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

Laser Type/

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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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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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