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Foveal choroidal neovascularization secondary to accidental laser exposure in a dermatologist

A case report

Lee, You Hyun MD; Kim, Yu Cheol MD, PhD*

Section Editor(s): NA.,

doi: 10.1097/MD.0000000000015429
Research Article: Clinical Case Report
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Rationale: Most laser-induced retinal injuries are caused by accidental laser discharge during the preparation of laser devices without protective goggles, laser injury during the cosmetic procedure in a dermatologist, is very rare, with no prior case reports.

Patient concerns: A 55-year-old Asian male dermatologist visited our hospital with a 2-week history of visual disturbance in his right eye. He had experienced sudden central scotoma in the right eye while using a Q-switched Nd:YAG laser (1064 nm, 2 J/cm2, 6-mm spot size, 750 ps) 2 to 3 cm from the target without proper eye protection. He had applied a glass slide firmly onto the treatment area prior to commencing the procedure. The choroidal neovascularization (CNV) was detected via optical coherence tomography angiography (OCTA) 2 weeks after the laser injury.

Diagnosis: Foveal CNV secondary to laser energy reflected from the glass slide.

Intervention: Intravitreal bevacizumab (1.25 mg/0.05 mL) injection was performed.

Outcomes: Regression of CNV was observed.

Lessons: Retinal injury can occur not only by direct laser beam exposure but also by way of a beam reflected from a glass slide. Operators should always use laser safety eyewear during cosmetic procedures involving laser devices, so as to prevent the occurrence of ocular complications. Thorough short-term follow-up with OCTA is recommended for the prompt detection of CNV in cases of retinal laser injury.

Department of Ophthalmology, Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea.

Correspondence: Yu Cheol Kim, Department of Ophthalmology, Keimyung University School of Medicine, #56 Dalseong-ro, Jung-gu, Daegu 41931, Korea (e-mail: eyedr@dsmc.or.kr).

Abbreviations: BCVA = best corrected visual acuity, CNV = choroidal neovascularization, OCTA = optical coherence tomography angiography.

This work was supported by the National Research Foundation of Korea (NRF) Grant funded by the Korea Government (MSIP) (No. 2014R1A5A2010008).

The authors have no conflicts of interest to disclose.

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0

Received December 10, 2018

Received in revised form March 26, 2019

Accepted April 2, 2019

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1 Introduction

Various wavelengths of laser light can damage the eye. Wavelengths between 400 and 1400 nm can damage the retina, as they can be transmitted through the clear media of the eye.[1,2] Most laser-induced retinal injuries are caused by accidental laser discharge during the preparation of laser devices without protective eyewear.[3,4] Herein, we describe a case of foveal choroidal neovascularization (CNV) that developed within 2 weeks after accidental laser exposure in a dermatologist.

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2 Case report

A 55-year-old Asian male dermatologist visited our hospital within 2 weeks of developing visual disturbance in his right eye. He had experienced sudden central scotoma in the right eye while using a picosecond pulse duration Q-switched Nd:YAG laser (enlighten; Cutera Inc, Brisbane, CA) to treat a depressed scar on a patient's nose without proper eye protection. The laser settings were 2 J/cm2 power, 6-mm spot size, 1064-nm wavelength, and 750-ps pulse duration, and it was fired at a distance of 2 to 3 cm from the target with a microlens array attached to the handpiece. The dermatologist had applied a glass slide firmly onto his patient's treatment area to reduce the pain and decrease epidermal damage during the procedure.

On ocular examination, best corrected visual acuity (BCVA) was 4/32 in the right eye and 20/20 in the left (Snellen chart). Dilated fundus examination was normal in the left eye, but the right eye exhibited an area of intraretinal and subretinal hemorrhaging of approximately 3/4 disc diameter in size on the macula, with elevated retina (Fig. 1A). Optical coherence tomography angiography (OCTA; DRI OCT Triton; Topcon, Tokyo, Japan) revealed mild subretinal fluid and CNV with disruption of the retinal pigment epithelium, ellipsoid zone, and outer retina. Angiography depicted a “Medusa head” appearance of the CNV in the outer retinal layer (Fig. 1B, C). Fluorescein angiography (HRA-2; Heidelberg Engineering, Dossenheim, Germany) depicted mild hyperfluorescence in the arteriovenous phase (Fig. 2A) and leakage in the late phase around the fovea (Fig. 2B). An intravitreal bevacizumab injection (1.25 mg/0.05 mL) was administered, followed by a 2nd injection 4 weeks later. Twelve weeks thereafter, BCVA had improved to 20/80 and fundus examination revealed a flattened retina with resolution of the intraretinal and subretinal hemorrhaging in the right eye (Fig. 3A). OCTA revealed improvement of subretinal fluid and reduction in the size of the CNV (Fig. 3B, C). Close monitoring of BCVA changes and CNV progression was scheduled. At 4 months after the 2nd intravitreal injection, his right eye BCVA was 20/63 and fundus findings were similar to those of the previous visit (Fig. 4A). However, OCTA revealed an increase in the size of the CNV with extensive arborization (Fig. 4B, C). The patient was treated with another intravitreal bevacizumab injection. Informed written consent was obtained from the patient for publication of this case report and accompanying images.

