Retinal Injury Secondary to Laser Pointers in Pediatric PatientsKunyong Xu, MD, MHSc, a Eric K. Chin, MD, b Polly A. Quiram, MD, PhD, c John B. Davies, MD, c D. Wilkin Parke III, MD, c David R.P. Almeida, MD, MBA, PhDc
aDepartment of Ophthalmology, Queen’s University,
Kingston, Ontario, Canada; bRetina Consultants of Southern
California, Redlands, California; and cVitreoRetinal Surgery,
PA, Minneapolis, Minnesota
Drs Xu and Almeida conceptualized and designed
the study and drafted the initial manuscript; Drs
Chin, Quiram, Davies, and Parke carried out the
initial analysis and reviewed and revised the
manuscript; and all authors approved the fi nal
manuscript as submitted.
DOI: 10.1542/peds.2016-1188
Accepted for publication Jul 6, 2016
Address correspondence to David R.P. Almeida, MD,
MBA, PhD, VitreoRetinal Surgery, PA, 7760 France
Ave S, Minneapolis, MN 55435. E-mail: dalmeida@
evolation-medical.com
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
1098-4275).
Copyright © 2016 by the American Academy of
Pediatrics
FINANCIAL DISCLOSURE: The authors have
indicated they have no fi nancial relationships
relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors
have indicated they have no potential confl icts of
interest to disclose.
Laser pointers are low-energy
light sources that can emit focal
nonionizing radiation. They are
used in various situations and are
inappropriately used as toys for some
children. Most laser pointer devices
are red (670 nm wavelength) or green
diode lasers (532 nm wavelength).
In the United States, the safety level of
laser devices is categorized according
to the American National Standard
Institute Z136.1 and most consumer
laser pointers fall under class II or class
IIIA level of safety, which encompasses
lasers of 1 to 5 mW or less of power.
Handheld lasers can be more powerful,
either class 3B (5–500 mW) or class
4 (> 500 mW), and these lasers may
cause immediate eye hazard when
viewed directly. 1 Previously, laser
pointers were considered as harmless;
however, in recent years, there have
been increasing number of cases of
retinal injury caused by mishandling
of laser pointers among in children. 2 – 12
Hence, accidental retinal injury among
children due to laser pointer exposure
represents a serious, but preventable,
public health issue.
We report 4 children with retinal
injury caused by laser pointer exposure
to emphasize the significance of
vision loss due to improper use of the
devices. Moreover, it is important for
health professionals to recognize and
be cognizant of the presentation and
natural history of retinal injury from
laser pointer use.
METHODS
A retrospective review of all cases of
laser pointer induced damage to the
abstractThis case report describes 4 male children (age, 9–16) who had laser-related
retinal injury to the macula of 1 eye or both eyes due to the mishandling
of the laser pointer devices at a single vitreoretinal clinical practice. The
presenting symptoms associated with laser pointer injury include central
vision loss, central scotoma, and metamorphopsia. Clinical findings of
laser-related retinal injury include reduced visual acuity, disruption of
the photoreceptor ellipsoid zone, retinal pigment epithelium atrophy,
and choroidal neovascular membrane formation. Disruption of the foveal
ellipsoid zone (photoreceptor inner segment/outer segment layer) is the
most common finding on optical coherence tomography imaging. Three
patients had potential irreversible vision loss. Laser pointers are readily
available and appropriate use of laser pointers in the pediatric population
must be emphasized due to the potential irreversible retinal injury. Health
professionals, school teachers, and parents should raise public awareness of
this emerging public health issue by educating children about the dangers of
laser pointers. Laser pointer devices among children should be discouraged
and limited due to the possibility of permanent harm to themselves and
others. Legislation and laws may be required to better control the sale and
use of these devices.
CASE REPORTPEDIATRICS Volume 138 , number 4 , October 2016 :e 20161188
To cite: Xu K, Chin EK, Quiram PA, et al. Retinal
Injury Secondary to Laser Pointers in Pediatric
Patients. Pediatrics. 2016;138(4):e20161188
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XU et al
retina in the pediatric population
(<18 years of age) at a single
centered vitreoretinal medical/
surgery practice.
RESULTS
Case 1
A 12-year-old boy presented with
bilateral central scotomas and
decreased vision shortly after he
directly looked at the green laser
pointer for ~1 minute. His best
corrected Snellen visual acuity
(BCVA) was 20/20 OD and 20/30 OS.
Funduscopic examination identified
pigment clumping with focal retinal
pigment epithelium (RPE) atrophy
for both eyes ( Fig 1 A and B). Optical
coherence tomography (OCT) of the
macula revealed bilateral disruption
of the foveal photoreceptor ellipsoid
zone (photoreceptor inner segment/
outer segment; Fig 1 C and D).
