral-domain optical coherence tomography showed partial resolution of the outer retinal disruption noted on his initial visit with persistent, small foveal photoreceptor defects in both eyes.

CONCLUSION

Laser pointer maculopathy may disturb the outer retinal architecture in a manner evident on spectral-domain optical coherence tomography and fundus autofluorescence, resulting in decreased visual acuity. Proper warnings should accompany these devices and access to them by minors should be limited.

Thermal macular injury from a 154 mW green laser pointer

We report a case of accidental thermal injury due to improper use of a laser pointer obtained outside of the United States. A 13-year-old received a laser pointer as a gift and looked at a reflection of the beam. The patient underwent full ophthalmologic examination with fundus photography, spectral domain optical coherence tomography, and fluorescein angiography. Visual acuity in the left eye was 20/100 at presentation. Fundus examination and ancillary tests were consistent with thermal macular injury. The laser pointer was analyzed and found to be a green diode laser with average power output of 154 mW.

Photoblepharokeratoconjunctivitis caused by invisible infrared radiation emitted from a green laser pointer

There are a wide variety of laser pointers sold to the general public. Among those are the high-powered diode-pumped solid-state lasers (>5 mW), which do not follow the laser safety regulations for packing, and are sold as regular lasers without the infrared (IR) filters. In this case report, we encountered a patient with photoblepharokeratoconjunctivitis caused by the invisible IR radiations emitted from a green laser pointer. Owing to the thermal effect of the invisible IR rays led to the disease.

Laser pointer induced macular damage: case report and mini review

To report laser pointer induced damage to retina and choroid and briefly review literature. A case report of a 13-year old Caucasian boy developed blurry central vision and central scotoma in right eye (OD). He was exposed for one minute to class IIIA green laser pointer of 650 nm wavelength and 5 mW power. Clinical examination showed a grayish lesion in foveal region. Ancillary testing revealed disruption of the retinal pigment epithelial (RPE) layer in foveal region and indocyanine green angiography demonstrated evidence of choroidal hypofluorescence suggestive of choroidal infarction in OD. Visual acuity improved from 20/100 to 20/60 in one day and he was treated with tapering doses of oral prednisolone (40 mg) for 3 weeks. Laser pointer with a power of >5 mW caused damage to RPE in the macula. Children should not be given laser pointers as toys especially those with label of danger instructions.

SD-OCT features of laser pointer maculopathy before and after systemic corticosteroid therapy

The authors report spectral-domain optical coherence tomography findings of laser pointer-induced maculopathy in a 25-year-old man after accidental laser pointer exposure of less than 1 second. The Class 3R laser pointer (output wavelength 532 nm and output power 3.5 to 4.5 mW [continuous wave]) had U.S. Food and Drug Administration certification. One day after exposure, he had visual blurring and metamorphopsia of his right eye. He was treated with a systemic high-dose corticosteroid. Spectral-domain optical coherence tomography disclosed a hyperreflective band in the foveal region. After 1 week of treatment, disappearance of hyperreflectivity was observed on spectral-domain optical coherence tomography. At 6 months, residual disruption of the outer retinal layer at the fovea remained unchanged. Spectral-domain optical coherence tomography was a useful and sensitive tool for evaluating retinal damage and subsequent resolution after treatment.

Green laser pointers for visual astronomy: how much power is enough?

PURPOSE

Green laser pointers with output powers in the tens to hundreds of milliwatt (mW) range, clearly exceeding the limiting 5 mW of American National Standards Institute class 3a (International Electrotechnical Commission class 3R), are now easily available in the global market. They are increasingly being used in public sky observations and other nighttime outreach activities by educators and science communicators in countries where their use is not well regulated, despite the fact that such high power levels may represent a potential threat to visual health. The purpose of this study was to determine the output power reasonably required to perform satisfactorily this kind of activities.

METHODS

Twenty-three observers were asked to vary continuously the output power of a green laser source (wavelength 532 nm) until clearly seeing the laser beam propagating skyward through the atmosphere in a heavily light-polluted urban setting. Measurements were conducted with observers of a wide range of ages (9 to 56 years), refractions (spherical equivalents -8.50 to +1.50 diopters), and previous expertise in using lasers as pointing devices outdoors (from no experience to professional astronomers). Two measurement runs were made in different nights under different meteorological conditions.

RESULTS

The output power chosen by observers in the first run (11 observers) averaged to 1.84 mW (+/-0.68 mW, 1 SD). The second run (17 observers) averaged to 2.91 mW (+/-1.54 mW). The global average was 2.38 mW (+/-1.30 mW). Only one observer scored 5.6 mW, just above the class 3a limit. The power chosen by the remaining 22 observers ranged from 1.37 to 3.53 mW.

CONCLUSIONS

Green laser pointers with output powers below 5 mW (laser classes American National Standards Institute 3a or International Electrotechnical Commission 3R) appear to be sufficient for use in educational nighttime outdoors activities, providing enough bright beams at reasonable safety levels.

Shedding some light on laser pointer eye injuries

OBJECTIVES

Laser use has become common in the home and workplace. We present a review of laser eye injuries and guidance for the emergency medicine physician on evaluation of laser eye injury-related complaints.

METHODS

A review of the literature on the potential for injury, concerning signs and symptoms, evaluation, and referral recommendations is discussed.

RESULTS

The scientific literature finds that laser eye injuries are uncommon from use of nonindustrial lasers. Furthermore, an eye injury from a regulated Class 2 or Class 3A by a transient sweep across the line of vision does not result in injury, but injury can occur with a direct intentional prolonged exposure.

CONCLUSIONS

Patient's history of the length and type of laser exposure is important. A significant direct eye exposure to a laser, persistent after images, and decreased visual acuity should initiate urgent referral to an ophthalmologist for further ophthalmologic testing. Brief laser exposure or indirect exposures with complaints of headaches or blurry vision require other diagnostic explanations.

The power output of laser pointers: do they exceed federal standards?

BACKGROUND

Concern about the safety of laser pointers has increased as these devices have become readily available to the public, which includes children who may use them improperly. According to federal (Food and Drug Administration) standards, laser pointers are class 3a devices, and power output cannot exceed 5.0 mW.

METHODS

We tested a sample consisting of 29 red diode laser pointers obtained from various sources that were equipped with fresh batteries. Power output was measured with an optical power meter with the sensor 5.0 cm from the laser. The laser was turned on for 60 s and a reading was taken every 10 s. This procedure was repeated five times for every laser.

RESULTS

The power output of unaltered lasers ranged from 0.7 mW to a high of 3.9 mW. Alterations to some of the lasers increased the output slightly above 5.0 mW.

CONCLUSIONS

When the laser pointers in our sample were used as packaged, they did not exceed the federal standards of 5.0 mW.