Laser-induced ocular injury: a narrative review
Keywords:Eye injuries, Lasers, Safety
There is an increasing trend of reported laser-induced ocular injury. We aimed to review the
literature on the basic principles of laser, clinical management and safety precaution of laser-induced ocular injury. A literature search on the PubMed database was conducted to include articles dated up to April 2020. One example case of laser-induced ocular injury is provided. Clinical presentation of laser-induced ocular injury is variable. The clinical features can be transient and subtle. Appropriate investigations are useful to establish a diagnosis and to evaluate the severity of the injury. Laser-induced ocular injury most commonly involves the macula, which can be complicated by intraocular haemorrhage, macular hole, epiretinal membrane, and choroidal neovascularization. There are currently no evidence-based or well-recognized treatments for laser-induced retinopathy. Surgical intervention might be considered if there is significant intraocular hemorrhage or macular hole. Laser-induced ocular injury may cause permanent visual sequelae and functional disability. Diagnosis of an eye injury should be supported by objective clinical findings and/or appropriate investigations. As medical and surgical treatment options are currently limited, the key to combat laser ocular injuries lies in prevention and awareness of the general public should be reinforced.
Barkana Y, Belkin M. Laser eye injuries. Surv Ophthalmol 2000;44:459-78.
Torp-Pedersen T, Welinder L, Justesen B, et al. Laser pointer maculopathy – on the rise? Acta Ophthalmol 2018;96:749-54.
Altwijri R, Alsuliman SA, Alanazi L, et al. Knowledge and attitude towards hazardous effects of laser pointers among attendees of football matches in Riyadh, Saudi Arabia. Saudi J Ophthalmol 2020.
Neffendorf JE, Hildebrand GD, Downes SM. Handheld laser devices and laser-induced retinopathy (LIR) in children: an overview of the literature. Eye (Lond) 2019;33:1203-14.
Nakagawara VB, Montgomery RW. Laser pointers and aviation safety. Aviat Space Environ Med 2000;71:1060-2.
Alsulaiman SM, Al-Qahtani A, Mousa A, Ghazi NG. Laser pointers: how much does the general medical community know? Graefes Arch Clin Exp Ophthalmol 2017;255:635-6.
Birtel J, Harmening WM, Krohne TU, et al. Retinal injury following laser pointer exposure. Dtsch Arztebl Int 2017;114:831-7.
American National Standards Institute. American National Standard for Safe Use of Lasers, ANSI Z136.1. 2007.
BSEN 60825: 992. Radiation safety of laser products, equipment, classification, requirements and users guide. British Standards Institution; 1992.
Hadler J, Tobares EL, Dowell M. Random testing reveals excessive power in commercial laser pointers. J Laser Appl 2013;10:2351/1.4798455.
Xu K, Chin EK, Quiram PA, Davies JB, Parke DW 3rd, Almeida DR. Retinal injury secondary to laser pointers in pediatric patients. Pediatrics 2016;138:e20161188.
Retail shops fined for supplying unsafe laser pointers. Customs and Excise Department https://www.customs.gov.hk/en/publication_press/press/index_id_1583.html. Accessed 15 May 2020.
Safety of Laser Products - Part 1: Equipment Classification and Requirements. 2nd ed. International Electrotechnical Commission; 2007.
Mainster MA, Sliney DH, Belcher CD 3rd, Buzney SM. Laser photodisruptors. Damage mechanisms, instrument design and safety. Ophthalmology 1983;90:973-91.
Marshall J. Thermal and mechanical mechanisms in laser damage to the retina. Invest Ophthalmol 1970;9:97-115.
Ham WT Jr, Ruffolo JJ Jr, Mueller HA, Guerry D 3rd. The nature of retinal radiation damage: dependence on wavelength, power level and exposure time. Vision Res 1980;20:1105-11.
Boettner EA, Wolter JR. Transmission of the ocular media. Invest Ophthalmol Vis Sci 1962;1:776-83.
Whitmer DL, Stuck BE. Directed energy (laser) induced retinal injury: current status of safety, triage, and treatment research. US Army Med Dep J 2009:51-6.
Krauss JM, Puliafito CA, Steinert RF. Laser interactions with the cornea. Surv Ophthalmol 1986;31:37-53.
Peppers NA, Vassiliadis A, Dedrick KG, et al. Corneal damage thresholds for CO2 laser radiation. Appl Opt 1969;8:377-81.
Alsulaiman SM, Alrushood AA, Almasaud J, et al. High-power handheld blue laser-induced maculopathy: the results of the King Khaled Eye Specialist Hospital Collaborative Retina Study Group. Ophthalmology 2014;121:566-72.e1.
