LAUSR

© BMJ Publishing Group Limited 2022. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION A 53yearold man presented with complaints of bilateral painless progressive vision reduction for the previous year. He suffered from type 2 diabetes mellitus and hypertension for which he had been on oral medications for 5 years. His bestcorrected visual acuity was 20/200 in the right eye and 20/100 in the left eye. The anterior segment evaluation of both eyes indicated the presence of cataractous lens with nuclear sclerosis of grade 2–3 and the intraocular pressures were within normal limits. Fundus evaluation indicated the presence of proliferative diabetic retinopathy (PDR) with extramacular tractional retinal detachment and hypertensive retinopathy with sclerosed vessels in the right eye and PDR with hypertensive retinopathy with sclerosed vessels in the left eye. He was then advised for panretinal photocoagulation (PRP) threedisc diameter away from the fibrovascular proliferation in both the eyes. The patient underwent first sitting of multispot 532 nm frequencydoubled NdYAG pattern scan laser (PASCAL) in two of the quadrants in both the eyes on the same day. The laser parameters for the PRP included a spot size of 200 μm, at 250–300 mW power for the duration of 40–50 ms, with each burn one spotsize apart to achieve a total of 1800 burns in two quadrants. A week later when the patient came for the second sitting laser there was a massive 360° choroidal detachment in the right eye (figure 1A) and nasal choroidal detachment in the left eye (figure 1B) with closely spaced high intense fresh laser burns in some areas. Visual acuity and intraocular pressure values remained stable in both eyes. The second sitting laser was withheld and the patient was started on hourly topical steroid (1% prednisolone acetate) and topical cycloplegic (2% homatropine hydrobromide) three times a day in both the eyes. On a high index of suspicion, the patient was also asked for physician evaluation with renal profile. The systemic evaluation by physician revealed an uncontrolled blood pressure of 200/134 mm Hg and also raised serum creatinine of 2.4 and blood urea levels of 51 indicating the presence of newly detected early diabetic nephropathy. Two weeks later, the choroidal detachment had completely subsided in both the eyes (figure 2) and the patient underwent second sitting laser after his blood pressure was under control. There was no choroidal detachment noted after the second sitting of laser. However, the patient developed preretinal haemorrhage and vitreous haemorrhage in his left eye 6 weeks later due to unstable PDR and was advised vitreoretinal surgery for the same. The incidence of serous choroidal detachment has decreased with advent of multispot PASCAL laser which uses short pulse duration of laser when compared with the single spot laser. The acute adverse effects like macular oedema, serous choroidal detachment and exudative retinal detachment can be expected due to high thermal energy delivery to retina and choroid due to increase in power, increase in duration and more number of spots per sitting. The autoregulatory mechanism of choroidal vessels will be compromised in patients with malignant hypertension with renal failure due to fibrinous necrosis of vessel wall and hence their recovery to an insult like laser will be hampered making them more prone for serous choroidal detachment and exudative retinal detachments. 6 In our case although the spots were dense and closely packed in few areas we suspected that Figure 1 A (Right eye) B (Left eye): Right eye fundus image shows massive 360° choroidal detachment with fresh laser burns in inferior and nasal quadrants. Left eye fundus image shows nasal choroidal detachment with fresh laser burns superior and nasal quadrants.