Purpose
To describe the clinical and imaging findings in 3 patients with maculopathy secondary to handheld laser exposure.
Design
Retrospective, observational case series.
Methods
We evaluated the multimodal imaging including fundus autofluorescence and spectral-domain optical coherence tomography (OCT) for 3 patients with histories of exposure to handheld lasers.
Results
An 18-year-old woman with a history of repetitive self-inflicted handheld laser exposure was found to have bilateral outer retinal streaks in the macula and the superior peripheral retina on both ophthalmoscopy and multimodal imaging. Initial spectral-domain OCT revealed vertical hyper-reflective bands at the level of the outer retina corresponding to the streaks. An 11-year-old boy who played with a green laser developed a yellow foveal lesion and outer retinal streaks in the superior macula. Spectral-domain OCT showed vertical hyper-reflective bands in the outer retina corresponding to the streaks. A 14-year-old boy developed bilateral focal foveal lesions and ellipsoid loss on spectral-domain OCT following peer-inflicted laser injury.
Conclusions
In a series of 3 patients, outer retinal streaks were associated with self-inflicted handheld laser injury. In contrast, accidental and peer-inflicted laser injuries were found to result in focal foveal lesions.
Retinal phototoxicity may follow exposure to a variety of light sources, including sunlight, surgical illumination during anterior and posterior segment intraocular surgery, and lasers. Handheld laser devices are now readily accessible to the public for purchase and, correspondingly, a number of reports of handheld laser-induced maculopathy have appeared in the literature.
Several studies have described the spectral-domain optical coherence tomography (OCT) findings of vertical hyper-reflective bands, ellipsoid and external limiting membrane disruption, and hyporeflective cavities in patients with laser-induced maculopathy. In addition, Alsulaiman and colleagues described choroidal neovascularization and subhyaloid hemorrhage as well as macular hole and epimacular membrane formation following laser injury. We describe multimodal imaging in 3 young patients who developed handheld laser-induced maculopathy, including the development of distinctive outer retinal streaks in 2 patients in whom the injury was self-inflicted.
Methods
This study was declared exempt by the Western Institutional Review Board, and it adhered to the tenets of the Declaration of Helsinki as well as all federal and state laws. The records of 3 patients with laser-induced maculopathy were examined. The following data were collected for each of the 3 cases: demographic information, past medical histories, Snellen visual acuity at presentation and follow-up, and clinical examination findings. Multimodal imaging was analyzed including fundus photographs, spectral-domain OCT, fundus autofluorescence, and fluorescein angiography.
Results
Case 1
An 18-year-old woman previously in good health described blurred vision in both eyes for 3 weeks. Best-corrected visual acuity was 20/50 OD and 20/40 OS. Ophthalmoscopic examination revealed bilateral perifoveal retinal pigment epithelial (RPE) changes. After 4 weeks, her visual acuity had declined to 20/150 OD and 20/200 OS. Ophthalmoscopic examination of the macula revealed marked progression, including the formation of contiguous irregular gray-white streaks at the level of the outer retina and RPE ( Figure 1 , Top row) that were readily visible on fluorescein angiography ( Figure 1 , Second row). Spectral-domain OCT showed bilateral disruption of the ellipsoid zone and outer retinal hyper-reflective bands associated with the streaks, as well as lamellar macular hole formation OD ( Figure 1 , Third and Fourth rows).
Given these findings and the progression, the patient was asked about a history of laser exposure. The mother was a flight attendant and had bought 3 laser pointers during a recent trip to China, including red (50 mW), green (100 mW), and purple (50 mW) wavelengths. The patient admitted to playing with these lasers in her bedroom including staring directly at the laser beam. Risks for retinal injury from handheld lasers were discussed with the patient and family.
Follow-up examination 5 weeks after initial consultation showed stabilization of the visual acuity to 20/160 OD and 20/100 OS. Ophthalmoscopic examination showed curvilinear tracks of RPE alteration in the superior periphery of each eye ( Figure 2 , Top left). Both the central and peripheral lesions were hyper-autofluorescent ( Figure 2 , Top right and Bottom left). Spectral-domain OCT revealed progression to full-thickness macular hole OD ( Figure 2 , Bottom right).
Case 2
An 11-year-old boy previously in good health presented with acute severe loss of vision OS for 1 day. Best-corrected visual acuity was 20/20 OD and hand motions OS. Ophthalmoscopic examination revealed a deep, yellow foveal lesion and prominent gray-white linear streaks at the level of the outer retina in the superior macula OS ( Figure 3 , Top left). No lesions were visualized OD.
Autofluorescence imaging showed central hypoautofluorescent streak lesions consistent with RPE disruption ( Figure 3 , Top right). Fluorescein angiography revealed the linear streaks to be hyperfluorescent in the early phase due to window defect. Spectral-domain OCT revealed significant disruption of the ellipsoid zone and of the external limiting membrane at the fovea ( Figure 3 , Bottom right, upper image). Additionally, vertical hyper-reflective bands extended from the ellipsoid zone through the outer nuclear layer and corresponded to the outer retinal streaks seen on ophthalmoscopic examination. The patient was asked about exposure to handheld lasers and admitted to playing with a green laser pointer of unknown power and to having peered directly into the laser beam. He denied using reflective surfaces including mirrors, during play. Risks for retinal injury caused by handheld lasers were discussed with the patient and family.
Follow-up examination 1 month after initial evaluation showed that visual acuity had improved to counting fingers at 5 feet OS. Ophthalmoscopic examination showed resolution of the yellow foveal lesion and subsequent formation of granular perifoveal RPE changes. The previously visualized streaks had resolved ( Figure 3 , Bottom left). Spectral-domain OCT revealed re-formation of the external limiting membrane and patchy restructuring of the ellipsoid zone ( Figure 3 , Bottom right, lower image). The vertical hyper-reflective bands had fully resolved. The laser was provided and confirmed to be of the green wavelength; however, no brand or property information was labeled on the device.
Case 3
A 14-year-old boy previously in good health presented with bilateral gradual loss of vision over 5 weeks duration. Best-corrected visual acuity was 20/50 OD and 20/70 OS. Ophthalmoscopic examination revealed perifoveal RPE changes greater in the left eye than in the right eye. No linear streaks were identified.
Autofluorescence imaging showed central hypo-autofluorescence consistent with RPE disruption bilaterally. A hyper-autofluorescent rim was identified surrounding the lesion OS. Fluorescein angiography revealed granular RPE changes. Spectral-domain OCT showed focal disruption of the ellipsoid zone with patchy preservation of the external limiting membrane OD. Both the external limiting membrane and the ellipsoid zone were disrupted at the fovea OS. The patient was asked about exposure to handheld lasers and admitted that another boy had repeatedly shined a laser into his eye when he had been at summer camp 5 weeks earlier.
Follow-up examination 1 month after initial evaluation showed that visual acuity had improved to 20/20 OD and 20/30 OS. Ophthalmoscopic examination showed bilateral, mild granular perifoveal RPE changes. Spectral-domain OCT revealed complete re-formation of the external limiting membrane and ellipsoid zone in both eyes.
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