Raoof N, Bradley P, Theodorou M, Moore AT, Michaelides M. The new pretender: a large UK case series of retinal injuries in children secondary to handheld lasers. Am J Ophthalmol 2016;171:88-94.
Linton E, Walkden A, Steeples LR, et al. Retinal burns from laser pointers: a risk in children with behavioural problems. Eye (Lond) 2019;33:492-504.
Dirani A, Chelala E, Fadlallah A, Antonios R, Cherfan G. Bilateral macular injury from a green laser pointer. Clin Ophthalmol 2013;7:2127-30.
Bhavsar KV, Wilson D, Margolis R, et al. Multimodal imaging in handheld laser-induced maculopathy. Am J Ophthalmol 2015;159:227-31.e2.
Sethi CS, Grey RH, Hart CD. Laser pointers revisited: a survey of 14 patients attending casualty at the Bristol Eye Hospital. Br J Ophthalmol 1999;83:1164-7.
Scollo P, Herath G, Lobo A. Retinal injury by industrial laser burn. Occup Med (Lond) 2014;64:220-2.
Aras C, Koyluoglu N, Hasheminia A, Akaydin O. Inadvertent laser-induced retinal injury following a recreational laser show. Clin Exp Ophthalmol 2009;37:529-30.
Asiri MS, Alharbi M, Alkadi T, et al. Ocular injuries secondary to alexandrite laser-assisted hair removal. Can J Ophthalmol 2017;52:e71-e75.
Brilakis HS, Holland EJ. Diode-laser-induced cataract and iris atrophy as a complication of eyelid hair removal. Am J Ophthalmol 2004;137:762-3.
Halkiadakis I, Skouriotis S, Stefanaki C, et al. Iris atrophy and posterior synechiae as a complication of eyebrow laser epilation. J Am Acad Dermatol 2007;57(2 Suppl):S4-5.
Crowell EL, Jampel H, Berkenstock M. Alexandrite laser induced uveitis & pigment dispersion: a case report and review of the literature. Am J Ophthalmol Case Rep 2020;18:100632.
Yalcindag FN, Uzun A. Anterior uveitis associated with laser epilation of eyebrows. J Ophthalmic Inflamm Infect 2013;3:45.
Sheikh A, Hodge W, Coupland S. Diode laser-induced uveitis and visual field defect. Ophthalmic Plast Reconstr Surg 2007;23:321-3.
Lin CC, Tseng PC, Chen CC, Woung LC, Liou SW. Iritis and pupillary distortion after periorbital cosmetic alexandrite laser. Graefes Arch Clin Exp Ophthalmol 2011;249:783-5.
Gulmez Sevim D, Oner AO, Unlu M, Mirza GE. Ocular complications after cosmetic periocular diode laser application to the eyelids. J Cosmet Laser Ther 2018;20:447-8.
Alhalel A, Glovinsky Y, Treister G, Bartov E, Blumenthal M, Belkin M. Long-term follow up of accidental parafoveal laser burns. Retina 1993;13:152-4.
Mader TH, Aragones JV, Chandler AC, et al. Ocular and ocular adnexal injuries treated by United States military ophthalmologists during Operations Desert Shield and Desert Storm. Ophthalmology 1993;100:1462-7.
Gosling DB, O'Hagan JB, Quhill FM. Blue laser induced retinal injury in a commercial pilot at 1300 ft. Aerosp Med Hum Perform 2016;87:69-70.
Yan MK, Kocak E, Yoong K, Kam JK. Ocular injuries resulting from commercial cosmetic procedures. Clin Exp Optom 2020;103:430-3.
Huang A, Phillips A, Adar T, Hui A. Ocular injury in cosmetic laser treatments of the face. J Clin Aesthet Dermatol 2018;11:15-8.
Miedziak AI, Gottsch JD, Iliff NT. Exposure keratopathy after cosmetic CO2 laser skin resurfacing. Cornea 2000;19:846-8.
Widder RA, Severin M, Kirchhof B, Krieglstein GK. Corneal injury after carbon dioxide laser skin resurfacing. Am J Ophthalmol 1998;125:392-4.
Karabela Y, Eliacik M. Anterior uveitis following eyebrow epilation with alexandrite laser. Int Med Case Rep J 2015;8:177-9.
Parver DL, Dreher RJ, Kohanim S, et al. Ocular injury after laser hair reduction treatment to the eyebrow. Arch Ophthalmol 2012;130:1330-4.
