SURVEY OF OPHTHALMOLOGY VOLUME 45 • NUMBER 3 • NOVEMBER-DECEMBER 2000
week after the injury, the patient’s visual acuity was counting fingers at 3 feet and a full-thickness macular hole developed. Two weeks later, the choroidal rupture sites became hyperpigmented. Six months later, subretinal neovascularization was identified along the superior edge of the macular hole with a typical gray-green appearance. Metaplastic scar tissue developed with enlargement of the macular hole, and the vision stabilized at 20/200. This unfortunate combination of macular choroidal rupture followed by macular hole formation with the development of subretinal neovascularization and enlargement of the hole has not been previously reported. The macular hole was not instantaneous, but took 7 days to develop. It gradually enlarged over a period of 6 years, but the final visual acuity was 20/ 200. The visual acuity remained stable for 9 years following the injury. The initial retinal defect interpreted as the impact site was 100 microns in size. The macular hole when first diagnosed was 500 microns in size, but enlarged with the development of metaplastic scarring to 1500 microns. A Goldmann field examination showed a 10⬚ central scotoma. Unfortunately, treatment for this patient was not possible. It would be interesting to speculate whether our current technology of vitrectomy surgery with fluid/gas exchange and tamponade of the macula might have halted the progression in this patient.
A New Report of Laser Eye Injury To the Editor: The review “Laser Eye Injuries” by Barkana and Belkin (Surv Ophthalmol 44 (6):459–78, 2000) reveals that laser injuries are an uncommon but persistent fact of life in a world in which use of lasers is increasing. The review indicated that laser accidents are seldom reported because of the lack of new information. We have encountered a case of laser injury to the eye associated with choroidal rupture, macular hole formation, and the later development of subretinal neovascularization. To the best of our knowledge, this information has not been previously reported and makes an interesting postscript to the review. Our patient was a 40-year-old woman who presented one hour after sustaining an injury at work, where she was employed as a technician for a manufacturer of YAG lasers. She was lining up the mirrors of a laser, using her left eye without safety glasses, when the trigger mechanism went off, releasing nine millijoules of energy. She noticed immediate vision loss with hazy vision in her left eye. She recalled no popping sounds or pain, but noticed immediately that she had a black spot in the central vision of her left eye. One hour after injury, she could only count fingers in the involved eye. There was no afferent pupillary defect. The applanation tension and anterior segment examination were normal. There was no color perception with pseudoisochromic plates. A mild vitreous hemorrhage was present and an impact site close to the fovea was noted. Intravenous fluorescein angiography performed 24 hours after the injury showed a small amount of superficial hemorrhage and two choroidal ruptures at right angles to each other through the center of the fovea. There was no evidence of a macular hole. The angiogram highlighted the mild vitreous hemorrhage and choroidal ruptures in the early phase with intense staining in the late phase. One
Daniel F. Marcus, MD James Ravin, MD, MS PII S0039-6257(00)00157-0
Authors’ response: The case report by Drs. Marcus and Ravin highlights some important lessons associated with laserinduced eye injuries. 1. The importance of eye protection. There is no excuse for not using the proper filters when one knows what is the emitted wavelength of the laser one 262
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