A 61-year-old healthy patient was seen for a second opinion regarding
whether additional laser treatment was needed to treat a retinal break in
his left eye. He had been seen elsewhere for monitoring of retinoschisis,
where a superiorly located horseshoe tear, unassociated with the schisis cavity,
and a smaller break were found in his left eye. Laser treatment was recommended.
At that time, a contact lens was placed on the left eye under topical anesthesia,
and approximately 100 moderate-intensity argon laser lesions were applied
at the slitlamp, some of which were uncomfortable. Treatment required him
to remain motionless, and after about 10 minutes, he told his laser surgeon
that he felt light-headed. The surgeon stopped treatment but the patient lost
consciousness, fell off his stool, and struck his head against the floor.
The physician immediately went to summon assistance. On return with ancillary
medical personnel, the patient was found on the linoleum floor, semiconscious.
He was examined in the emergency department, where x-rays and a computed
tomographic scan of his head were obtained. As all findings were negative
except for an ecchymosis on his scalp, the patient was released with the diagnosis
of a vasovagal event and returned home. During the ensuing weeks, his wife
noted some short-term memory loss, and he complained of a fullness in the
head. On his return from a business trip, he was reunited with a physician
friend of his who had not seen him for some time. She noted a change in her
friend's affect. Both she and another physician questioned the patient and
were concerned that he might have experienced a subdural hematoma from the
fall. A repeated computed tomographic scan was ordered, and a marked shift
(30 mm) of the falx cerebri was found, confirming the diagnosis (Figure 1).
Computed tomographic image taken 2 months after an aborted laser
treatment to a retinal break, showing a radiolucent hygroma (small white arrows)
and subdural hemorrhage (black arrows) that have grossly shifted the falx
cerebri from right to left (large white arrow). Evacuation of the hemorrhage
required 2 serial craniotomies.
The patient then underwent a craniotomy, 8 weeks after the photocoagulation
session. A second craniotomy was necessary 1 month later because he developed
paresis of his left hand, secondary to a reaccumulation of the hematoma. His
paresis eventually resolved.
Four months after the accident, the patient was seen at our center.
The retinal break had been incompletely treated, and additional photocoagulation
was necessary. This time, an indirect laser delivery system was suggested
to allow him to lie in a more comfortable, supine position during treatment
and to avoid the necessity of placing a contact lens on his eye. He returned
2 months and then 8 months later and has remained stable and free from neurologic
and visual symptoms.
Laser photocoagulation is customarily a safe outpatient procedure associated
with few complications.1 However, laser
surgery to an eye is never trivial. Proper facilities, equipment, and extensive
training are necessary to safely perform it and to manage potential complications.
While treatment with excessive powers can cause chorioretinal hemorrhage and
subsequent choroidal neovascularization, the development of subdural hematoma
precipitated by discomfort occurring during laser treatment is distinctly
Many laser surgeons are currently exploring the use of several newer
laser strategies for the treatment of macular degeneration, such as photodynamic
therapy2 and transpupillary thermal therapy.3 Such treatment, along with the application of many
lesions during conventional panretinal photocoagulation, requires that the
patient remain motionless, often for extended periods of time. In this case,
the production of strong chorioretinal lesions for retinopexy necessitated
the use of moderately intense laser spots. These conditions and perhaps pressure
on the eye from the contact lens ultimately precipitated a vasovagal response
in this case, which in turn resulted in severe consequences.
The head-mounted binocular indirect ophthalmoscope laser delivery system
is preferred by many surgeons for panretinal photocoagulation and for the
treatment of retinal breaks in the outpatient setting. With this delivery
system, patients can be treated while lying down in a relaxed, supine position,
which minimizes their discomfort and eliminates their chance of falling backward
during photocoagulation.4 Such an option
should be considered for the initial treatment of a patient with a peripheral
lesion, and especially in a patient for whom discomfort and instability of
positioning have been apparent during previous slitlamp laser delivery.
Regardless of the technique used, this case underscores the fact that
very serious and unexpected sequelae can develop secondary to laser treatment
of the human eye. All laser surgeons should have the appropriate medical training
to deal with such issues.
The authors do not have any proprietary interest relevant to this study.
Corresponding author: Thomas R. Friberg, MD, MS, Department of Ophthalmology,
203 Lothrop St, Suite 824, Pittsburgh, PA 15213 (e-mail: firstname.lastname@example.org).
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