Shneck M, Levy J, Klemperer I, Lifshitz T. Retinal laser injury during a laser show. Retin Cases Brief Rep 2007;1:178-81.
Lee GD, Baumal CR, Lally D, Pitcher JD, Vander J, Duker JS. Retinal injury after inadvertent handheld laser exposure. Retina 2014;34:2388-96.
Tran K, Wang D, Scharf J, Sadda S, Sarraf D. Inner choroidal ischaemia and CNV due to handheld laser-induced maculopathy: a case report and review. Eye (Lond) 2020.
McCanna R, Chandra SR, Stevens TS, Myers FL, de Venecia G, Bresnick GH. Argon laser-induced cataract as a complication of retinal photocoagulation. Arch Ophthalmol 1982;100:1071-3.
Lakhanpal V, Schocket SS, Richards RD, Nirankari VS. Photocoagulation-induced lens opacity. Arch Ophthalmol 1982;100:1068-70.
Herbold TM, Busse H, Uhlig CE. Bilateral cataract and corectopia after laser eyebrow [corrected] epilation. Ophthalmology 2005;112:1634-5.
Christiansen SP, Bradford JD. Cataract in infants treated with argon laser photocoagulation for threshold retinopathy of prematurity. Am J Ophthalmol 1995;119:175-80.
Irvine WD, Smiddy WE, Nicholson DH. Corneal and iris burns with the laser indirect ophthalmoscope. Am J Ophthalmol 1990;110:311-3.
Keithahn MA, Gross RH, Mannis MJ, Morales RB, Morse LS. Corneal perforation associated with argon laser photocoagulation for a retinal tear. Am J Ophthalmol 1997;123:125-7.
Yeo DC, Osei-Bempong C, Shirodkar A, Williams GS. Foveal haemorrhage from makeshift 'Lightsaber': funduscopy and optical coherence tomography findings. BMJ Case Rep 2016;2016: bcr2016214711.
Yiu G, Itty S, Toth CA. Ocular safety of recreational lasers. JAMA Ophthalmol 2014;132:245-6.
Perez-Montano CR, Palomares-Ordonez JL, Ramirez-Estudillo A, Sanchez-Ramos J, González-Saldivar G. Sub-hyaloid and sub-internal limiting membrane macular hemorrhage after laser exposure at music festival: a case report. Doc Ophthalmol 2019;138:71-6.
Zhang L, Zheng A, Nie H, et al. Laser-induced photic injury phenocopies macular dystrophy. Ophthalmic Genet 2016;37:59-67.
Dolz-Marco R, Cunha Souza E, Iida T, et al. Iris atrophy: a novel sign of repeated self-inflicted laser pointer maculopathy. Retina 2017;37:e26-e28.
Mainster MA, Stuck BE, Brown J Jr. Assessment of alleged retinal laser injuries. Arch Ophthalmol 2004;122:1210-7.
Dhrami-Gavazi E, Lee W, Balaratnasingam C, Kayserman L, Yannuzzi LA, Freund KB. Multimodal imaging documentation of rapid evolution of retinal changes in handheld laser-induced maculopathy. Int J Retina Vitreous 2015;1:14.
Shum JW, Iu LP, Cheung DN, Wong IY. A case of accidental ocular injury from cosmetic laser burn. Retin Cases Brief Rep 2016;10:115-20.
Thach AB. Laser injuries of the eye. Int Ophthalmol Clin 1999;39:13-27.
Hacker HD, Brown J Jr, Cheramie R, Stuck BE. New approaches to the diagnosis and management of laser eye injury. Proceeding of SPIE 6426, Ophthalmic Technologies XVII, 642623. 5 March 2007.
Hossein M, Bonyadi J, Soheilian R, Soheilian M, Peyman GA. SD-OCT features of laser pointer maculopathy before and after systemic corticosteroid therapy. Ophthalmic Surg Lasers Imaging 2011;42:e135-e138.
Lim ME, Suelzer J, Moorthy RS, Vemuri G. Thermal macular injury from a 154 mW green laser pointer. J AAPOS 2014;18:612-4.
Takahashi K, Lam TT, Fu J, Tso MO. The effect of high-dose methylprednisolone on laser-induced retinal injury in primates: an electron microscopic study. Graefes Arch Clin Exp Ophthalmol 1997;235:723-32.
Brown J Jr, Hacker H, Schuschereba ST, Zwick H, Lund DJ, Stuck BE. Steroidal and nonsteroidal antiinflammatory medications can improve photoreceptor survival after laser retinal photocoagulation. Ophthalmology 2007;114:1876-83.
