Retinal Injury Secondary to Pointers in Pediatric Patients Kunyong Xu, MD, MHSc,a Eric K. Chin, MD,b Polly A. Quiram, MD, PhD, c John B. Davies, MD,c D. Wilkin Parke III, MD, c David R.P. Almeida, MD, MBA, PhDc

This case report describes 4 male children (age, 9–16) who had laser-related abstract retinal injury to the macula of 1 eye or both eyes due to the mishandling of the 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 a Department of Ophthalmology, Queen’s University, b this emerging public health issue by educating children about the dangers of Kingston, Ontario, Canada; Retina Consultants of Southern California, Redlands, California; and cVitreoRetinal Surgery, laser pointers. Laser pointer devices among children should be discouraged PA, Minneapolis, Minnesota and limited due to the possibility of permanent harm to themselves and Drs Xu and Almeida conceptualized and designed others. Legislation and laws may be required to better control the sale and the study and drafted the initial manuscript; Drs use of these devices. Chin, Quiram, Davies, and Parke carried out the initial analysis and reviewed and revised the manuscript; and all authors approved the fi nal Laser pointers are low-energy been increasing number of cases of manuscript as submitted. light sources that can emit focal retinal injury caused by mishandling DOI: 10.1542/peds.2016-1188 2–12 nonionizing radiation. They are of laser pointers among in children. Accepted for publication Jul 6, 2016 used in various situations and are Hence, accidental retinal injury among Address correspondence to David R.P. Almeida, MD, inappropriately used as toys for some children due to laser pointer exposure MBA, PhD, VitreoRetinal Surgery, PA, 7760 France children. Most laser pointer devices represents a serious, but preventable, Ave S, Minneapolis, MN 55435. E-mail: dalmeida@ are red (670 nm ) or green public health issue. evolation-medical.com diode (532 nm wavelength). PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). In the United States, the safety level of We report 4 children with retinal laser devices is categorized according injury caused by laser pointer exposure Copyright © 2016 by the American Academy of Pediatrics to the American National Standard to emphasize the significance of Institute Z136.1 and most consumer vision loss due to improper use of the FINANCIAL DISCLOSURE: The authors have devices. Moreover, it is important for indicated they have no fi nancial relationships laser pointers fall under class II or class relevant to this article to disclose. IIIA level of safety, which encompasses health professionals to recognize and FUNDING: No external funding. lasers of 1 to 5 mW or less of power. be cognizant of the presentation and Handheld lasers can be more powerful, natural history of retinal injury from POTENTIAL CONFLICT OF INTEREST: The authors laser pointer use. have indicated they have no potential confl icts of either class 3B (5–500 mW) or class interest to disclose. 4 (> 500 mW), and these lasers may cause immediate eye hazard when METHODS viewed directly.1 Previously, laser To cite: Xu K, Chin EK, Quiram PA, et al. Retinal pointers were considered as harmless; A retrospective review of all cases of Injury Secondary to Laser Pointers in Pediatric Patients. Pediatrics. 2016;138(4):e20161188 however, in recent years, there have laser pointer induced damage to the

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 138 , number 4 , October 2016 :e 20161188 CASE REPORT FIGURE 1 Color fundus photos of right eye (A) and left eye (B) for case 1 revealing pigment clumping with focal RPE atrophy (arrow). OCT imaging of the macula right eye (C) and left eye (D) revealing disruption of the inner segment/outer segment band of the fovea (arrow). retina in the pediatric population for both eyes ( Fig 1 A and B). Optical Funduscopic examination revealed (<18 years of age) at a single coherence tomography (OCT) of the macular pigment changes in the centered vitreoretinal medical/ macula revealed bilateral disruption right eye only ( Fig 2 A and B). OCT surgery practice. of the foveal photoreceptor ellipsoid OD revealed subfoveal outer retinal zone (photoreceptor inner segment/ hyperreflectivity with disruption of outer segment; Fig 1 C and D). the foveal photoreceptors ( Fig 2C). At 7-month follow-up, the BCVA The patient was treated with RESULTS and macular findings remained prednisolone 1% 3 times per day for Case 1 unchanged. OD for 2 weeks. After 1 month, the visual acuity improved to 20/30 OD A 12-year-old boy presented with Case 2 with persistent abnormalities of the bilateral central scotomas and photoreceptors OD. His examination decreased vision shortly after he A 9-year-old boy presented with OS was unchanged. directly looked at the green laser a 4-day history of central scotoma pointer for ~1 minute. His best and vision loss OD. Symptoms Case 3 corrected Snellen visual acuity occurred ~5 to 10 seconds after (BCVA) was 20/20 OD and 20/30 OS. looking at the reflection of a green A 16-year-old boy presented with Funduscopic examination identified laser pointer into a mirror that was a 3-day history of bilateral central pigment clumping with focal retinal directed at his right eye. His BCVA vision loss and central scotoma pigment epithelium (RPE) atrophy was 20/50 OD and 20/25 for OS. that occurred immediately after

