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.
- BCVA —
- best corrected Snellen visual acuity
- OCT —
- optical coherence tomography
- RPE —
- retinal pigment epithelium
Laser pointers are low-energy light sources that can emit focal nonionizing radiation. They are used in various situations and are inappropriately used as toys for some children. Most laser pointer devices are red (670 nm wavelength) or green diode lasers (532 nm wavelength).
In the United States, the safety level of laser devices is categorized according to the American National Standard Institute Z136.1 and most consumer laser pointers fall under class II or class IIIA level of safety, which encompasses lasers of 1 to 5 mW or less of power. Handheld lasers can be more powerful, either class 3B (5–500 mW) or class 4 (> 500 mW), and these lasers may cause immediate eye hazard when viewed directly.1 Previously, laser pointers were considered as harmless; however, in recent years, there have been increasing number of cases of retinal injury caused by mishandling of laser pointers among in children.2–12 Hence, accidental retinal injury among children due to laser pointer exposure represents a serious, but preventable, public health issue.
We report 4 children with retinal injury caused by laser pointer exposure to emphasize the significance of vision loss due to improper use of the devices. Moreover, it is important for health professionals to recognize and be cognizant of the presentation and natural history of retinal injury from laser pointer use.
A retrospective review of all cases of laser pointer induced damage to the retina in the pediatric population (<18 years of age) at a single centered vitreoretinal medical/surgery practice.
A 12-year-old boy presented with bilateral central scotomas and decreased vision shortly after he directly looked at the green laser pointer for ∼1 minute. His best corrected Snellen visual acuity (BCVA) was 20/20 OD and 20/30 OS. Funduscopic examination identified pigment clumping with focal retinal pigment epithelium (RPE) atrophy for both eyes (Fig 1 A and B). Optical coherence tomography (OCT) of the macula revealed bilateral disruption of the foveal photoreceptor ellipsoid zone (photoreceptor inner segment/outer segment; Fig 1 C and D). At 7-month follow-up, the BCVA and macular findings remained unchanged.
A 9-year-old boy presented with a 4-day history of central scotoma and vision loss OD. Symptoms occurred ∼5 to 10 seconds after looking at the reflection of a green laser pointer into a mirror that was directed at his right eye. His BCVA was 20/50 OD and 20/25 for OS. Funduscopic examination revealed macular pigment changes in the right eye only (Fig 2 A and B). OCT OD revealed subfoveal outer retinal hyperreflectivity with disruption of the foveal photoreceptors (Fig 2C). The patient was treated with prednisolone 1% 3 times per day for OD for 2 weeks. After 1 month, the visual acuity improved to 20/30 OD with persistent abnormalities of the photoreceptors OD. His examination OS was unchanged.
A 16-year-old boy presented with a 3-day history of bilateral central vision loss and central scotoma that occurred immediately after playing with a green laser pointer for approximately half minute. On examination, BCVA was 20/30 OU. Funduscopic examination revealed macular chorioretinal scars and focal RPE atrophy (Fig 3 A and B). The OCT revealed disruption of the photoreceptor ellipsoid zone in both eyes (Fig 3 C and D). Two weeks after presentation, the patient complained about worsening central vision with enlarging scotomas in both eyes. On examination, the maculae had significantly worse pigmentary changes with increases in RPE atrophy (Fig 4 A and B). Visual acuity decreased to 20/40 in both eyes and did not further improve.
A 12-year-old boy presented with central vision loss and metamorphopsia with a central scotoma right eye, which occurred immediately after looking directly at the light of a red laser pointer shown into his right eye for ∼15 seconds. His BCVA was 20/70 OD and 20/20 OS. Funduscopic examination revealed RPE atrophy and a choroidal neovascular membrane with subretinal hemorrhage. Examination of left eye was normal. He received an intravitreal bevacizumab 1.25 mg/0.05 mL OD and his BCVA and symptoms gradually improved after 1 injection. At 1-year follow-up, BCVA improved to 20/20 OD with significant improvement in his subjective metamorphopsia.
