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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 25-28

Preretinal hemorrhages after accidental exposure to a laser pointer: Two case reports


Eye Unit, University Hospital Southampton NHS Foundation Trust, Southampton, England

Date of Submission06-Apr-2020
Date of Acceptance07-Oct-2020
Date of Web Publication11-Dec-2020

Correspondence Address:
Dr. Mohamed ElDakkak
55 Cardinal Place, SO16 4HR, Southampton
England
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/erj.erj_6_20

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  Abstract 


We report here cases of subhyaloid premacular haemorrhage and vitreous haemorrhage in two young patients after accidental exposure to a laser pointer.

Keywords: Hemorrhage, laser, retina


How to cite this article:
ElDakkak M. Preretinal hemorrhages after accidental exposure to a laser pointer: Two case reports. Egypt Retina J 2020;7:25-8

How to cite this URL:
ElDakkak M. Preretinal hemorrhages after accidental exposure to a laser pointer: Two case reports. Egypt Retina J [serial online] 2020 [cited 2021 Jun 21];7:25-8. Available from: https://www.egyptretinaj.com/text.asp?2020/7/1/25/302996




  Introduction Top


Handheld lasers are commonly used as pointers in academic, laboratory, and industrial settings. These devices are more frequently used by the general public because of the ease of availability from the Internet and their low cost. In 2010, the Food and Drug Administration released a report highlighting the potential eye and skin hazards of available handheld lasers, particularly when used recreationally by children.[1]

Here, we report cases of subhyaloid premacular hemorrhage and vitreous hemorrhage in two young patients after accidental exposure to a laser pointer.


  Methods Top


The patients were examined at their initial presentation and follow-up visits for full ophthalmological examination including best-corrected visual acuity, intraocular pressure, slit-lamp examination, and detailed fundus examination. Follow-up was from 8 to 16 weeks. The first patient was followed up by fundus photography and optical coherence tomography (OCT). The second patient needed B-scan ultrasound and fundus photography at the initial presentation and was followed up by fundus photography only on later visits.


  Case Reports Top


Case 1

A 20-year-old male patient presented with an acute drop in vision in his right eye 5 days ago, after direct accidental exposure to a laser pen torch held by a friend.

His past ocular and medical history was negative. He sought medical advice in another hospital and was prescribed topical nonsteroidal anti-inflammatory eye drops. He was a smoker, and no other relevant history was reported.

On examination, unaided visual acuity was counting fingers at 1 m in the right eye and 20/20 in his left eye. He was emmetropic, and anterior segment examination revealed no abnormal findings. Applanation tonometry was 18 mmHg for both eyes. The pupils were round, were regular, and were reactive in both eyes. Fundus examination revealed right premacular subhyaloid hemorrhage. OCT was done which showed subhyaloid dense premacular hemorrhage obscuring macular details [Figure 1].
Figure 1: Fundus pictures and optical coherence tomography of the right eye in case 1 showing initial presentation with subhyaloid premacular hemorrhage (top left and right) and then after 16 weeks of follow-up with total clearance of hemorrhage and formation of a nontractional epimacular membrane associated with macular retinal pigment epithelium atrophic changes (bottom left and right)

Click here to view


After 2 weeks, examination showed that unaided visual acuity was counting fingers 1 m in the right eye with mild improvement of subhyaloid hemorrhage. The intraocular pressure was 17 mmHg OU. After 6 weeks, vision had improved to 20/400 with more clearing of subhyaloid hemorrhage, and there was evidence of mild fibrinoid changes. After 8 weeks, more improvement was reported in his vision in the right eye to be 20/80, with more healing of subhyaloid hemorrhage.

Total clearance of subhyaloid hemorrhage was reported after 16 weeks of follow-up with a notable improvement in the vision of the right eye to be 20/40 and formation of a nontractional epimacular membrane associated with macular retinal pigment epithelium atrophic changes [Figure 1].

Case 2

A 15-year-old male patient presented with a sudden drop in vision in his left eye 1 day ago, after direct exposure to a laser pen torch to the left eye. His past ocular history was negative. He had a history of seasonal bronchial asthma controlled by inhaled steroids and bronchodilators.

On examination, unaided visual acuity was 20/25 in the right eye and counting fingers near face in his left eye. His refraction showed low-grade myopia in both eyes, and anterior segment examination revealed no abnormal findings. Applanation tonometry was 13 mmHg for both eyes. The pupils were round, were regular, and were reactive in both eyes.

