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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 3  |  Page : 538-541

Intravitreal anti-vascular endothelial growth factor therapy for choroidal neovascularization secondary to laser pointer injury in a child


1 Department of Ophthalmology, University Hospital Virgen Macarena, Seville, Spain
2 Department of Ophthalmology, University Hospital Virgen Macarena, Seville; Retics Oftared, Institute of Health Carlos III, Madrid, Spain

Date of Submission01-Sep-2020
Date of Acceptance24-Jan-2021
Date of Web Publication02-Jul-2021

Correspondence Address:
Dr. María José Morillo-Sánchez
Department of Ophthalmology, University Hospital Virgen Macarena, C/Avda, Doctor Fedriani, 3, Seville - 41071
Spain
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijo.IJO_2835_20

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  Abstract 


Laser pointers are readily available and are often labeled as toys. A 12-year-old girl was brought to the emergency department complaining of a central scotoma in the right eye after being exposed to a laser pointer. Fundus examination revealed severe maculopathy in both eyes. Optical coherence tomography angiography and fundus angiography examinations revealed choroidal neovascularization in the area of the laser injury in the right eye. One intravitreal anti-VEGF injection was administered in the right eye, resulting in good clinical and structural responses. Intravitreal anti-VEGF may be effective for improving visual outcomes in laser pointer-induced maculopathy complicated with choroidal neovascularization.

Keywords: Anti-VEGF, choroidal neovascularization, laser pointer, maculopathy, optical coherence tomography angiography


How to cite this article:
Llavero-Valero P, Morillo-Sánchez MJ, Domínguez-Serrano B, Gómez-Escobar AJ, Gutiérrez-Sánchez E, de la Rúa Franch ER. Intravitreal anti-vascular endothelial growth factor therapy for choroidal neovascularization secondary to laser pointer injury in a child. Indian J Ophthalmol Case Rep 2021;1:538-41

How to cite this URL:
Llavero-Valero P, Morillo-Sánchez MJ, Domínguez-Serrano B, Gómez-Escobar AJ, Gutiérrez-Sánchez E, de la Rúa Franch ER. Intravitreal anti-vascular endothelial growth factor therapy for choroidal neovascularization secondary to laser pointer injury in a child. Indian J Ophthalmol Case Rep [serial online] 2021 [cited 2021 Jul 26];1:538-41. Available from: https://www.ijoreports.in/text.asp?2021/1/3/538/320015



Laser devices are readily available, particularly via the internet, and are assumed to be safe toys for children that are not associated with a potential to harm their vision. The American National Standards Institute (ANSI) assigns lasers into one of four broad hazard Classes (1, 2, 3a, 3b, and 4) depending on the potential for causing biological damage. Classification is determined by calculations based on exposure time, laser wavelength and average power for CW or repetitively-pulsed lasers and total energy per pulse for pulsed lasers. Green wavelengths are more easily absorbed and therefore cause more damage to the eye than red wavelengths of equivalent power.[1]

Clinically, retinopathy caused by a laser pointer is very similar to solar retinopathy. The main difference is that the exposure time required for damage to occur is very short due to the high energy emitted by a laser pointer.[2] Retinal pigment epithelium (RPE) is known to be primarily damaged, but the choriocapillaris is also involved in laser-induced injuries.[3] Structural optical coherence tomography (OCT) and OCT angiography (OCT-A) examinations are essential for comprehension of the pathogenesis of the damage and the determination of possible treatments for this maculopathy. Although partial functional and histological recovery is possible, the burn caused by a laser often results in permanent visual impairment, and the development of neovascular complications is common.[2]


  Case Report Top


The patient was a 12-year-old girl who was brought to the emergency department reporting painless visual loss. Amsler grid testing identified central scotoma in the right eye. In the right eye her best-corrected visual acuity (Snellen 20 feet) at presentation was 20/2000, and in the left eye it was 20/60. On direct questioning, she admitted to playing with a green laser pointer 3 weeks previously. Written informed consent was obtained from one of the girl's parents for clinical tests.