At 7-month follow-up, the BCVA
and macular findings remained
unchanged.
Case 2
A 9-year-old boy presented with
a 4-day history of central scotoma
and vision loss OD. Symptoms
occurred ~5 to 10 seconds after
looking at the reflection of a green
laser pointer into a mirror that was
directed at his right eye. His BCVA
was 20/50 OD and 20/25 for OS.
Funduscopic examination revealed
macular pigment changes in the
right eye only ( Fig 2 A and B). OCT
OD revealed subfoveal outer retinal
hyperreflectivity with disruption of
the foveal photoreceptors ( Fig 2C).
The patient was treated with
prednisolone 1% 3 times per day for
OD for 2 weeks. After 1 month, the
visual acuity improved to 20/30 OD
with persistent abnormalities of the
photoreceptors OD. His examination
OS was unchanged.
Case 3
A 16-year-old boy presented with
a 3-day history of bilateral central
vision loss and central scotoma
that occurred immediately after
e2
FIGURE 1Color fundus photos of right eye (A) and left eye (B) for case 1 revealing pigment clumping with focal RPE atrophy (arrow). OCT imaging of the macula right eye (C) and left eye (D) revealing disruption of the inner segment/outer segment band of the fovea (arrow).
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PEDIATRICS Volume 138 , number 4 , October 2016
playing with a green laser pointer
for approximately half minute. On
examination, BCVA was 20/30 OU.
Funduscopic examination revealed
macular chorioretinal scars and
focal RPE atrophy ( Fig 3 A and B).
The OCT revealed disruption of the
photoreceptor ellipsoid zone in both
eyes ( Fig 3 C and D). Two weeks after
presentation, the patient complained
about worsening central vision
with enlarging scotomas in both
eyes. On examination, the maculae
had significantly worse pigmentary
changes with increases in RPE
atrophy ( Fig 4 A and B). Visual acuity
decreased to 20/40 in both eyes and
did not further improve.
Case 4
A 12-year-old boy presented
with central vision loss and
metamorphopsia with a central
scotoma right eye, which occurred
immediately after looking directly
at the light of a red laser pointer
shown into his right eye for ~15
seconds. His BCVA was 20/70 OD and
20/20 OS. Funduscopic examination
revealed RPE atrophy and a choroidal
neovascular membrane with
subretinal hemorrhage. Examination
of left eye was normal. He received
an intravitreal bevacizumab 1.25
mg/0.05 mL OD and his BCVA and
symptoms gradually improved after
1 injection. At 1-year follow-up,
BCVA improved to 20/20 OD with
significant improvement in his
subjective metamorphopsia.
DISCUSSION
Over the past 15 years, there has
been an alarming increase in reports
of laser pointer induced retinal
injury among children. 2 –11 Here, we
describe 4 cases of retinal injury
caused by laser pointers among
children within a 2-year period, the
youngest of which was only 9 years
of age. A summary of all 4 cases
can be found in Table 1. Factors
attributed to eye injury in our series
include the following: availability
e3
FIGURE 2Color fundus photo of right eye (A) for case 2 revealing yellow pigmentary change of the fovea (arrow). The fundus photo of the left eye was unremarkable (B). OCT imaging of the macula right eye (C) revealing subfoveal outer retinal hyperrefl ectivity with some disruption of the foveal photoreceptors at the fovea center (arrow).
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XU et al
of these devices, lack of awareness
of the potential dangers associated
with laser pointers, and the improper
use of the devices. Currently, laser
pointers are readily available and,
owing to various questionable
online merchants, these devices
are increasingly more powerful. 13
Because retinal injury due to laser
pointers might be irreversible, we
feel that this is a significant public
health issue.
Laser-related retinal injury is
dependent on both patient-related
(eg, pupil size, refractive status,
degree of retinal pigmentation,
proximity of incident laser beam
to the fovea) and laser-related
factors (eg, wavelength, pulsatile
duration, and energy of the laser
beam). 14 Among those, 3 of the
most important variables include
the following: the amount of energy
delivered by the laser, the duration of
exposure, and location of the retinal
involvement. 14 In our case series, the
retinal injury occurred in 3 children
who were playing with green laser
pointers. Green laser pointers are
becoming increasingly more popular
and abundantly available, 15 which
is concerning because experiments
reveal that green laser pointers
(490–575 nm) are more harmful to
the retina compared with red laser
pointers (630–750 nm). 16, 17
e4
FIGURE 3Color fundus photo of right eye (A) and left eye (B) for case 3 revealed chorioretinal scars and focal RPE atrophy, at the macula (arrow). OCT imaging of the macula for both eyes (C and D) revealed disruption of the inner segment/outer segment layer of the retina (arrow).
