An 11-year-old girl was referred to our practice with a 3-week history of visual decrease in her right eye. She reported that, while on the school bus, one of her classmates had attempted to determine whether a laser pointer would cause pupillary constriction. During the episode she stared at the activated laser pointer for several multisecond exposures with the right eye. She immediately noted decreased vision and a central scotoma in the affected eye.
Three weeks later the best-corrected visual acuity was 20/60 −2 OD and 20/25 +2 OS. Amsler grid in the right eye revealed a relative central scotoma involving the center 2°. Anterior segment was normal in both eyes. Ophthalmoscopy of the right eye disclosed pigmentary clumping in the central fovea with loss of the central foveal reflex (Figure 1). Results of a fundus examination of the left eye were normal.
Fundus photograph of the right eye at first visit.
Fluorescein angiogram of the right eye demonstrated a mild early transmission defect in the central fovea corresponding to the area of pigment clumping without late staining (Figure 2). Fluorescein pattern in the left eye was normal.
Fluorescein angiogram of the right eye at first visit.
During the next 6 months the patient became gradually asymptomatic. Three months after the injury, the visual acuity improved to 20/25 −2 OD with a small relative central scotoma. Ophthalmoscopy revealed improvement in the appearance of the right fovea with less pigmentary disturbance (Figure 3). Fluorescein angiogram demonstrated a less prominent transmission defect (Figure 4). On last examination, 11 months after the injury, the visual acuity improved to 20/25 +1 OD uncorrected. The patient reported normal vision with no relative scotoma. Ophthalmoscopy revealed continued improvement in the foveal pigment pattern (Figure 5). Mild pigmentary clumping was present but was much less prominent than at the initial visit.
Fundus photograph of the right eye 3 months after injury.
Fluorescein angiogram of the right eye 3 months after injury.
Fundus photograph of the right eye 11 months after injury.
Our patient was exposed to a commonly available handheld laser pointer. These are class 3a devices, producing a wavelength of approximately 670 nm with less than 5 mW of power.1 Animal experiments have previously established the theoretical possibility of retinal photocoagulation in a clear ocular media by staring at a collimated class 3a laser beam for more than 10 seconds.2,3 This is, to our knowledge, the first case report of human foveal damage from this type of laser. However, a possible laser injury in a 34-year-old man has also been reported.4
The clinical course of gradual visual recovery over several months with mild laser injury is consistent with previously reported cases.3,5,6 At 6-month follow-up her vision had returned to normal with significant improvement in the clinical foveal appearance. However, the long-term effects of mild laser burns are not known.
Our case emphasizes the danger of diode lasers in the hands of children. GaA1A diode lasers have been known to have a relatively low aversion response caused by the visual sensitivity of 670 nm.7 A person cannot stare directly into the laser without experiencing painful brightness, but considering the cooperation and perseverance of a child, a potential for foveal damage exists. The ophthalmic community as well as the public should be aware of the potential danger.
All fundus and fluorescein angiogram photographs were taken by Linda Radcliff, CRA, COT.
Reprints: Clive H. Sell, MD, Associated Retina Consultants Ltd, 5501 N 19th Ave, Suite 310, Phoenix, AZ 85015.
Sell CH, Bryan JS. Maculopathy From Handheld Diode Laser Pointer. Arch Ophthalmol. 1999;117(11):1557–1558. doi: