|Year : 2020 | Volume
| 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 Submission||06-Apr-2020|
|Date of Acceptance||07-Oct-2020|
|Date of Web Publication||11-Dec-2020|
Dr. Mohamed ElDakkak
55 Cardinal Place, SO16 4HR, Southampton
Source of Support: None, Conflict of Interest: None
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
| Introduction|| |
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.
Here, we report cases of subhyaloid premacular hemorrhage and vitreous hemorrhage in two young patients after accidental exposure to a laser pointer.
| Methods|| |
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|| |
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)|
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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].
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|| |
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.
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.,,,,,,,,,,,,,,,,,,,,,
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.
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.,,,,,,,,,,, Two patients only required yttrium aluminum garnet (YAG) laser posterior hyaloidotomy and vitrectomy for preretinal hemorrhage and macular hole, respectively., Only one patient received an intravitreal ranibizumab injection for a dense macular subretinal hemorrhage. Another patient received only medical treatment in the form of nonsteroidal anti-inflammatory drugs. There were three patients who received oral steroids for their conditions.,,
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.
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.
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.
| Summary|| |
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
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]