FIGURE 4Two-week follow-up color fundus photos of both eyes (A and B) for case 3 revealed dark pigmentary changes of the macula (arrow).
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PEDIATRICS Volume 138 , number 4 , October 2016
The most commonly used laser
pointers have a power output <5
mW, which are not considered as
harmful to human eye because of
the limited exposure aided by innate
ocular protective mechanisms
(such as blink reflex and aversion
response). 18 However, as shown in
case series, children increase their
chance to retinal injury by staring
at the laser beam without blinking
or averting the eye for a prolonged
duration. 7 In addition, the labeling of
the power output of a laser point may
be different from the device’s actual
specifications. Recent work reveals
that, after measuring the power of
122 laser pointers labeled as 1 to
5 mW, it was found that 90%
of green laser pointers and 44% of
red laser pointers tested had power
outputs >5 mW. 19
As health professionals, it is
important to be aware of the
symptoms of retinal injury caused
by laser pointers and to emphasize
the potential irreversible harm of
laser pointers to retinal injury among
children. A systematic approach,
including the history of laser
exposure, presenting symptoms, and
physical examination, could facilitate
an appropriate evaluation and
referral. Vision loss and persistent
central scotoma normally occur
immediately after the laser beam
exposure. These symptoms can occur
in 1 eye or both eyes, which can
be preceded by the perception of a
bright flash or accompanied by an
audible “popping” sound. 18 Although
eye pain, redness, and/or irritation
are common complaints, none of
those symptoms are typically caused
by the direct laser pointer exposure.
A study suggested various questions
to help health professionals
diagnose alleged laser eye injuries:
whether eye symptoms could have
been caused by a laser, whether
they have been documented
by ophthalmoscopy and retinal
imaging, and whether any somatic
complaints are supported by
scientific evidence. 18 If decrease
vision and persistent after-images
or scotoma are present, and their
history demonstrates a likelihood
of significant exposure, one should
refer the child to an ophthalmologist
for full ophthalmologic workup
such as Amsler grid testing, dilated
funduscopic examination, and OCT or
fluorescein angiography imaging. 18, 20
The treatment of retinal injury
associated with a laser pointer
is limited and also controversial.
Current treatment of macular injury
induced by laser beam is mainly
limited to systemic corticosteroids,
which has shown mixed results. 14
Observation is an option, as many of
these patients will have stabilization
of visual acuity over time. If a
choroidal neovascular membrane
forms as a result of direct trauma
from the laser to Bruch’s membrane,
a vascular endothelial growth factor
inhibitor (such as with intravitreal
bevacizumab) is recommended to
arrest neovascular growth. Final
visual recovery is dependent on
lesion location and size. 1 In our case
series, all children suffered foveal
laser burns and 3 boys had a final
BCVA 2 lines worse than the 20/20
line.
To our knowledge, this is the
largest reported case series of laser
pointer-induced retinal damage
in the pediatric population in
a developed country to date. It
emphasizes the need for increased
recognition of the potential dangers
of retinal injury caused by laser
pointers. Potential irreversible
vision-threatening consequences due
to the mishandling of these devices
should be communicated to health
professionals, school teachers, and
guardians in an attempt to raise the
public awareness of this emerging
public health issue. Unsupervised use
of these laser pointer devices among
children should be discouraged,
and there is a need for legislation to
limit these devices in the pediatric
population.
ABBREVIATIONS
BCVA: best corrected Snellen
visual acuity
OCT: optical coherence
tomography
RPE: retinal pigment epithelium
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e5
TABLE 1 Summary of Pediatric Patients Who Suffered From Laser Pointer Damage to the Retina
Patient/
Case
Age at
Presentation, y
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DOI: 10.1542/peds.2016-1188 originally published online September 1, 2016; 2016;138;Pediatrics
David R.P. AlmeidaKunyong Xu, Eric K. Chin, Polly A. Quiram, John B. Davies, D. Wilkin Parke III and
Retinal Injury Secondary to Laser Pointers in Pediatric Patients
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DOI: 10.1542/peds.2016-1188 originally published online September 1, 2016; 2016;138;Pediatrics
David R.P. AlmeidaKunyong Xu, Eric K. Chin, Polly A. Quiram, John B. Davies, D. Wilkin Parke III and
Retinal Injury Secondary to Laser Pointers in Pediatric Patients
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