Fundus examination revealed left vitreous and subhyaloid hemorrhages obscuring central fundus view with stable retinal periphery. B-scan ultrasonography was done for the left eye, which showed dense vitreous hemorrhage with a flat, stable retina [Figure 2]. The patient was advised to be under rest in semi-sitting position and to be followed up after 4 days.
Figure 2: (a and b) Fundus photography and B-scan ultrasound of the left eye of case 2 showing vitreous and subhyaloid hemorrhages at the initial presentation. (c) Fundus photography after 4 days showing diffuse vitreous hemorrhage. (d) Fundus photography after 8 weeks showing resolved vitreous hemorrhage

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After 4 days, the patient presented with no change in his visual acuity, and his left eye showed more diffuse vitreous hemorrhage. On follow-up after 10 days following the initial presentation, the patient showed an improvement of the vision in his left eye, and uncorrected visual acuity was 20/25 in the right eye and 20/70 in the left eye. This improvement was consistent with the fundus examination findings as well, which showed an improvement of the vitreous hemorrhage in the same eye.

After 8 weeks, the patient presented with uncorrected visual acuity of 20/20 in the right eye and 20/25 in his left eye. The intraocular pressure was 13 mmHg in the right eye and 14 mmHg in the left eye. Fundus examination showed left inferior residual and organized vitreous hemorrhage with a stable peripheral retina in this eye [Figure 2]. A further visit was recommended in 4 weeks to ensure total clearance of the vitreous hemorrhage in the left eye.


  Discussion Top


There is an evidence of laser-induced maculopathy and retinopathy in different forms. Lasers can affect the retina through several mechanisms, including photocoagulation, photodisruption, or photochemical interaction. The wavelength, duration of exposure, spot size, power, and location can determine the severity of retinal damage. It has been found that blue lasers are more likely to cause retinal injury compared with green or red lasers.[2]

Many case reports of handheld laser or laser pointer injury were reported between 1999 and 2014. There seem to be increased reports of injuries in literature since 2007 from commercially available handheld lasers of various wavelengths. This may be related to its increased availability to the public by the Internet, promotion of handheld laser for recreational use such as popping balloons, and increased awareness of this entity. For all cases of inadvertent exposure, there is a slight preponderance of males as well as for teenagers and young adults.[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24]

In a Collaborative Retina Study of 14 patients in 2013, the reported types of maculopathies with laser-induced injuries were full-thickness macular hole (FTMH), premacular subhyaloid hemorrhage, premacular subinternal limiting membrane hemorrhage, outer retinal disruption at the fovea, epimacular membrane, and schisis-like cavity.[5]

In most of the reported cases of laser-induced retinal injury, observation of the laser injury from 3 weeks up to 11 months was the main line of treatment.[4],[13],[14],[15],[16],[18],[19],[20],[21],[22],[23],[24] Two patients only required yttrium aluminum garnet (YAG) laser posterior hyaloidotomy and vitrectomy for preretinal hemorrhage and macular hole, respectively.[5],[7] Only one patient received an intravitreal ranibizumab injection for a dense macular subretinal hemorrhage.[17] Another patient received only medical treatment in the form of nonsteroidal anti-inflammatory drugs.[12] There were three patients who received oral steroids for their conditions.[6],[9],[11]

In another retina collaborative study, only 29% of the reported patients improved spontaneously with a spontaneous increase in vision and 71% of patients required intervention in the form of YAG laser posterior hyaloidotomy with subhyaloid hemorrhage and pars plana vitrectomy for eyes with FTMH and epimacular membrane.[5]

The use of oral steroids in those patients with laser-induced retinal injury reported some changes in OCT in the form of disappearance of hyperreflective band in the foveal region on OCT after 1 week of treatment, and at 6 months, although, the residual disruption of the outer retinal layer at the fovea remained unchanged.[11]

It is also important to know that laser pointer damage in children can occasionally be misdiagnosed as a macular dystrophy, especially if the detailed history of laser injury cannot be obtained, but the distinctive lesions and OCT features are helpful for differentiating laser damage from other conditions.[25]


  Summary Top


Laser-induced retinal injury through commercially available laser pointers and other similar instruments increased in incidence in the last two decades. Laser injury maculopathies and retinopathies can present in different forms. One of the reported injuries is vitreous and preretinal hemorrhages. Although most complications, including these hemorrhages, may be reversible, still many patients may require intervention in the form of YAG laser posterior hyaloidotomy, especially with subhyaloid hemorrhages. In our two reported patients, we did not intervene and both had a spontaneous improvement of vision over weeks. Despite that, the reported complications should raise the concern of the significant drawbacks on the vision of young children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Food and Drug Administration. Illuminating the Hazards of Powerful Laser Products. Silver Spring, Maryland: FDA; 2009.  Back to cited text no. 1
    
2.
Barkana Y, Belkin M. Laser eye injuries. Surv Ophthalmol 2000;44:459-78.  Back to cited text no. 2
    
3.
Lee GD, Baumal CR, Lally D, Pitcher JD, Vander J, Duker JS. Retinal injury after inadvertent handheld laser exposure. Retina 2014;34:2388-96.  Back to cited text no. 3
    
4.
Yiu G, Itty S, Toth CA. Ocular safety of recreational lasers. JAMA Ophthalmol 2014;132:245-6.  Back to cited text no. 4
    