Slit lamp biomicroscopy did not yield any remarkable findings in the anterior segments. Color fundus photographs depicted a gray foveal lesion surrounded by subretinal hemorrhage, perilesional folds, and associated serous detachment in the right eye. The left eye exhibited small welldefined orange lesions. In the right eye, fundus fluorescein angiography revealed a stippled hyperfluorescent lesion in early frames, and late leakage that obscured its boundaries. It was surrounded by hypofluorescent lesions corresponding to subretinal hemorrhages. In late frames a hyperfluorescent rim surrounding choroidal neovascularization (CNV) corresponding to serous neuroepithelial detachment was evident. The left eye exhibited three small hyperfluorescent foveal lesions from the start of the examination that persisted during the late frames (RPE atrophy) [Figure 1].
Figure 1: Appearance of the fundus at diagnosis. (a) Fundus photographs of the right eye depicted a grey macular lesion with associated subretinal hemorrhage and serous detachment. (b) Fundus angiography of the right eye depicted a hyperfluorescent lace-patterned lesion in the fovea, surrounded by hypofluorescence (subretinal hemorrhages) and a hyperfluorescent rim that appeared in late frames corresponding to the serous neuroepithelial detachment. (c) Fundus examination of the left eye depicted small well-defined orange lesions. (d) Fundus angiography of the left eye depicted three small hyperfluorescent foveal lesions (retinal pigment epithelium atrophy)

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OCT scans were obtained with the DRI OCT Triton system. In the right eye OCT revealed intraretinal fluid causing increased retinal thickness and subretinal liquid, which was compatible with subfoveal CNV type 2. In left eye OCT revealed disruption of the ellipsoid zone. The patient also underwent OCT A. In the current patient a hyperintense flow signal correlating with the location of the neovascular lesion was detected in the right eye. It extended from the choroidal vessels in right eye [Figure 2].
Figure 2: Optical coherence tomography and optical coherence tomography angiography in the right eye. A1. Optical coherence tomography (OCT) at diagnosis depicted a subfoveal hyperreflective lesion compatible with choroidal neovascularization type 2, intraretinal fluid causing increased retinal thickness, and subretinal liquid. A2. OCT angiography depicted hyperintense flow signal corresponding with the location of the neovascular lesion. A3. At the avascular retina slab the lesion appeared as a round hyperreflective image. B1. OCT of right eye 6 weeks after intravitreal therapy depicted reduction of the subfoveal lesion. B2. OCT angiography depicted a substantial reduction in intralesional flow. B3. Reduction of the hyperreflective area in the avascular retina slab. C1. As depicted in OCT, after 4 months of follow-up the lesion remained inactive. C2. OCT angiography depicted the disappearance of intralesional flow. C3. Minimum hyperreflective point in the avascular retina slab

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Because there is no recognized treatment for laser-induced CNV, we suggested that the patient be treated with one dose of intravitreal anti-VEGF therapy (aflibercept) in the right eye as compassionate use of the drug. No treatment was performed in the left eye. Four months later the patient's visual acuity had improved to 20/100 in the right eye and 20/25 in the left eye [Figure 3]. Sequential OCT-A demonstrated a reduction in the intralesional flow after the intravitreal therapy. Structural OCT depicted complete resolution of the CNV activity at the last follow-up [Figure 4].
Figure 3: Follow-up fundus images of both eyes at 4 months. (a) Fundus photographs of the right eye depicted a small well-defined foveal lesion. (b) Fundus photographs of the left eye showed a small atrophic macular lesion

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Figure 4: Optical coherence tomography and optical coherence tomography angiography in the left eye. A1. Optical coherence tomography (OCT) at diagnosis depicted a small ellipsoid zone disruption. A2, A3. OCT angiography and avascular retina slab where no alterations were depicted. B1. OCT of left eye at the last follow-up visit showed no alterations. B2, B3. OCT angiography and avascular retina slab remained without changes

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  Discussion Top


Anti-VEGF may be effective for improving visual acuity in patients with CNV secondary to conditions other than age-related macular degeneration.[4] It was for that reason that it was suggested that the current patient be treated with intravitreal aflibercept. To the best of our knowledge, there are few reports describing the use of anti-VEGF as treatment for CNV caused by laser damage. Similar to the present patient, Xu et al.[5] described a case of CNV induced by laser injury in a patient who exhibited a good response to intravitreal injection of bevacizumab. Forshaw et al.[6] described another patient treated with two doses of intravitreal ranibizumab with no recurrence during the follow-up period. Li et al.[7] reported a good response to intravitreal conbercept administration in a patient with CNV induced by laser damage. Recently Amoroso et al.[8] reported a case of using ranibizumab injection for CNVM secondary to laser pointer injury.

