Inner choroidal ischaemia and CNV due to handheld laser-induced maculopathy: a case report and review

Abstract

There has been a sharp rise of reported handheld laser-induced maculopathy (HLIM) cases over the past decade, a concerning trend that may continue due to unregulated online access to high power lasers. Though HLIM has distinct clinical features, not uncommonly it may masquerade as other retinal disorders. It is critical therefore to recognise the clinical and multimodal imaging characteristics of this important and potentially devastating condition. As HLIM patients are typically young, unique issues need to be considered, such as delayed presentation, difficult history, poor compliance and behavioural or psychiatric comorbidity. This article will review the clinical and diagnostic features of laser injury, with a special emphasis on the multimodal retinal findings. In addition, we present a unique case of HLIM, resembling the presentation of a placoid disease variant and illustrating choroidal ischaemia using advanced retinal imaging, that offers further insight into the mechanisms of laser injury and its complications. The issues addressed in this review aim to increase recognition of an increasingly important and trending condition with potentially profound visual complications.

Fig. 1. Colour fundus photographs of each eye at baseline presentation.

a Colour fundus photograph of the right eye at baseline presentation illustrates a white plaque in the macula associated with a central pigment scar and vertical linear streaks typical of self-inflicted HLIM. Radiating inner retinal folds are also noted. b Colour fundus photograph of the left eye illustrates a large plaque of retinal whitening associated with vertical linear streaks at presentation.

Fig. 2. Near-infrared reflectance and corresponding SD-OCT images of each eye at baseline presentation.

a Near-infrared reflectance image of the right eye illustrates a central hyperreflective plaque associated with linear vertical streaks representing outer retinal disruption and fine radiating inner retinal folds. b Near-infrared reflectance image of the left macula shows a central hyperreflective plaque with less distinct borders corresponding with early outer retinal alterations on SD-OCT B scan. c SD-OCT of the right macula illustrates a central hyperreflective scar associated with intraretinal pigment migration (i.e., hyperreflective foci), loss of the outer retinal layers, but no evidence of fluid. d SD-OCT of the left macula in the acute phase of HLIM illustrates disruption of the outer retinal layers and radiating hyperreflective lesions in the Henle fibre layer.

Fig. 3. Fundus autofluorescent images of the right and left eyes at baseline presentation.

Fundus autofluorescent images illustrate hyperautofluorescence of the vertical streaks in each eye. Note the hypoautofluorescent atrophic central scar OD (a); and the hyperautofluorescent plaque central OS (b), indicating the outer retinal and RPE injury is more severe and longstanding in the right eye.

Fig. 4. Swept-source en face OCTA and OCT images of each eye at presentation.

Swept-source OCTA of the right (a) and left (b) eyes at the level of choriocapillaris illustrates large geographic areas of flow deficit corresponding to inner choroidal ischaemia and masquerading as a placoid variant. The registered OCT B-scans show the corresponding level of segmentation. A CNV was noted inferotemporal to the fovea in the right eye within the area of choroidal nonperfusion (yellow arrow).

Fig. 5. Intravenous fluorescein angiography images of each eye at baseline presentation, demonstrating the unique differences between chronic and acute laser injury.

a Intravenous fluorescein angiography (IVFA) of the right eye illustrates mottled fluorescent staining of the atrophic and fibrotic central scar. b IVFA of the left eye illustrates window defects corresponding to the remarkable hyperfluorescent streaks.

Fig. 6. En face SD-OCTA images and registered SD-OCT B-scans of the right macula at baseline and following intravitreal aflibercept injection.

Spectral domain-OCTA and OCT of the right macula at the level of the outer retina before (a) and after (b) aflibercept intravitreal injection OD. Note the complete resolution of the CNV and its flow signal on both the en face OCTA and the cross-sectional B scan overlay.