5.
Alsulaiman SM, Alrushood AA, Almasaud J, Alzaaidi S, Alzahrani Y, Arevalo JF, et al. High-power handheld blue laser-induced maculopathy: The results of the King Khaled Eye Specialist Hospital Collaborative Retina Study Group. Ophthalmology 2014;121:566-72.  Back to cited text no. 5
    
6.
Dirani A, Chelala E, Fadlallah A, Antonios R, Cherfan G. Bilateral macular injury from a green laser pointer. Clin Ophthalmol 2013;7:2127-30.  Back to cited text no. 6
    
7.
Dhoot DS, Xu D, Srivastava S. High-powered laser pointer injury resulting in macular hole formation. J Pediatr 2014;164:668.e1.  Back to cited text no. 7
    
8.
Rusu I, Sherman J, Gallego-Pinazo R, Lam M, Freund KB. Spectral-domain optical coherence tomography and fundus autofluorescence findings in a case of laser pointer-induced maculopathy. Retin Cases Brief Rep 2013;7:371-5.  Back to cited text no. 8
    
9.
Turaka K, Bryan JS, Gordon AJ, Reddy R, Kwong HM Jr., Sell CH. Laser pointer induced macular damage: Case report and mini review. Int Ophthalmol 2012;32:293-7.  Back to cited text no. 9
    
10.
Pollithy S, Ach T, Schaal KB, Dithmar S. Acute bilateral impaired vision with central scotoma in an 11-year-old boy. Ophthalmologe 2012;109:907-10.  Back to cited text no. 10
    
11.
Hossein M, Bonyadi J, Soheilian R, Soheilian M, Peyman GA. SD-OCT features of laser pointer maculopathy before and after systemic corticosteroid therapy. Ophthalmic Surg Lasers Imaging 2011;42:e135-8.  Back to cited text no. 11
    
12.
Ueda T, Kurihara I, Koide R. A case of retinal light damage by green laser pointer (Class 3b). Jpn J Ophthalmol 2011;55:428-30.  Back to cited text no. 12
    
13.
Boosten K, Van Ginderdeuren R, Spileers W, Stalmans I, Wirix M, Van Calster J, et al. Laser-induced retinal injury following a recreational laser show: Two case reports and a clinicopathological study. Bull Soc Belge Ophtalmol 2011;???:11-6.  Back to cited text no. 13
    
14.
Kandari JA, Raizada S, Razzak AA. Accidental Laser Injury to the Eye. Ophthalmic Surg Lasers Imaging. 2010 Mar 9:1-5. PMID: 20337345 - DOI: 10.3928/15428877-20100215-26.  Back to cited text no. 14
    
15.
Fujinami K, Yokoi T, Hiraoka M, Nishina S, Azuma N. Choroidal neovascularization in a child following laser pointer-induced macular injury. Jpn J Ophthalmol 2010;54:631-3.  Back to cited text no. 15
    
16.
Ziahosseini K, Doris JP, Turner GS. Laser eye injuries. Maculopathy from handheld green diode laser pointer. BMJ 2010;340:c2982.  Back to cited text no. 16
    
17.
Wyrsch S, Baenninger PB, Schmid MK. Retinal injuries from a handheld laser pointer. N Engl J Med 2010;363:1089-91.  Back to cited text no. 17
    
18.
Wong R, Sim D, Rajendram R, Menon G. Class 3A laser pointer-induced retinal damage captured on optical coherence tomography. Acta Ophthalmol Scand 2007;85:227-8.  Back to cited text no. 18
    
19.
Robertson DM, McLaren JW, Salomao DR, Link TP. Retinopathy from a green laser pointer: A clinicopathologic study. Arch Ophthalmol 2005;123:629-33.  Back to cited text no. 19
    
20.
Robertson DM, Lim TH, Salomao DR, Link TP, Rowe RL, McLaren JW. Laser pointers and the human eye: A clinicopathologic study. Arch Ophthalmol 2000;118:1686-91.  Back to cited text no. 20
    
21.
Zamir E, Kaiserman I, Chowers I. Laser pointer maculopathy. Am J Ophthalmol 1999;127:728-9.  Back to cited text no. 21
    
22.
Luttrull JK, Hallisey J. Laser pointer-induced macular injury. Am J Ophthalmol 1999;127:95-6.  Back to cited text no. 22
    
23.
Sell CH, Bryan JS. Maculopathy from handheld diode laser pointer. Arch Ophthalmol 1999;117:1557-8.  Back to cited text no. 23
    
24.
Sethi CS, Grey RH, Hart CD. Laser pointers revisited: A survey of 14 patients attending casualty at the Bristol Eye Hospital. Br J Ophthalmol 1999;83:1164-7.  Back to cited text no. 24
    
25.
Zhang L, Zheng A, Nie H, Bhavsar KV, Xu Y, Sliney DH, et al. Laser-induced photic injury phenocopies macular dystrophy. Ophthalmic Genet 2016;37:59-67.  Back to cited text no. 25
    


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  [Figure 1], [Figure 2]



 

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