OPTICAL COHERENCE TOMOGRAPHY FINDINGS IN WELDER’S MACULOPATHY Raj S. Lucas, MBBS,* C. Alex Harper, FRANZCO,*† Mark F. MCCombe, FRANZCO, FRACS, FRCOPHTH,* Martin A. Mainster, PHD, MD, FRCOPHTH,‡ David H. Sliney, PHD,§ Ehud Zamir, MD, FRANZCO*
Purpose: To describe the optical coherence tomography (OCT) findings in two patients with welder’s maculopathy. Methods: Retrospective cases series. In addition to examination by slit lamp biomicroscopy, color fundus photographs and OCT images were obtained from patients with welder’s maculopathy. Results: Both patients had a history of bilateral decreased central vision after welding without appropriate eye protection. Yellowish foveal spots developed in the acute stage, evolving over several months into well demarcated lamellar foveal defects with surrounding retinal pigment epithelium changes. OCT showed interruption of the inner high reflective layer (HRL) corresponding to the level of the outer neurosensory retina. These appearances are similar to those seen in solar maculopathy. Conclusions: OCT shows disruption of the inner HRL in late welder’s maculopathy. These appearances are similar to those seen in late solar maculopathy. OCT can be a useful tool in confirming the diagnosis and understanding the pathogenesis of photic maculopathy. RETINAL CASES & BRIEF REPORTS 1:169 –171, 2007
as well as welder’s maculopathy.1 Violet (400 – 440 nm) and blue (440 –500 nm) lights pose the greatest phototoxic risk for phakic eyes.1 Welder’s maculopathy usually occurs in young apprentice welders who are at increased risk of retinal injury because of their presumably clear ocular media and occupational inexperience.1–3 We used optical coherence tomography (OCT; Zeiss OCT3, Zeiss-Humphrey Systems, Dublin, CA) to examine intraretinal abnormalities due to welder’s maculopathy in two individuals.
From the *Royal Victorian Eye & Ear Hospital and the †Centre for Eye Research Australia, East Melbourne, Victoria, Australia; and the ‡Department of Ophthalmology, University of Kansas Medical School, Kansas City, Kansas, and the §US Army Laser/Optical Radiation Program, Aberdeen Proving Ground, Maryland, USA.
A
rc welding units emit radiation wavelengths between 200 nm and 2,000 nm. The cornea and crystalline lens block most ultraviolet radiation of ⬍400 nm but transmit visible and infrared radiation between 400 nm and 1,400 nm to the retina. Photic retinopathy (retinal phototoxicity) can occur when prolonged light exposure overwhelms retinal defenses against oxidative damage.1 Retinal phototoxicity is the primary cause of solar
Case Reports Case 1 A 17-year-old boy presented with acutely decreased vision 3 days after welding in a vocational training course. He had been wearing a welding helmet with a fixed clear glass shield, but the additional shaded visor was not in position. He described flashes in his vision during welding and later decreased central vision. He reported no ocular pain or photophobia. Best-corrected visual acuity was 20/80 in each eye. Fundus examination revealed bilateral yellowish foveal spots, similar to
None of the authors have any proprietary interest in any product described in this report. No competing interests were identified. Reprint requests: Ehud Zamir, Royal Victorian Eye & Ear Hospital, Locked Bag 8, East Melbourne, Victoria 8002, Australia; e-mail: [email protected]
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Fig. 1. Welder’s maculopathy in a 17-year-old boy (Case 1). A, Color fundus photograph of the left eye 5 months after injury showing mottling of foveal retinal pigment epithelium. B, Optical coherence tomography image of the left eye 8 months after injury showing a well defined outer retinal hyporeflective space interrupting the inner high reflective layer. The inner high reflective layer probably corresponds to the junction of photoreceptor inner and outer segments.4
Fig. 2. Welder’s maculopathy in a 37-year-old man (Case 2). A, Color fundus photograph of the left eye 2 months after injury showing a foveolar lamellar defect and perifoveal retinal pigment epithelium changes. B, Optical coherence tomography image of the left eye 2 months after injury showing a hyporeflective space in the inner high reflective layer. This corresponds to the superior juxtafoveal region, accounting for the relatively thinner appearance of the outer retina.