Over the past 15 years, there has been an alarming increase in reports of laser pointer induced retinal injury among children.2–11 Here, we describe 4 cases of retinal injury caused by laser pointers among children within a 2-year period, the youngest of which was only 9 years of age. A summary of all 4 cases can be found in Table 1. Factors attributed to eye injury in our series include the following: availability 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.
Laser-related retinal injury is dependent on both patient-related (eg, pupil size, refractive status, degree of retinal pigmentation, proximity of incident laser beam to the fovea) and laser-related factors (eg, wavelength, pulsatile duration, and energy of the laser beam).14 Among those, 3 of the most important variables include the following: the amount of energy delivered by the laser, the duration of exposure, and location of the retinal involvement.14 In our case series, the retinal injury occurred in 3 children who were playing with green laser pointers. Green laser pointers are becoming increasingly more popular and abundantly available,15 which is concerning because experiments reveal that green laser pointers (490–575 nm) are more harmful to the retina compared with red laser pointers (630–750 nm).16,17
The most commonly used laser pointers have a power output <5 mW, which are not considered as harmful to human eye because of the limited exposure aided by innate ocular protective mechanisms (such as blink reflex and aversion response).18 However, as shown in case series, children increase their chance to retinal injury by staring at the laser beam without blinking or averting the eye for a prolonged duration.7 In addition, the labeling of the power output of a laser point may be different from the device’s actual specifications. Recent work reveals that, after measuring the power of 122 laser pointers labeled as 1 to 5 mW, it was found that 90% of green laser pointers and 44% of red laser pointers tested had power outputs >5 mW.19
As health professionals, it is important to be aware of the symptoms of retinal injury caused by laser pointers and to emphasize the potential irreversible harm of laser pointers to retinal injury among children. A systematic approach, including the history of laser exposure, presenting symptoms, and physical examination, could facilitate an appropriate evaluation and referral. Vision loss and persistent central scotoma normally occur immediately after the laser beam exposure. These symptoms can occur in 1 eye or both eyes, which can be preceded by the perception of a bright flash or accompanied by an audible “popping” sound.18 Although eye pain, redness, and/or irritation are common complaints, none of those symptoms are typically caused by the direct laser pointer exposure.
A study suggested various questions to help health professionals diagnose alleged laser eye injuries: whether eye symptoms could have been caused by a laser, whether they have been documented by ophthalmoscopy and retinal imaging, and whether any somatic complaints are supported by scientific evidence.18 If decrease vision and persistent after-images or scotoma are present, and their history demonstrates a likelihood of significant exposure, one should refer the child to an ophthalmologist for full ophthalmologic workup such as Amsler grid testing, dilated funduscopic examination, and OCT or fluorescein angiography imaging.18,20
The treatment of retinal injury associated with a laser pointer is limited and also controversial. Current treatment of macular injury induced by laser beam is mainly limited to systemic corticosteroids, which has shown mixed results.14 Observation is an option, as many of these patients will have stabilization of visual acuity over time. If a choroidal neovascular membrane forms as a result of direct trauma from the laser to Bruch’s membrane, a vascular endothelial growth factor inhibitor (such as with intravitreal bevacizumab) is recommended to arrest neovascular growth. Final visual recovery is dependent on lesion location and size.1 In our case series, all children suffered foveal laser burns and 3 boys had a final BCVA 2 lines worse than the 20/20 line.
To our knowledge, this is the largest reported case series of laser pointer-induced retinal damage in the pediatric population in a developed country to date. It emphasizes the need for increased recognition of the potential dangers of retinal injury caused by laser pointers. Potential irreversible vision-threatening consequences due to the mishandling of these devices should be communicated to health professionals, school teachers, and guardians in an attempt to raise the public awareness of this emerging public health issue. Unsupervised use of these laser pointer devices among children should be discouraged, and there is a need for legislation to limit these devices in the pediatric population.
- Accepted July 6, 2016.
- Address correspondence to David R.P. Almeida, MD, MBA, PhD, VitreoRetinal Surgery, PA, 7760 France Ave S, Minneapolis, MN 55435. E-mail:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2016 by the American Academy of Pediatrics