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3 Discussion

Laser-induced ocular injuries have become more common as lasers have become more widely used in many different fields, such as cosmetic medicine, scientific research, and industry.[5] The eye can be injured during cosmetic laser procedures involving the face, and most such injuries are reportedly associated with improper eye protection of the patients receiving laser treatments.[6] To date, there are few reports pertaining to injury to the operator during cosmetic laser procedures.

In the present case of foveal CNV secondary to accidental laser exposure in a dermatologist, he was not looking directly at the laser source. The vision loss occurred during a scar removal procedure he was administering without proper eye protection, and the circumstances at the time (specifically, the presence of a glass slide) suggest that reflection of the laser caused foveal damage and resulted in the development of secondary CNV. All Q-switched Nd:YAG lasers are Class IV, which means they incorporate a direct beam, and specular reflection and diffused reflection are hazardous to the eye.[7] Wang et al reported a patient who suffered CNV secondary to exposure to an Alexandrite laser (750 nm, 5–80 milliseconds pulse duration).[3] The laser used in the present case was a Q-switched Nd:YAG with a 1064-nm wavelength and 750-picosecond pulse duration. Higher wavelengths and shorter pulse durations cause more severe mechanical damage to the retina.[5]

In the present study, laser energy reflected off a glass slide into the operator's eye, and damaged the retina. CNV developed within 2 weeks, which is rapid compared to other secondary CNV causes such as traumatic choroidal rupture in which the CNV typically presents several months after the event.[8] In the present case, the laser energy reflected from the glass slide inflicted more damage to a small region of the retina, and resulted in more rapid progression of the CNV. From this perspective, thorough short-term follow-up is important in cases of laser-induced retinal injury. OCTA is a noninvasive imaging modality that yields high-resolution depth-resolved images of the CNV network and changes to it after the injection of antivascular endothelial growth factor.[9] In the present case, OCTA facilitated clear visualization of the CNV network on the initial visit, regression after the 2nd intravitreal injection of bevacizumab, and an increase in size after 4 months. The BCVA of this patient improved gradually, and it is important to undertake OCTA examinations periodically so as not to miss CNV aggravation.

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4 Conclusion

To the best of our knowledge, this is the 1st case report of CNV secondary to laser energy reflected from the glass slide in a dermatologist. Our experience highlights that the operators should always use laser safety eyewear during cosmetic procedures involving laser devices, so as to prevent the occurrence of ocular complications. CNV progression secondary to laser injury may be more rapid than that associated with other causes, and short-term follow-up with OCTA is recommended.

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Author contributions

Conceptualization: Yu Cheol Kim.

Data curation: You Hyun Lee, Yu Cheol Kim.

Investigation: You Hyun Lee.

Methodology: You Hyun Lee, Yu Cheol Kim.

Visualization: You Hyun Lee, Yu Cheol Kim.

Writing – original draft: You Hyun Lee.

Writing – review & editing: Yu Cheol Kim.

Yu Cheol Kim orcid: 0000-0003-1615-6651.

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References

[1]. Yam JC, Kwok AK. Ultraviolet light and ocular diseases. Int Ophthalmol 2014;34:383–400.
[2]. Sayed MS, Ko MJ, Ko AC, et al. Ocular damage secondary to lights and lasers: how to avoid and treat if necessary. World J Ophthalmol 2014;4:1–6.
[3]. Wang R, Wykoff CC, Christie L, et al. Choroidal neovascularization secondary to Alexandrite laser exposure. Retin Cases Brief Rep 2016;10:244–8.
[4]. Park DH, Kim IT. A case of accidental macular injury by Nd: YAG laser and subsequent 6 year follow-up. Korean J Ophthalmol 2009;23:207–9.
[5]. Barkana Y, Belkin M. Laser eye injuries. Surv Ophthalmol 2000;44:459–78.
[6]. Huang A, Phillips A, Adar T, et al. Ocular injury in cosmetic laser treatments of the face. J Clin Aesthet Dermatol 2018;11:15–8.
[7]. Laser Institute of America. American National Standard for Safe Use of Lasers. America LIo, editor. United States of America; 2007.
[8]. Preziosa C, Corvi F, Pellegrini M, et al. Optical coherence tomography angiography findings in a case of choroidal neovascularization secondary to traumatic choroidal rupture. Retin Cases Brief Rep 2018;doi: 10.1097/ICB.0000000000000704 [Epub ahead of print].
[9]. Spaide RF. Optical coherence tomography angiography signs of vascular abnormalization with antiangiogenic therapy for choroidal neovascularization. Am J Ophthalmol 2015;160:6–16.
Keywords:

case report; choroidal neovascularization; fovea; laser; retina

Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.