the appearance of solar maculopathy. Over the following 6 weeks, his vision gradually improved to 20/20 in each eye. At 5 months, both foveal lesions had reduced in size, leaving mild mottling of the retinal pigment epithelium (Fig. 1A). OCT findings (Fig. 1B) were similar for each eye 8 months after the injury, with interruption of the inner high reflective layer, which recently has been thought to represent the junction of photoreceptor inner and outer segments.4 Eighteen months later, the patient still had symptomatic paracentral scotomata, and visual acuity was 20/30 in each eye.
2B). Visual acuity gradually improved to 20/20 in each eye, but the patient still had difficulty reading.
Case 2 A 37-year-old man presented with blurry central vision. Two days earlier, he had been taking a course in metal inert gas welding and had worn a shaded helmet during welding. He reported regularly lifting the shaded visor to initiate the welding arc. While welding, he had flashes and later blurred central vision. Best-corrected visual acuity was 20/40 in the right eye and 20/60 in the left eye. Fundus examination showed bilateral yellowish foveal spots. These spots gradually diminished over the next few weeks, leaving discrete foveolar lamellar defects and perifoveal retinal pigment epithelium changes (Fig. 2A). Fluorescein angiography revealed normal findings. OCT 2 months after the injury showed a mild inner high reflective layer disturbance in the right eye and a small interruption of the inner high reflective layer in the left eye, possibly due to loss of photoreceptor outer segments (Fig.
Discussion Most reported cases of welder’s maculopathy are caused by inadequate eye protective filters, as in Case 1, or by novice welders temporarily lifting or looking around a shaded visor while welding, as in Case 2.3 The initial creation of a welding arc produces a very high irradiance that, although short lived, is transmitted through unprotected ocular media and can cause retinal damage. Our OCT findings demonstrated focal hyporeflectivity at the level of the foveal inner high reflective layer, possibly due to direct photoreceptor phototoxicity, the indirect effects of retinal pigment epithelium phototoxicity, or both effects. The OCT findings for both patients are similar to one of three OCT patterns in late solar maculopathy that were reported by Jorge et al,4 namely, inner high reflective layer disturbance. OCT was not performed for our patients during the acute stage, but foveal hyperreflectivity has been re-
OPTICAL COHERENCE TOMOGRAPHY FINDINGS IN WELDER’S MACULOPATHY
ported early in solar maculopathy. Huang et al5 described a case of maculopathy in a patient with a remote history of welding. Welder’s maculopathy and solar maculopathy have a similar ophthalmoscopic appearance. We have shown that they also have similar OCT characteristics, suggesting that they share the same putative phototoxic etiology.1 Key words: optical coherence tomography, photic retinopathy, phototoxicity, welding.
References 1.
2. 3.
4.
Acknowledgment The authors thank the Medical Photography Unit at the Royal Victorian Eye and Ear Hospital for providing fundus photographs and optical coherence tomography images.
171
5.
Mainster MA, Turner PL. Retinal injuries from light: mechanisms, hazards and prevention. In: Ryan SJ, Hinton DR, Schachat AP, Wilkinson P, eds. Retina. 4th ed, Vol 2. London: Elsevier Publishers; 2005. Fich M, Dahl H, Fledelius H, et al. Maculopathy caused by welding arcs. Acta Ophthalmol (Copenh) 1993;71:402–404. Brittain GPH. Retinal burns caused by exposure to MIGwelding arcs: report of two cases. Br J Ophthalmol 1988;72: 570–575. Jorge R, Costa RA, Quirino LS, et al. Optical coherence tomography findings in patients with late solar retinopathy. Am J Ophthalmol 2004;137:1139–1142. Huang SJ, Gross NE, Costa DL, Yannuzzi LA. Optical coherence tomography findings in photic maculopathy. Retina 2003; 23:863–866.