Downloaded from www.aappublications.org/news by guest on September 26, 2021 e2 XU et al FIGURE 2 Color fundus photo of right eye (A) for case 2 revealing yellow pigmentary change of the fovea (arrow). The fundus photo of the left eye was unremarkable (B). OCT imaging of the macula right eye (C) revealing subfoveal outer retinal hyperrefl ectivity with some disruption of the foveal photoreceptors at the fovea center (arrow). playing with a green laser pointer Case 4 BCVA improved to 20/20 OD with for approximately half minute. On A 12-year-old boy presented significant improvement in his examination, BCVA was 20/30 OU. with central vision loss and subjective metamorphopsia. Funduscopic examination revealed metamorphopsia with a central macular chorioretinal scars and scotoma right eye, which occurred focal RPE atrophy ( Fig 3 A and B). immediately after looking directly DISCUSSION The OCT revealed disruption of the at the light of a red laser pointer Over the past 15 years, there has photoreceptor ellipsoid zone in both shown into his right eye for ~15 been an alarming increase in reports eyes ( Fig 3 C and D). Two weeks after seconds. His BCVA was 20/70 OD and of laser pointer induced retinal presentation, the patient complained 20/20 OS. Funduscopic examination injury among children. 2 –11 Here, we about worsening central vision revealed RPE atrophy and a choroidal describe 4 cases of retinal injury with enlarging scotomas in both neovascular membrane with caused by laser pointers among eyes. On examination, the maculae subretinal hemorrhage. Examination children within a 2-year period, the had significantly worse pigmentary of left eye was normal. He received youngest of which was only 9 years changes with increases in RPE an intravitreal bevacizumab 1.25 of age. A summary of all 4 cases atrophy ( Fig 4 A and B). Visual acuity mg/0.05 mL OD and his BCVA and can be found in Table 1. Factors decreased to 20/40 in both eyes and symptoms gradually improved after attributed to eye injury in our series did not further improve. 1 injection. At 1-year follow-up, include the following: availability

Downloaded from www.aappublications.org/news by guest on September 26, 2021 PEDIATRICS Volume 138 , number 4 , October 2016 e3 FIGURE 3 Color fundus photo of right eye (A) and left eye (B) for case 3 revealed chorioretinal scars and focal RPE atrophy, at the macula (arrow). OCT imaging of the macula for both eyes (C and D) revealed disruption of the inner segment/outer segment layer of the retina (arrow). of these devices, lack of awareness of the potential dangers associated with laser pointers, and the improper use of the devices. Currently, laser pointers are readily available and, owing to various questionable online merchants, these devices are increasingly more powerful. 13 Because retinal injury due to laser pointers might be irreversible, we feel that this is a significant public health issue. FIGURE 4 Laser-related retinal injury is Two-week follow-up color fundus photos of both eyes (A and B) for case 3 revealed dark pigmentary dependent on both patient-related changes of the macula (arrow). (eg, pupil size, refractive status, degree of retinal pigmentation, the following: the amount of energy becoming increasingly more popular proximity of incident laser beam delivered by the laser, the duration of and abundantly available, 15 which to the fovea) and laser-related exposure, and location of the retinal is concerning because experiments factors (eg, wavelength, pulsatile involvement. 14 In our case series, the reveal that green laser pointers duration, and energy of the laser retinal injury occurred in 3 children (490–575 nm) are more harmful to beam). 14 Among those, 3 of the who were playing with green laser the retina compared with red laser most important variables include pointers. Green laser pointers are pointers (630–750 nm). 16, 17

