An 11-year-old male, with a diagnosis of pathological demand avoidance (PDA) and migraine, presented to a community optometrist with a 2-day history of a black spot in the central vision of his right eye. The optometrist reported that the best corrected visual acuity (BCVA) in the right eye was reduced to 6/10 Snellen having been normal at a prior visit. Left was 6/5 Snellen. New pigmentary changes at both macula were observed by the optometrist and referral was made to the hospital eye service (HES). He was taking pizotifen prescribed for migraine. There was no relevant past ocular, medical or family history. Six weeks later, in the HES review, he described a persistent ‘blur’ in the central vision of the right eye. Unaided VAs were 6/9 right and 6/5 left. Pigmentary changes were noted at the central macula in both eyes. SD-OCT and imaging revealed bilateral outer lamellar layer defects (Fig. ). Electrodiagnostic tests were normal but with limited co-operation. His mother accompanied him for all HES visits. In due course and following direct questioning he admitted to constructing a device made from Lego™ consisting of a laser pointer with a condensing lens used just prior to the onset of visual symptoms. The patient’s mother revealed that she had purchased the laser pointer online for him. During follow-up he reported symptomatic improvement and the VA remained stable. Centre involving structural defects at both macula persisted on clinical examination and OCT imaging to most recent follow-up 24 months later. (Supplementary Image ). The mother confirmed the laser had been purchased from a well-known UK online retailer and was still available for online purchase a year following the incident.
A 12-year-old boy was referred with a several month history of reduced vision in both eyes. He had a history of expressive and receptive language impairment and was attending a specialist school for children with cognitive impairment and disturbed behaviour. He was under CAMHS for anger and behavioural problems. There was no relevant past ocular or family history. The presenting BCVA were 6/30 right eye and 6/75 left eye. Colour vision was reduced, with only 4/17 Ishihara plates correctly identified in the right eye and 9/17 in the left eye. Bilateral multifocal macular pigmentary changes were noted (Fig. ). To investigate abnormal visual function, electrodiagnostic tests and magnetic resonance imaging (MRI) of the brain and orbits were performed, both of which were normal.\nAt subsequent follow-up and on direct questioning, the boy revealed he had been playing with laser pointers at school, particularly in games involving looking directly into the beam of the laser pointer. His BCVA at 12 months follow-up was 6/19 right eye and 6/48 left eye. Fundus examination showed irregular pigmentation at the right macular and a scar at the left macular. OCT scan showed small, round, punched-out lesions more frequent in the left than the right macula.