Solberg Y, Dubinski G, Tchirkov M, Belkin M, Rosner M. Methylprednisolone therapy for retinal laser injury. Surv Ophthalmol 1999;44 Suppl 1:S85-92.
Mtanes K, Mimouni M, Zayit-Soudry S. Laser pointer-induced maculopathy: more than meets the eye. J Pediatr Ophthalmol Strabismus 2018;55:312-8.
Chen X, Dajani OAW, Alibhai AY, Duker JS, Baumal CR. Long-term visual recovery in bilateral handheld laser pointer-induced maculopathy. Retin Cases Brief Rep 2019;10.1097.
Robertson DM, McLaren JW, Salomao DR, Link TP. Retinopathy from a green laser pointer: a clinicopathologic study. Arch Ophthalmol 2005;123:629-33.
Weng CY, Baumal CR, Albini TA, Berrocal AM. Self-induced laser maculopathy in an adolescent boy utilizing a mirror. Ophthalmic Surg Lasers Imaging Retina 2015;46:485-8.
Turaka K, Bryan JS, Gordon AJ, Reddy R, Kwong HM Jr, Sell CH. Laser pointer induced macular damage: case report and mini review. Int Ophthalmol 2012;32:293-7.
Schuschereba ST, Bowman PD, Ferrando RE, Lund DJ, Quong JA, Vargas JA. Accelerated healing of laser-injured rabbit retina by basic fibroblast growth factor. Invest Ophthalmol Vis Sci 1994;35:945-54.
Zhao N, Liu L. Long-term changes in optic coherence tomography in a child with laser pointer maculopathy: a case report and mini review. Photodiagnosis Photodyn Ther 2017;18:264-6.
Bernstein PS, Steffensmeier A. Optical coherence tomography before and after repair of a macular hole induced by an unintentional argon laser burn. Arch Ophthalmol 2005;123:404-5.
Heichel J, Kuehn E, Eichhorst A, Hammer T, Winter I. Nd:YAG laser hyaloidotomy for the treatment of acute subhyaloid hemorrhage: a comparison of two cases. Ophthalmol Ther 2016;5:111-20.
Gabel VP, Birngruber R, Gunther-Koszka H, Puliafito CA. Nd:YAG laser photodisruption of hemorrhagic detachment of the internal limiting membrane. Am J Ophthalmol 1989;107:33-7.
Dhoot DS, Xu D, Srivastava S. High-powered laser pointer injury resulting in macular hole formation. J Pediatr 2014;164:668.e1.
Petrou P, Patwary S, Banerjee PJ, Kirkby GR. Bilateral macular hole from a handheld laser pointer. Lancet 2014;383:1780.
Thach AB, Lopez PF, Snady-McCoy LC, Golub BM, Frambach DA. Accidental Nd:YAG laser injuries to the macula. Am J Ophthalmol 1995;119:767-73.
Alsakran WA, Alsulaiman SM, Ghazi NG. Delayed spontaneous closure of blue laser-induced full thickness macular hole. Am J Ophthalmol Case Rep 2019;13:154-6.
Alsulaiman SM, Alrushood AA, Almasaud J, et al. Full-thickness macular hole secondary to high-power handheld blue laser: natural history and management outcomes. Am J Ophthalmol 2015;160:107-13.e1.
Qi Y, Wang Y, You Q, Tsai F, Liu W. Surgical treatment and optical coherence tomographic evaluation for accidental laser-induced full-thickness macular holes. Eye (Lond) 2017;31:1078-84.
Safety Guidelines for Laser Products. Electrical and Mechanical Services Department https://www.emsd.gov.hk/en/other_regulatory_services/laser_safety/publications/safety_guidelines_for_laser_products/index.html. Accessed 15 May 2020.
Hammes S, Augustin A, Raulin C, Ockenfels HM, Fischer E. Pupil damage after periorbital laser treatment of a port-wine stain. Arch Dermatol 2007;143:392-4.
Bulut MN, Calli U, Goktas E, Bulut K, Kandemir B, Özertürk Y. Use of an intravitreal dexamethasone implant (Ozurdex) in a case with accidental foveal photocoagulation by alexandrite laser. Case Rep Ophthalmol 2016;7:130-4.
How to Cite
Copyright (c) 2020 Hong Kong Journal of Ophthalmology
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
The Journal has a fully Open Access policy and publishes all articles under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) licence. For any use other than that permitted by this license, written permission must be obtained from the Journal.