Treatment for retinal laser injuries remains largely uncharacterized. Most patients exhibit gradual improvement in visual acuity and in the scotoma without treatment.[2],[9] Nevertheless, several authors have reported improvements in visual acuity and OCT findings after the administration of oral steroids, in conjunction with improved photoreceptor survival.[10],[11] Notably, however, randomized controlled trials are necessary to demonstrate the benefits of such treatments.

There are several reports describing damage to the RPE due to thermal laser injuries, but there are less reports describing alteration of the choriocapillaris, as was evident in the present patient. The possible effects of laser pointers on the deeper layers of the retina should be considered. Multimodal imaging including OCT-A is essential in the diagnosis and follow-up of patients with laser-induced ocular injuries.[3]


  Conclusion Top


In conclusion, the present case demonstrates the importance of early treatment of laser-induced CNV with intravitreal anti-VEGF, and highlights the value of multimodal imaging including OCT-A in the diagnosis and follow-up of these maculopathies.

To our knowledge, this is the first case describing the use of Aflibercept for laser pointer induced CNV.

We emphasize the importance of including laser pointer retinopathy in the differential diagnosis of sudden-onset painless vision loss, especially in children. Lastly, we encourage national legislation to regulate laser pointers, and restrict public access to them due to their potential to induce lasting visual loss.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Alda J, Gómez Sanz F, González Martín-Moro J. Laser pointer maculopathy. A new public health problem? Arch Soc Esp Oftalmol 2017;92:1-3.  Back to cited text no. 1
    
2.
Tomasso L, Benatti L, La Spina C, Lattanzio R, Baldin G, Carnevali A, et al. Optical coherence tomography angiography findings in laser maculopathy. Eur J Ophthalmol 2017;2:e13-5.  Back to cited text no. 2
    
3.
Raevis J, Shrier E. Pediatric bilateral blue laser pointer-induced maculopathy. Case Rep Ophthalmol 2017;8:152-6.  Back to cited text no. 3
    
4.
Stuart A, Ford JA, Duckworth S, Jones C, Pereira A. Anti-VEGF therapies in the treatment of choroidal neovascularisation secondary to non-age-related macular degeneration: A systematic review. BMJ Open 2015;5:e007746.  Back to cited text no. 4
    
5.
Xu K, Chin EK, Quiram PA, Davies JB, Parke DW 3rd, Almeida DRP. Retinal injury secondary to laser pointers in pediatric patients. Pediatrics 2016;138:e20161188.  Back to cited text no. 5
    
6.
Forshaw TRJ, Sørensen TL, Munch IC. Accidental macular laser burn in a 12-year-old boy complicated with choroidal neovascularization: 4-year follow-up with spectral-domain optical coherence tomography. Acta Ophthalmol 2018;96:e899-901.  Back to cited text no. 6
    
7.
Li SS, Chu XR, Chen F. Formation of choroidal neovascularization under macular fovea after high-power laser irradiation: A case report. Int J Ophthalmol 2020;13:359-61.  Back to cited text no. 7
    
8.
Amoroso F, Souied EH, Ansary MF, Astroz P, Mouallem-Bézière A, Pedinielli A, et al. Optical coherence tomography angiography findings of choroidal neovascularization secondary to laser injury: A case report. Am J Ophthalmol Case Rep 2020;19:100767.  Back to cited text no. 8
    
9.
Neffendorf JE, Hildebrand GD, Downes SM. Handheld laser devices and laser-induced retinopathy (LIR) in children: An overview of the literature. Eye 2019;33:1203-14.  Back to cited text no. 9
    
10.
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 Online:e135-8.  Back to cited text no. 10
    
11.
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.  Back to cited text no. 11
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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