Bilateral macular hole from a handheld laser pointer

In March, 2012, a 15-year-old boy presented to our vitreoretinal department with a 3 week history of reduced vision in both eyes. He reported an acute drop in central vision, immediately after looking directly at a powerful laser pointer while lighting a cigarette. His vision had deteriorated further over the following 3 weeks, before seeking medical advice. The device had been purchased online, and had an emission power of 1000 mW and a wavelength of 474 nm (reading from the label of the device). On clinical examination, his visual acuity was 6/18 in both eyes. Fundus examination showed bilateral macular holes with irregular scalloped edges (fi gure, appendix). Optical coherence tomography (OCT) confi rmed the diagnosis (fi gure). Surgical treatment with vitrectomy, internal limiting membrane peeling, and gas tamponade was off ered, but the patient declined. At fi nal follow up, in March, 2012, the vision remained the same. The patient was discharged on the understanding that he would contact our department should he change his mind about surgery. Although the use of handheld laser devices has become common in everyday life, their potential as an ocular hazard has not been adequately described. In recent years high-power laser pointers, identical in appearance to those used in lecture theatres, have become easily obtainable at low cost via the internet. These devices have become popular among young people for their novel application in lighting cigarettes, popping balloons, and burning holes in objects. Laser pointers with an output power of less than 5 mW are regarded as harmless to the human eye because of the limited exposure aided by innate ocular protective mechanisms (blink refl ex and aversion response). Devices with an output power of more than 150 mW are capable of causing severe ocular damage. Retinal damage from high-power lasers has been reported mostly in the setting of military, industrial, or hospital use. The severity of damage is directly dependent on the laser type, wavelength, duration of exposure, and spot size. Diff erent ocular structures absorb light of varying wavelengths, with photochemical retinal damage (photocoagulation and photodisruption) more likely to be caused by blue light. Previous reports describe varying retinal pathology caused by handheld lasers. Wyrsch et al reported a 15-year-old boy who sustained a submacular haemorrhage after using a handheld green laser pointer with an output power of 150 mW. Similar fi ndings were recently published by Alsulaiman et al after the use of handheld lasers with 750 mW output power at 450 nm wavelength. Outer retinal disruption, epiretinal membrane with subretinal fl uid, and unilateral macular holes were also presented in this series; macular holes were associated with a shorter ocular-laser exposure distance. In our case, although the patient reported that the bilateral injury occurred when he was attempting to light a cigarette with simultaneous foveal exposure, it is more likely that each eye was separately exposed to the full beam while his gaze was at the output aperture. We are unaware of other reports of bilateral macular holes caused by the use of a handheld laser pointer. The device was obtained from the internet at low cost and was identical in appearance to low-power laser pointers. We suggest that these devices be classifi ed as seriously hazardous for vision and urge government action to raise public and physician awareness.