Purpose: To describe the optical coherence tomography (OCT) findings in two patients with welder’s maculopathy. Methods: Retrospective cases series. In addition to examination by slit lamp biomicroscopy, color fundus photographs and OCT images were obtained from patients with welder’s maculopathy. Results: Both patients had a history of bilateral decreased central vision after welding without appropriate eye protection. Yellowish foveal spots developed in the acute stage, evolving over several months into well demarcated lamellar foveal defects with surrounding retinal pigment epithelium changes. OCT showed interruption of the inner high reflective layer (HRL) corresponding to the level of the outer neurosensory retina. These appearances are similar to those seen in solar maculopathy. Conclusions: OCT shows disruption of the inner HRL in late welder’s maculopathy. These appearances are similar to those seen in late solar maculopathy. OCT can be a useful tool in confirming the diagnosis and understanding the pathogenesis of photic maculopathy. RETINAL CASES & BRIEF REPORTS 1:169 –171, 2007
as well as welder’s maculopathy.1 Violet (400 – 440 nm) and blue (440 –500 nm) lights pose the greatest phototoxic risk for phakic eyes.1 Welder’s maculopathy usually occurs in young apprentice welders who are at increased risk of retinal injury because of their presumably clear ocular media and occupational inexperience.1–3 We used optical coherence tomography (OCT; Zeiss OCT3, Zeiss-Humphrey Systems, Dublin, CA) to examine intraretinal abnormalities due to welder’s maculopathy in two individuals.
From the *Royal Victorian Eye & Ear Hospital and the †Centre for Eye Research Australia, East Melbourne, Victoria, Australia; and the ‡Department of Ophthalmology, University of Kansas Medical School, Kansas City, Kansas, and the §US Army Laser/Optical Radiation Program, Aberdeen Proving Ground, Maryland, USA.
A
rc welding units emit radiation wavelengths between 200 nm and 2,000 nm. The cornea and crystalline lens block most ultraviolet radiation of ⬍400 nm but transmit visible and infrared radiation between 400 nm and 1,400 nm to the retina. Photic retinopathy (retinal phototoxicity) can occur when prolonged light exposure overwhelms retinal defenses against oxidative damage.1 Retinal phototoxicity is the primary cause of solar
Case Reports Case 1 A 17-year-old boy presented with acutely decreased vision 3 days after welding in a vocational training course. He had been wearing a welding helmet with a fixed clear glass shield, but the additional shaded visor was not in position. He described flashes in his vision during welding and later decreased central vision. He reported no ocular pain or photophobia. Best-corrected visual acuity was 20/80 in each eye. Fundus examination revealed bilateral yellowish foveal spots, similar to
None of the authors have any proprietary interest in any product described in this report. No competing interests were identified. Reprint requests: Ehud Zamir, Royal Victorian Eye & Ear Hospital, Locked Bag 8, East Melbourne, Victoria 8002, Australia; e-mail: [email protected]
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Fig. 1. Welder’s maculopathy in a 17-year-old boy (Case 1). A, Color fundus photograph of the left eye 5 months after injury showing mottling of foveal retinal pigment epithelium. B, Optical coherence tomography image of the left eye 8 months after injury showing a well defined outer retinal hyporeflective space interrupting the inner high reflective layer. The inner high reflective layer probably corresponds to the junction of photoreceptor inner and outer segments.4
Fig. 2. Welder’s maculopathy in a 37-year-old man (Case 2). A, Color fundus photograph of the left eye 2 months after injury showing a foveolar lamellar defect and perifoveal retinal pigment epithelium changes. B, Optical coherence tomography image of the left eye 2 months after injury showing a hyporeflective space in the inner high reflective layer. This corresponds to the superior juxtafoveal region, accounting for the relatively thinner appearance of the outer retina.
