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Arch Ophthalmol. 2001;119:137-139.

The increasing use of high-energy laser instrumentation for scientific and therapeutic purposes has resulted in the proliferation of inadvertent retinal injuries. The expanding use of Nd:YAG technology poses new threats from accidental exposure. Reaction of retinal tissues from Nd:YAG laser insult differs from the typical thermal injuries caused by argon and krypton lasers. We report a case of laser injury to the macula in which we were able to closely monitor the evolving retinal response to Nd:YAG disruption.

Report of a Case
A 23-year-old researcher suffered sudden vision loss in his right eye while focusing a reflected beam from a frequency-doubled Nd:YAG laser. He was not wearing protective eyewear. His best-corrected visual acuity was 20/200 OD and 20/15 OS. He noted a large gray floater, with metamorphopsia and central scotoma identified by Amsler grid. Fundus evaluation revealed vitreous hemorrhage obstructing adequate macular visualization. Examination results from the left eye were unremarkable.

The next day, his visual acuity had improved to 20/60 OD (Figure 1A). Fluorescein angiogram showed early and late foveal hyperfluorescence, consistent with Bruch's membrane penetration. Within 2 weeks his visual acuity had improved to 20/25 OD (Figure 1B). However, 2 weeks later, the patient had a decline in visual acuity to 20/40 OD. Fundus evaluation revealed a distinct epiretinal membrane (Figure 2A).

View larger version (24K): [in this window] [in a new window] Figure 1. A, Fundus photographs obtained 1 day after injury. There was some clearing of the vitreous hemorrhage permitting visualization of the macula. Preretinal and vitreous hemorrhages are noted with focal foveal hypopigmentation. B, Two weeks after injury, only small amounts of vitreous hemorrhage persist. Magnified view of the macula reveals the presence of a small macular hole with residual subretinal blood and surrounding gray discoloration.

View larger version (26K): [in this window] [in a new window] Figure 2. A, Photograph taken 1 month following initial injury demonstrating well-organized epiretinal membrane measuring 2 x 1.5 mm with striae radiating to the arcades. Contracture of these striae resulted in wrinkling of the underlying retina. B, Seven months later, the epiretinal membrane has spontaneously peeled and rolled into a small parafoveal scroll residing superotemporal to the fovea. The retinal striae have also resolved.

Seven months later the patient had a visual acuity of 20/20 OU and spontaneous regression of the epiretinal membrane (Figure 2B). On subsequent visits, the patient's vision and retinal examination results have remained stable.

Comment
Previously reported cases of accidental Nd:YAG laser injuries describe several common features such as early subretinal, retinal, and vitreous hemorrhage with macular hole and pucker.^1-4 We describe a single case of Nd:YAG injury that demonstrated several interesting features of the retinal response to focal thermomechanical disruption. Vitreous and subretinal blood likely act as stimulants for fibroglial and retinal pigment epithelium proliferation, resulting in an epiretinal membrane over the macular hole. Contraction of the gliotic membrane causes macular pucker and reapproximation of the edges of the hole. In this case, subsequent spontaneous peeling of the membrane resulted in restoration of visual acuity and resolution of the macular hole. Similar progression was reported in an idiopathic macular hole associated with an epiretinal membrane.⁵

The vast majority of retinal laser injuries occur in the absence of appropriate eyewear, illustrating the paramount importance of eye protection while operating lasers.

AUTHOR INFORMATION

Subhransu Ray, MD, PhD; Trexler Topping, MD; Lucy H. Y. Young, MD, PhD
Boston, Mass

Corresponding author: Lucy H. Y. Young, MD, PhD, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, 243 Charles St, Boston, MA 02114.

REFERENCES
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