Pupil Damage After Periorbital Laser Treatment of a Port-wine Stain
REPORT OF A CASE
A 33-year-old woman was born with a port-wine stain on the left side of her face that extended from the left corner of her mouth past the eye (1 cm from the edge of the eyelid) and up to the forehead. She had already undergone 28 sessions with a pulsed-dye laser and 3 sessions with a long-pulsed KTP–Nd:YAG laser (VersaPulse; Coherent, Palo Alto, Calif), but the port-wine stain had not responded to treatment. After an additional session during which a pulsed-dye laser was used on her cheek, a 755-nm long-pulsed alexandrite laser (Apogee 9300; Cynosure, Inc, Chelmsford, Calif) with cold air cooling (Cryo5; Zimmer Elektromedizin GmbH, Neu-Ulm, Germany) was used on her cheek and in the periorbital area during the same session at a laser treatment center. The fluence of the alexandrite laser was 50 J/cm2 with a pulse duration of 20 milliseconds and a beam diameter of 12.5 mm. The periorbital segment of the treatment was conducted while the patient kept her eyes shut. Safety guidelines were ignored, and the patient was not provided with eye shields; the operator wore wavelength-adapted goggles. The pulses were aimed at the edge of the zygomatic bone, the skin was held taut, and the probe was pointed away from the eyeball. The immediate postoperative state began normally with intense swelling and reddening of the eyes. On the third day after the procedure, the patient complained of a painful sensitivity to light and blurred vision. The pupil of her left eye was irregular and did not respond to light.
On the fourth day, an ophthalmologist diagnosed inflammation of the sclera and posterior synechia (Figure 1). Further examination revealed a slight reduction of vision and a direct alteration of the pupillary sphincter. The posterior synechia, which showed evidence of a laser-induced intraocular (iritic) inflammation, could not be broken with mydriatic eyedrops. Three months later, the left pupil was still irregular (oval) and more dilated than that of the other eye but responded to light (Figure 2).