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A Mysterious Central Scotoma in a Teenage Male Patient

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A white teenage boy was referred for 3 months of bilateral reduced central visual acuity characterized as atraumatic, painless, constant, symmetric, and nonprogressive. His parents reported that he had recently been hospitalized for a suspected overdose with the medications atomoxetine, quetiapine, melatonin, fluoxetine, bupropion, and clonazepam, and shortly after, he reported central visual acuity loss. A dilated fundus examination with normal results had been documented 6 months prior to our examination.

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Self-inflicted laser eye injury (laser maculopathy)

C. Inquire about bright light exposures

Laser-pointer maculopathy is a rare complication resulting from ocular exposure to laser light. In this case, the source was a green laser pointer. Of the listed choices, only choice C diagnoses laser-pointer maculopathy as the cause of vision loss. Stopping medications (choice A) would be unwarranted, given these findings. Initiating oral steroids (choice D) would be premature without a diagnosis. Obtaining an electroretinogram (choice B) should not be considered prior to obtaining additional history (choice C).

Laser-pointer maculopathy was first reported in 1999 and commonly presents in young male patients. Exposure is often unintentional but can be intentional in patients with a history of behavioral problems.1 The reported age at onset ranges from 7 to 36 years, but the condition may not be exclusive to this demographic.24 Fundoscopy reveals focal retinal pigment epithelium damage with yellow or gray discoloration.1,2,48 Additional ocular manifestations include a full-thickness macular hole, premacular hemorrhage, epiretinal membrane, schisis formation, and cystoid macular edema.24 Ancillary imaging, including OCT, fluorescein angiography, and fundus autofluorescence, should be obtained. The OCT image reveals outer retinal layer disruption and hyperreflective bands from the outer photoreceptors to the Henle layer.4,69 A distinctive finding in this patient’s fluorescein angiography is a vertical streak superior to the fovea, likely the result of an involuntary Bell reflex while staring at the laser pointer (Figure 2).

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Article Information

Corresponding Author: Andrew W. Francis, MD, NorthShore University HealthSystem, 2650 Ridge Ave, Evanston, IL 60201 (afrancis@northshore.org).

Published Online: February 13, 2020. doi:10.1001/jamaophthalmol.2019.5383

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient’s father for granting permission to publish this information.

References
1.
Luttrull  JK , Hallisey  J .  Laser pointer-induced macular injury.   Am J Ophthalmol. 1999;127(1):95-96. doi:10.1016/S0002-9394(98)00254-2 PubMedGoogle ScholarCrossref
2.
Torp-Pedersen  T , Welinder  L , Justesen  B ,  et al.  Laser pointer maculopathy—on the rise?   Acta Ophthalmol. 2018;96(7):749-754. doi:10.1111/aos.13856 PubMedGoogle ScholarCrossref
3.
Alsulaiman  SM , Alrushood  AA , Almasaud  J ,  et al; King Khaled Eye Specialist Hospital Collaborative Retina Study Group.  High-power handheld blue laser-induced maculopathy: the results of the King Khaled Eye Specialist Hospital Collaborative Retina Study Group.   Ophthalmology. 2014;121(2):566-72.e1. doi:10.1016/j.ophtha.2013.09.006 PubMedGoogle ScholarCrossref
4.
Mtanes  K , Mimouni  M , Zayit-Soudry  S .  Laser pointer-induced maculopathy: more than meets the eye.   J Pediatr Ophthalmol Strabismus. 2018;55(5):312-318. doi:10.3928/01913913-20180405-01 PubMedGoogle ScholarCrossref
5.
Rusu  I , Sherman  J , Gallego-Pinazo  R , Lam  M , Freund  KB .  Spectral-domain optical coherence tomography and fundus autofluorescence findings in a case of laser pointer-induced maculopathy.   Retin Cases Brief Rep. 2013;7(4):371-375. doi:10.1097/ICB.0b013e3182965291 PubMedGoogle Scholar
6.
Chen  X , Dajani  OAW , Alibhai  AY , Duker  JS , Baumal  CR .  Long-term visual recovery in bilateral handheld laser pointer-induced maculopathy.   Retin Cases Brief Rep. 2019. doi:10.1097/ICB.0000000000000845 PubMedGoogle Scholar
7.
Bhavsar  KV , Wilson  D , Margolis  R ,  et al.  Multimodal imaging in handheld laser-induced maculopathy.   Am J Ophthalmol. 2015;159(2):227-31.e2. doi:10.1016/j.ajo.2014.10.020 PubMedGoogle ScholarCrossref
8.
Raoof  N , O’Hagan  J , Pawlowska  N , Quhill  F .  ‘Toy’ laser macular burns in children: 12-month update.   Eye (Lond). 2016;30(3):492-496. doi:10.1038/eye.2015.222 PubMedGoogle ScholarCrossref
9.
Hossein  M , Bonyadi  J , Soheilian  R , Soheilian  M , Peyman  GA .  SD-OCT features of laser pointer maculopathy before and after systemic corticosteroid therapy.   Ophthalmic Surg Lasers Imaging. 2011;42 Online:e135-e138. doi:10.3928/15428877-20111208-03PubMedGoogle Scholar
10.
Chen  YY , Lu  N , Li  JP , Yu  J , Wang  L .  Early treatment for laser-induced maculopathy.   Chin Med J (Engl). 2017;130(17):2121-2122. doi:10.4103/0366-6999.213412 PubMedGoogle ScholarCrossref
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