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Exposure to high-powered hand-held lasers linked to macular hole formation
The study authors hypothesize that the mechanism of macular hole formation was mainly photodisruption causing initial retinal dehiscence.
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Brief exposure to hand-held high-powered blue-light lasers was associated with full-thickness macular hole formation in a group of young male patients, according to a study.
Most cases of full-thickness macular hole required surgical intervention, the study authors reported in American Journal of Ophthalmology.
Nicola G. Ghazi, MD, the corresponding author, said there is an increased incidence of macular hole and other injuries caused by exposure to powerful hand-held lasers.
“[At the time] of our initial paper published in the journal Ophthalmology, we only had four cases of macular hole. The remaining 13 cases published in the recent AJO report as part of the 17 cases were all seen shortly after, over the following year. In addition, we have seen other forms of ocular laser injury that have not been previously described and that we are preparing for publication now. We continue to see various forms of injuries related to such lasers,” Ghazi told Ocular Surgery News.
Patients
The retrospective case series included 17 eyes of 17 patients with full-thickness macular holes caused by exposure to high-powered hand-held blue-light laser devices. Mean patient age was 18 years.
Most injuries were inflicted by others during play; one injury was self-inflicted.
Mean duration of exposure to laser light was less than 1 second. Mean distance from the laser device to the injured eye was about 0.95 m. The interval from time of injury to presentation in a hospital ranged from 2 days to 16 months.
“[The distance of exposure] appears to be important,” Ghazi said. “We noted that all cases of macular hole had a distance of exposure of less than 2 m. In our experience, these macular holes rarely close spontaneously, and a long period of observation awaiting spontaneous closure is not recommended because, almost invariably, these holes enlarge with time.”
Mean Snellen best corrected visual acuity at presentation was 20/210 (range: 20/30 to 20/400). Mean macular hole minimum diameter was 351 µm (range: 168 µm to 620 µm); mean macular hole base diameter was 733 µm.
Fourteen eyes underwent 23-gauge pars plana vitrectomy, posterior hyaloid peeling, internal limiting membrane peeling and fluid-air exchange. Twelve eyes underwent gas tamponade, and two eyes underwent silicone oil tamponade. Patients were instructed to maintain face-down positioning for at least 5 days postoperatively.
All patients underwent full ophthalmic examination, fundus photography, macular spectral-domain OCT and fundus fluorescein angiography.
The main outcome measure was macular hole closure; the secondary measure was final visual acuity.
Mean follow-up after surgical intervention was 7 months. Nine patients (64.3%) had at least 3 months of follow-up.
Results and conclusions
Eleven of the 14 operated eyes (78.6%) had complete closure of the macular hole at final follow-up. Of the three unoperated eyes, the eye with the smallest macular hole closed spontaneously with observation, one patient declined surgery, and one patient was lost to follow-up.
“In our series, only one case resolved spontaneously. Surgical repair can be successfully achieved with vitrectomy in about 80% of cases, which is also less than the success rate we know for idiopathic macular hole, which is currently in the range of 95% to 100%,” Ghazi said.
Mean BCVA among the 11 successfully operated eyes improved from 20/230 preoperatively to 20/43 postoperatively. BCVA was better than 20/40 in seven of the 11 successfully operated eyes (63.6%).
SD-OCT at final follow-up showed that after macular hole closure, eight of the 11 operated eyes had varying degrees of disruption in the ellipsoid and interdigitation zones sparing the external limiting membrane.
Mean BCVA was 20/23 in the eyes without outer retinal disruption and 20/55 in the eyes with disruption. A meaningful statistical comparison could not be performed because of the small number of eyes in each group.
No cases of macular hole recurrence were reported.
Macular hole persisted after surgery in three of the 14 operated eyes (21.4%); further surgical intervention was declined. The three eyes had a mean preoperative macular hole minimum diameter of 567 µm.
The authors postulated that initial retinal dehiscence is caused by the photodisruptive effect of the high-power laser, and then tractional forces act to enlarge the insult to full-thickness macular hole. – by Matt Hasson
- Reference:
- Alsulaiman SM, et al. Am J Ophthalmol. 2015;doi:10.1016/j.ajo.2015.04.014.
- For more information:
- Nicola G. Ghazi, MD, can be reached at nicola.ghazi@gmail.com.
Disclosure: Ghazi reports no relevant financial disclosures.
Perspective
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Veeral S. Sheth, MD, MBA, FACS
This paper highlights a growing and alarming trend facilitated by the ubiquitous access to high-powered hand-held laser pointers. The FDA has limited the energy output of these lasers to 5 mW, but a quick Internet search will yield many outlets selling pointers with output up to 1,400 mW. As the authors point out, the rate of macular holes and other retinal injuries created by even momentary exposures to these lasers is on the rise worldwide.
The macular holes created by laser pointers appear to result from photodisruption of the retina. This may be the reason why closure rates after surgery are not as high as they are for idiopathic macular holes, which may be more related to traction and tangential forces. Fortunately, 79% of patients in this series achieved macular hole closure, but there were a number of patients with persistent vision loss. Just as important to the conversation is that all of these injuries were avoidable.
Relying on retailers or the FDA to better regulate the sale of these devices may prove futile. Creating more public awareness, however, may help stem the tide.
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