Macular burn secondary to diode laser epilation

Abstract

Laser epilation is a cosmetic procedure that is becoming more popular in the modern era. Alexandrite (755 nm), diode (810 nm), Nd:YAG (1064 nm), and intense pulsed-light (IPL; 590–1200 nm) lasers are all commonly employed for cosmetic purposes.1Gan SD Graber EM. Laser hair removal: a review.Dermatol Surg. 2013; 39: 823-838Crossref PubMed Scopus (89) Google Scholar Eye injuries are a serious complication of laser epilation. The increased accessibility of laser epilation devices, their use in places without the proper equipment, and their use by individuals lacking the essential training may result in injuries that result in irreversible vision loss. Cases of complications such as iritis, iris atrophy, uveitis, pupillary distortion, and retinal burn during facial and periocular laser epilation have been reported previously.2Shulman S Bichler I. Ocular complications of laser-assisted eyebrow epilation. Eye (Lond). 2009; 23: 982-983Google Scholar3Parver DL Dreher RJ Kohanim S et al.Ocular injury after laser hair reduction treatment to the eyebrow.Arch Ophthalmol. 2012; 130: 1330-1334Crossref PubMed Scopus (20) Google Scholar With this case report, we aim to raise awareness about retinal injuries that may develop during laser applications by presenting retinal diode laser exposure as a result of an accident that occurred while an untrained practitioner was trying to perform a laser epilation procedure on a nonfacial region. A 30-year-old woman complained of impaired vision in her right eye for 3 days. There were no systemic or ophthalmologic disease histories. The best-corrected visual acuity was 2/10 in the right eye and 10/10 in the left eye. The intraocular pressures were 14 and 16 mm Hg. Bilateral anterior segments were normal under slit-lamp examination. In the fundus examination, a yellow-white lesion was observed in the inferior of the fovea in the right eye (Fig. 1). Given the fundus appearance indicating a retinal burn, the clinical history of the patient was expanded in terms of laser exposure. It was learned that the patient had received laser epilation 3 days prior at a beauty clinic. Additionally, it was learned that she desired to administer the pubic region treatment herself and that her right eye was exposed to laser light as a result of the device head slipping from her hand during the procedure. It was learned that the patient did not use protective eyewear during the laser epilation procedure. The laser epilation device used was a diode laser with a wavelength of 810 nm. Optical coherence tomography (OCT) of the right eye revealed irregular hyperreflectivity in the retinal pigment epithelium (RPE) and outer retinal layers (Fig. 2A). Leakage was not seen during fluorescein angiography. The patient was treated with topical corticosteroid, and the dose was gradually reduced over a 4-week period. In the follow-up 1 week later, there was no change in the patient's visual level, although she stated subjective improvement. Hyporeflective spaces were found at the inner-outer segment junction line in the first week's OCT scan. At the follow-up examination 1 month later, the patient's right eye's best-corrected visual acuity had increased to 4/10, and the interruption in the RPE and inner-outer segment bands became more noticeable on OCT (Fig. 2B). Laser epilation has increasingly gained popularity in science, industry, and medicine as a result of advancements in laser technology. Laser-related eye injuries immediately followed these developments. Today, laser epilation devices have become widely used. Laser epilation targets melanin at the dermis level of the hair follicle by selective thermolysis. The melanin in the hair root absorbs light at wavelengths of 600–1100 nm.1Gan SD Graber EM. Laser hair removal: a review.Dermatol Surg. 2013; 39: 823-838Crossref PubMed Scopus (89) Google Scholar For the retina, the danger range is wavelengths in the visible (400–720 nm) and near-infrared (720–1400 nm) ranges that may cause retinal burns and visual damage after intraocular penetration.4Youssef PN Sheibani N Albert DM. Retinal light toxicity.Eye (Lond). 2011; 25: 1Crossref PubMed Scopus (190) Google Scholar Although corticosteroids, nonsteroidal anti-inflammatory drugs, vitamins, and antioxidants are used in the treatment of laser retinal burns today, their benefits are quite limited. Wang et al.,5Wang R Wykoff CC Christie L et al.Choroıdal neovascularization secondary to alexandrite laser exposure.Retin Cases Brief Rep. 2016; 10: 244-248Crossref PubMed Scopus (10) Google Scholar in a case report of accidental alexandrite laser exposure, reported that choroidal neovascularization and subretinal hemorrhage occurred throughout the follow-up period, and they applied intravitreal ranibizumab injection. Placinta et al.6Plăcintă IA De Freitas RA Rahhal-Ortuño M Udaondo P. Retinal toxicity after facial laser epilation.Rom J Ophthalmol. 2020; 64: 70Crossref PubMed Google Scholar reported a case of subretinal fluid and retinal pigment epithelial detachment in a patient who had facial epilation with an Nd:YAG laser without using proper eye protection. They reported that in this case, unlike our case, the patient fully regained his visual acuity without any treatment. We administered topical steroid therapy in decreasing doses to our patient. We detected a partial improvement in the patient's visual acuity. These clinical differences seen after retinal injuries may be due to different laser energy exposure, laser exposure time, laser absorption levels of melanin, or retinal location of the lesion. It is important to have the appropriate protective equipment and implement safety procedures to prevent possible accidents that may result in irreversible visual damage. In a study conducted to evaluate the amount of adherence to optical safety criteria in centres performing laser-assisted epilation, it was determined that only 9.5% of the implementing facilities met the appropriate level of adherence.7AlTaleb RM Alsharif HM Younis AS Alsulaiman SM Abouammoh MA. Adherence to optical safety guidelines for laser-assisted hair removal.Photodermatol Photoimmunol Photomed. 2019; 35: 313-317Crossref PubMed Scopus (2) Google Scholar Before beginning laser epilation, eye protection or glasses must be worn by the patient, the practitioner, and every observer in the area. Each device demands the use of proper eye protection or glasses based on its wavelength. For this reason, glasses should not be switched between laser devices.1Gan SD Graber EM. Laser hair removal: a review.Dermatol Surg. 2013; 39: 823-838Crossref PubMed Scopus (89) Google Scholar Patients should be informed of basic safety precautions such as avoiding staring directly into the laser beam, even when wearing safety glasses.7AlTaleb RM Alsharif HM Younis AS Alsulaiman SM Abouammoh MA. Adherence to optical safety guidelines for laser-assisted hair removal.Photodermatol Photoimmunol Photomed. 2019; 35: 313-317Crossref PubMed Scopus (2) Google Scholar Patients should be informed of any potential dangers associated with laser epilation. Because the thin structure of the eyelid skin allows laser energy to penetrate deep ocular structures, periocular laser epilation applications involve significant dangers. It is crucial that patients understand the risk-to-benefit ratio prior to treatment of this location.2Shulman S Bichler I. Ocular complications of laser-assisted eyebrow epilation. Eye (Lond). 2009; 23: 982-983Google Scholar In our case, neither the face nor the periocular region was the application site. During the application to the pubic region, retinal burn developed as a result of an accident involving predisposing factors such as a lack of protective glasses and the self-administration of laser epilation by an untrained practitioner. With this case report, we wished to emphasize the significance of laser epilation practitioner training and the necessity of wearing protective eyewear during laser epilation procedures. Laser epilation devices are not suitable for untrained users. Inadequate knowledge and equipment can result in accidents. Because of the severity and irreversibility of retinal laser injuries, protective eyewear is essential. Compliance with safety precautions effectively prevents accidental laser-related ocular injury. Regarding laser-induced eye injuries, it is important to inform both laser epilation practitioners and the general public. The authors have no proprietary or commercial interest in any materials discussed in this correspondence.