the appearance of solar maculopathy. Over the following 6 weeks, his vision gradually improved to 20/20 in each eye. At 5 months, both foveal lesions had reduced in size, leaving mild mottling of the retinal pigment epithelium (Fig. 1A). OCT findings (Fig. 1B) were similar for each eye 8 months after the injury, with interruption of the inner high reflective layer, which recently has been thought to represent the junction of photoreceptor inner and outer segments.4 Eighteen months later, the patient still had symptomatic paracentral scotomata, and visual acuity was 20/30 in each eye.
2B). Visual acuity gradually improved to 20/20 in each eye, but the patient still had difficulty reading.
Case 2 A 37-year-old man presented with blurry central vision. Two days earlier, he had been taking a course in metal inert gas welding and had worn a shaded helmet during welding. He reported regularly lifting the shaded visor to initiate the welding arc. While welding, he had flashes and later blurred central vision. Best-corrected visual acuity was 20/40 in the right eye and 20/60 in the left eye. Fundus examination showed bilateral yellowish foveal spots. These spots gradually diminished over the next few weeks, leaving discrete foveolar lamellar defects and perifoveal retinal pigment epithelium changes (Fig. 2A). Fluorescein angiography revealed normal findings. OCT 2 months after the injury showed a mild inner high reflective layer disturbance in the right eye and a small interruption of the inner high reflective layer in the left eye, possibly due to loss of photoreceptor outer segments (Fig.
Discussion Most reported cases of welder’s maculopathy are caused by inadequate eye protective filters, as in Case 1, or by novice welders temporarily lifting or looking around a shaded visor while welding, as in Case 2.3 The initial creation of a welding arc produces a very high irradiance that, although short lived, is transmitted through unprotected ocular media and can cause retinal damage. Our OCT findings demonstrated focal hyporeflectivity at the level of the foveal inner high reflective layer, possibly due to direct photoreceptor phototoxicity, the indirect effects of retinal pigment epithelium phototoxicity, or both effects. The OCT findings for both patients are similar to one of three OCT patterns in late solar maculopathy that were reported by Jorge et al,4 namely, inner high reflective layer disturbance. OCT was not performed for our patients during the acute stage, but foveal hyperreflectivity has been re-
OPTICAL COHERENCE TOMOGRAPHY FINDINGS IN WELDER’S MACULOPATHY
ported early in solar maculopathy. Huang et al5 described a case of maculopathy in a patient with a remote history of welding. Welder’s maculopathy and solar maculopathy have a similar ophthalmoscopic appearance. We have shown that they also have similar OCT characteristics, suggesting that they share the same putative phototoxic etiology.1 Key words: optical coherence tomography, photic retinopathy, phototoxicity, welding.
References 1.
2. 3.
4.
Acknowledgment The authors thank the Medical Photography Unit at the Royal Victorian Eye and Ear Hospital for providing fundus photographs and optical coherence tomography images.
171
5.
Mainster MA, Turner PL. Retinal injuries from light: mechanisms, hazards and prevention. In: Ryan SJ, Hinton DR, Schachat AP, Wilkinson P, eds. Retina. 4th ed, Vol 2. London: Elsevier Publishers; 2005. Fich M, Dahl H, Fledelius H, et al. Maculopathy caused by welding arcs. Acta Ophthalmol (Copenh) 1993;71:402–404. Brittain GPH. Retinal burns caused by exposure to MIGwelding arcs: report of two cases. Br J Ophthalmol 1988;72: 570–575. Jorge R, Costa RA, Quirino LS, et al. Optical coherence tomography findings in patients with late solar retinopathy. Am J Ophthalmol 2004;137:1139–1142. Huang SJ, Gross NE, Costa DL, Yannuzzi LA. Optical coherence tomography findings in photic maculopathy. Retina 2003; 23:863–866.
