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.
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).
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
A, Photograph taken 1 month following
initial injury demonstrating well-organized epiretinal membrane measuring
2 × 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
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.
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.
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.
Ray S, Topping T, Young LHY. Spontaneous Peeling of Epiretinal Membrane Associated With Nd:YAG Laser Injury. Arch Ophthalmol. 2001;119(1):137-139. doi: