Ocular Injuries Due to Cosmetic Laser

From EyeWiki


Introduction

Laser-assisted hair removal is a commonly performed cosmetic procedure for semi-permanent hair reduction using laser machines that has been approved by the food and drug administration. These laser machines use a beam of light to remove unwanted hair. During the process, melanin pigment in the hair is absorbed by the focused light beam while producing heat that damages the hair follicle achieving photothermolysis.(1) There are three main mechanisms used for hair removal: photothermal, photomechanical and photochemical.(2)

Multiple types of laser can be used for hair removal such as ruby laser (694 nm), long-pulsed alexandrite laser (755 nm), long-pulsed diode laser (810 nm) and long-pulsed Nd: YAG (1064 nm).(3,4) Regarding efficacy of hair removal, alexandrite and diode laser were proven to be more effective when compared to other laser systems.(5)

Patient profile (skin type and color, hair type and color), technological parameter of the laser machines, technique used and the operator all play a role on the outcome of laser treatment.(2)

In general, laser hair removal is considered a safe procedure. Common self limited side effects include mild pain, transient redness and edema.(6) But unfortunately, unfavorable events can happen especially with non-physician operators.(7)

Rarely, ocular injuries can occur. A misdirected laser beam towards the eye or any reflective surface can penetrate the eye even when it is closed.(8) This can result in two main types of injury: anterior segment injury and posterior segment injury.


Anterior Segment Injury

Nuclear cataract and iris atrophy have been reported following the use of diode laser epilation to the eyelid area. Patients can present weeks after receiving the laser treatment with decreased vision and increased light sensitivity as well as history of pain during the time of the procedure. Concluding that diode laser can be cataractogenic.(8)

Iritis, pupillary distortion, iris atrophy and anterior uveitis were noted to be associated with alexandrite laser treatment of the eyelid. Patient may complain of photophobia, pain, tearing, irregular pupil, glare and blurred vision. On examination, the conjunctiva may be injected, superficial punctate keratopathy may be seen, transillumination defects may be present, cells in the anterior chamber may be found as well as a poor pupillary response. Intraocular pressure and posterior pole are usually spared.

The damage to the iris is irreversible and patient can suffer long term effect on vision. Steroids and cycloplegics were found to be beneficial in restoring vision.(9,10,12)


Posterior Segment Injury

Subfoveal and intraretinal hemorrhages were also reported with the inappropriate use of alexandrite hair laser treatment. Presentation can vary from eye discomfort with 20/20 vision to just decreased vision reaching 20/200. In addition, one patient reported seeing a black shadow right after the laser session. Anterior segment examination is expected to be within normal limits. As for fundus examination, subfoveal or intraretinal hemorrhage can be noted. Macular SD-OCT would reveal hyper reflective lesions.

Choroidal neovascularization can occur as an adverse event. In this case, a fundus fluorescein angiography would show hyperfluorescence in the early phase and late leakage. This is characteristic of a choroidal neovascular membrane. Intravitreal bevacizumab 1.25 mg/0.05 mL was found to be highly effective in these cases, restoring vision back to 20/20 with complete involution of the membrane.(12)

Recommendations

Using proper safety measurements prior to any laser treatment, including wearing protective eye glasses and/or ocular shields, patient education regarding avoiding direct gaze as well as avoiding the use of reflective floors in laser treatment rooms can prevent possible ocular injury from cosmetic laser.(13)


Prognosis

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Additional Resources

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References

1. Haedersdal M, Haak CS. Hair removal. Curr Probl Dermatol. 2011;42:111–21.

2. Arsiwala SZ, Majid IM. Methods to overcome poor responses and challenges of laser hair removal in dark skin. Indian J Dermatol Venereol Leprol. 2019;85(1):3–9. 3. Dierickx CC. Hair removal by lasers and intense pulsed light sources. Dermatologic Clinics. 2002. ;20(1):135-46.


4. Altshuler GB, Anderson RR, Manstein D, Zenzie HH, Smirnov MZ. Extended theory of selective photothermolysis. Lasers Surg Med. 2001;29(5):416–32.

5. Khoury JG, Saluja R, Goldman MP. Comparative evaluation of long-pulse alexandrite and long-pulse Nd:YAG laser systems used individually and in combination for axillary hair removal. Dermatologic Surg. 2008;34(5):665–71.

6. Gan SD, Graber EM. Laser hair removal: A review. Dermatologic Surgery. 2013. Jun;39(6):823-38.

7. Kelsall D. Laser hair removal: No training required? CMAJ. 2010. May 18;182(8):743.

8. Brilakis HS, Holland EJ. Diode-laser-induced cataract and iris atrophy as a complication of eyelid hair removal. Am J Ophthalmol. 2004;137(4):762–3.

9. Lin CC, Tseng PC, Chen CC, Woung LC, Liou SW. Iritis and pupillary distortion after periorbital cosmetic alexandrite laser. Graefe’s Arch Clin Exp Ophthalmol. 2011;249(5):783–5.

10. Elkin Z, Ranka MP, Kim ET, Kahanowicz R, Whitmore WG. Iritis and iris atrophy after eyebrow epilation with alexandrite laser. Clin Ophthalmol. 2011;5(1):1733–5.

11. Lin LT, Liang CM, Chiang SY, Yang HM, Chang CJ. Traumatic macular hole secondary to a Q-switch Alexandrite laser. Retina. 2005;25(5):662–5.

12. Asiri MS, Alharbi M, Alkadi T, Abouammoh M, Al-Amry M, ALZahrani Y, et al. Ocular injuries secondary to alexandrite laser-assisted hair removal. Canadian Journal of Ophthalmology. 2017. Apr;52(2):e71-e75.

13. AlTaleb RM, Alsharif HM, Younis AS, Alsulaiman SM, Abouammoh MA. Adherence to optical safety guidelines for laser-assisted hair removal. Photodermatol Photoimmunol Photomed. 2019;35(5):313–7.