Title

SUB-FOVEOMACULAR HEMORRHAGE INDUCED BY LASER POINT TRATED WITH SF6

Summary

Purpose: To report a case of sub-foveomacular hemorrhage (SFMH) induced by laser pointer that was treated successfully through pneumatic displacement with SF6 gas injection and prone positioning. Methods: Interventional case report. Results: A 38-year-old healthy male patient complained of sudden vision loss in his left eye after a quick exposure to a laser point in carnival. On initial presentation, the best corrected visual acuity (BCVA) was 20/20 in the right eye (RE) and 20/400 in the left eye (LE). The segment anterior examination was normal with no iris and lens changes in both eyes. The fundus examination revealed a SFMH in the LE with a masking effect at fluorescein angiography (FA) and sub-retinal blood at optical coherence tomography (OCT). We performed an intravitreal 0.4cc of 100% SF6 and oriented him the importance of strict prone positioning. After a short period of 5 days, there was a substantial improvement of the macular hemorrhage and in 2 months a complete resolution of it with marked vision improvement (20/70). The last time we saw the patient (8 years after he first visit) the BCVA was 20/25 in the LE, only with a small retinal pigment epithelial (RPE) defect in the foveomacular region, the OCT confirmed the RPE lesion with a cystic like lesion. We believe our prompt decision of gas tamponade and strict positioning to treat the SFMH was the key point to this rapid and impressive anatomic and visual results. Discussion: Accidental exposure to high-power handheld laser devices can cause a variety of maculopathies, which can reduce central vision permanently. Although vision may improve spontaneously, most cases require intervention. Lasers can affect the retina through several mechanisms, including photocoagulation, photodisruption, or photochemical interaction. The wavelength, duration of exposure, spot size, power, and location determine the severity of retinal damage. Retinal damage reported in the literature includes RPE disturbances; subretinal, intraretinal, subhyaloid, and vitreous hemorrhage; epimacular membrane; and full thickness macular hole. Subretinal hemorrhage is defined as blood collection between the neurosensory retina and RPE; one of its causes is ocular trauma by laser pointer and persisting SFMH leads to a damage of photoreceptors mediated by three main mechanisms: iron-related toxicity, impairment of diffusion of oxygen and nutriments, mechanical damage due to clot contraction. Since early photoreceptors’ damage has been reported within 24 h, it is suggested to provide an early treatment. The available treatment options are intravitreal tissue plasminogen activator (tPA) associated with pneumatic displacement, pars plana vitrectomy with subretinal tPA injection and pneumatic displacement, and intravitreal anti-vascular endothelial growth factor (VEGF) injection. We optioned pneumatic displacement because the patient’s age and because we believe in our point of view is less invasive and safer than vitrectomy associated with subretinal tPA injection with less risk of complications and in the absence of severe neuroretina damage, a chance of a better visual outcome.

Area

SURGICAL CASE

Authors

Heitor Amaral Simoes, Arnaldo Pacheco Cialdini, Marcos Pereira Ávila