Downloaded from www.aappublications.org/news by guest on September 26, 2021 e4 XU et al The most commonly used laser TABLE 1 Summary of Pediatric Patients Who Suffered From Laser Pointer Damage to the Retina pointers have a power output <5 Patient/ Age at Laser Type/ BCVA at Management Follow-up, BCVA at Final mW, which are not considered as Case Presentation, y Wavelength Presentation mo Follow-up (OD harmful to human eye because of (OD, OS) / OS) the limited exposure aided by innate 1 12 Green 20/20, 20/30 Observation 7 20/20, 20/30 ocular protective mechanisms 2 9 Green 20/50, 20/25 Topical 1 20/30, 20/25 (such as blink reflex and aversion prednisolone 18 3 16 Green 20/30, 20/30 Observation 0.5 20/40, 20/40 response). However, as shown in 4 12 Red 20/70, 20/20 Intravitreal 12 20/20, 20/20 case series, children increase their bevacizumab chance to retinal injury by staring injection at the laser beam without blinking or averting the eye for a prolonged duration. 7 In addition, the labeling of scientific evidence. 18 If decrease vision-threatening consequences due the power output of a laser point may vision and persistent after-images to the mishandling of these devices be different from the device’s actual or scotoma are present, and their should be communicated to health specifications. Recent work reveals history demonstrates a likelihood professionals, school teachers, and that, after measuring the power of of significant exposure, one should guardians in an attempt to raise the 122 laser pointers labeled as 1 to refer the child to an ophthalmologist public awareness of this emerging 5 mW, it was found that 90% for full ophthalmologic workup public health issue. Unsupervised use of green laser pointers and 44% of such as Amsler grid testing, dilated of these laser pointer devices among red laser pointers tested had power funduscopic examination, and OCT or children should be discouraged, outputs >5 mW. 19 fluorescein angiography imaging. 18, 20 and there is a need for legislation to limit these devices in the pediatric As health professionals, it is The treatment of retinal injury population. important to be aware of the associated with a laser pointer symptoms of retinal injury caused is limited and also controversial. by laser pointers and to emphasize Current treatment of macular injury the potential irreversible harm of induced by laser beam is mainly ABBREVIATIONS laser pointers to retinal injury among limited to systemic corticosteroids, BCVA: best corrected Snellen children. A systematic approach, which has shown mixed results. 14 visual acuity including the history of laser Observation is an option, as many of OCT: optical coherence exposure, presenting symptoms, and these patients will have stabilization tomography physical examination, could facilitate of visual acuity over time. If a RPE: retinal pigment epithelium an appropriate evaluation and choroidal neovascular membrane referral. Vision loss and persistent forms as a result of direct trauma central scotoma normally occur from the laser to Bruch’s membrane, immediately after the laser beam a vascular endothelial growth factor exposure. These symptoms can occur inhibitor (such as with intravitreal REFERENCES in 1 eye or both eyes, which can bevacizumab) is recommended to be preceded by the perception of a arrest neovascular growth. Final 1. American National Standards Institute. bright flash or accompanied by an visual recovery is dependent on American National Standard for Safe Use of Lasers. New York, NY: American audible “popping” sound. 18 Although lesion location and size. 1 In our case National Standards Institute, Inc; 2000 eye pain, redness, and/or irritation series, all children suffered foveal are common complaints, none of laser burns and 3 boys had a final 2. Turaka K, Bryan JS, Gordon AJ, Reddy those symptoms are typically caused BCVA 2 lines worse than the 20/20 R, Kwong HM Jr, Sell CH. Laser pointer by the direct laser pointer exposure. line. induced macular damage: case report and mini review. Int Ophthalmol. A study suggested various questions To our knowledge, this is the 2012;32(3):293–297 to help health professionals largest reported case series of laser diagnose alleged laser eye injuries: pointer-induced retinal damage 3. Lee GD, Baumal CR, Lally D, Pitcher JD, whether eye symptoms could have in the pediatric population in Vander J, Duker JS. Retinal injury after been caused by a laser, whether a developed country to date. It inadvertent handheld laser exposure. they have been documented emphasizes the need for increased Retina. 2014;34(12):2388–2396 by ophthalmoscopy and retinal recognition of the potential dangers 4. Yiu G, Itty S, Toth CA. Ocular safety of imaging, and whether any somatic of retinal injury caused by laser recreational lasers. JAMA Ophthalmol. complaints are supported by pointers. Potential irreversible 2014;132(3):245–246

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Downloaded from www.aappublications.org/news by guest on September 26, 2021 Retinal Injury Secondary to Laser Pointers in Pediatric Patients Kunyong Xu, Eric K. Chin, Polly A. Quiram, John B. Davies, D. Wilkin Parke III and David R.P. Almeida Pediatrics 2016;138; DOI: 10.1542/peds.2016-1188 originally published online September 1, 2016;

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