ABSTRACT

Maculopathy from prolonged exposure to solar light is a rare but well-recognized clinical entity of vision loss and macular damage. Photochemical damage precedes visual decline, and in mild cases, vision usually returns fully or partially. With the advancement of humanity, other forms of macular injuries induced by light radiation have emerged, increasing the group of photic maculopathies. In this report, we describe the cases of five patients where a diagnosis of photic maculopathy was made based on the anamnesis, clinical findings, and complementary exams. We compare the five cases regarding their similarities and differences, as well as review the literature on the subject.

Keywords:
Maculopathy; Sunlight/adverse effects; Solar radiation injuries

RESUMO

A maculopatia causada pela exposição prolongada à luz solar é uma entidade clínica rara, mas bem reconhecida, de perda de visão e dano macular. O dano fotoquímico precede o declínio visual e em casos leves a visão geralmente retorna total ou parcialmente. Com o avanço da humanidade, surgiram outras formas de lesões maculares induzidas pela radiação luminosa, aumentando o grupo das maculopatias fóticas. Neste relato, descrevemos os casos de cinco pacientes onde o diagnóstico de maculopatia fótica foi feito com base na anamnese, achados clínicos e exames complementares. Comparamos os quatro casos quanto às suas semelhanças e diferenças, bem como revisamos a literatura sobre o assunto.

Descritores:
Maculopatia; Luz solar/efeitos adversos; Lesões por radiação solar

INTRODUCTION

An optical experiment that children tend to enjoy is to burn things with a magnifying glass with the help of the sunlight, like a sheet of paper. The lens inside our eyeballs can produce a similar effect on the macular photoreceptors, causing an eye injury known as photic maculopathy (PM).

Maculopathy from prolonged exposure to solar light is a rare but well-recognized clinical entity of vision loss and macular damage. It is a disease that has been present in human history. According to Plato's Phaedo, Socrates advised individuals to watch an eclipse only through its reflection in the water.(¹1 Yannuzzi LA, Fisher YL, Slakter JS, Krueger A. Solar retinopathy: a photobiologic and geophysical analysis. 1989. Retina. 2012;32 Suppl 1:28-43.) Another report date back to the biblical ages, when Saint Paul was temporarily blinded by “a bright light,” with the recovery of vision a few days later.(²2 Bullock JD. The blindness of Saint Paul. Ophthalmology. 1978;85(10):1044-53.) The solar maculopathy of a student who observed an eclipse was also the central insight that made Gerhard Meyer-Schwickerath use sunlight to apply diathermy to the retina for treating retinal detachments. This revolutionary concept gave rise to photocoagulation in ophthalmology.(³3 Meyer-Schwickerath GR. The history of photocoagulation. Aust N Z J Ophthalmol. 1989;17(4):427-34.)

Photic maculopathy is a broad term that encompasses maculopathies caused by a photochemical injury to the macula due to exposure to light. Solar maculopathy is the oldest and best known form, which is also called “solar retinopathy”, “solar retinitis”, “photic maculopathy”, and “eclipse retinopathy”.(⁴4 Gass JD. Stereoscopic atlas of macular diseases. 4th ed. St. Louis: Mosby; 1997. Photic maculopathy. p. 760-5.). Macular injury in eclipse viewing is well known, and after major eclipse episode, case series of SM appear in the world literature.(¹1 Yannuzzi LA, Fisher YL, Slakter JS, Krueger A. Solar retinopathy: a photobiologic and geophysical analysis. 1989. Retina. 2012;32 Suppl 1:28-43.,⁵5 Khatib N, Knyazer B, Lifshitz T, Levy J. Acute eclipse retinopathy: a small case series. J Optom. 2014;7(4):225-8.

6 Ricks C, Montoya A, Pettey J. The ophthalmic fallout in Utah after the Great American Solar Eclipse of 2017. Clin Ophthalmol. 2018;12:1853-7.

7 Biswas S, Akbar US, Alam W. Solar eclipse induced retinopathy: a case report. Open Access J Ophthalmol. 2022. 7(1):1-3. doi: 10.23880/oajo-16000235
https://doi.org/10.23880/oajo-16000235...

8 Dobson R. UK hospitals assess eye damage after solar eclipse. BMJ. 1999;319(7208):469.

9 Dhir SP, Gupta A, Jain IS. Eclipse retinopathy. Br J Ophthalmol. 1981;65(1):42-5.

10 Kallmark FP, Ygge J. Photo-induced foveal injury after viewing a solar eclipse. Acta Ophthalmol Scand. 2005;83:586e9.

11 Codenotti M, Patelli F, Brancato R. OCT findings in patients with retinopathy after watching a solar eclipse. Ophthalmologica. 2002;216(6):463-6.-¹²12 Suzukim CR, Taba KE, Alhara E, Ramalho AM. Maculopatia solar. Relato de seis casos. Arq Bras Oftalmol. 1997;60(1):16-23.) Cases of solar maculopathy are also seen outside the time of the eclipse, with a higher incidence on extremely sunny days.(¹1 Yannuzzi LA, Fisher YL, Slakter JS, Krueger A. Solar retinopathy: a photobiologic and geophysical analysis. 1989. Retina. 2012;32 Suppl 1:28-43.) The habit of staring at the sun found in some populations increases the incidence of the lesion, such as in psychiatric patients,(¹³13 Anaclerio AM, Wicker HS. Self-induced solar retinopathy by patients in a psychiatric hospital. Am J Ophthalmol. 1970;69(5):731-6.

14 Gerbaldo H, Thaker G, Cassady S. Sun gazing and photophilia in schizophrenia. Am J Psychiatry. 1991;148(5):693.

15 Kobylski TP, Licamele WL. Sun gazing by patients with Tourette's disorder. Am J Psychiatry. 1991;148(3):394.-¹⁶16 Devadason DS, Mahmood S, Stanga PE, Bishop PN. Solar retinopathy in a patient with bipolar affective disorder. Br J Ophthalmol. 2006;90(2):247.) in some religious practices(¹⁷17 Mwanza JC, Kayembe DL, Kaimbo DK, Kabasele PM, Ngoy DK. [Solar retinopathy acquired after gazing at the sun during prayers]. Bull Soc Belge Ophtalmol. 2000;275:41-5. French.

18 Hope-Ross M, Travers S, Mooney D. Solar retinopathy following religious rituals. Br J Ophthalmol. 1988;72(12):931-4.

19 Sampaio ER, Casella AM, Farah ME. Retinopatia solar após ritual religioso na cidade de Londrina. Arq Bras Oftalmol. 2004;67(2):271-5.-²⁰20 Cangelosi GC, Newsome DA. Solar retinopathy in persons on religious pilgrimage. Am J Ophthalmol. 1988;105(1):95-7.) or with the use of psychoactive drugs.(²¹21 Schatz H, Mendelblatt F. Solar retinopathy from sun-gazing under the influence of LSD. Br J Ophthalmol. 1973;57(4):270-3.

22 Ewald RA. Sun gazing associated with the use of LSD. Ann Ophthalmol. 1971;3(1):15-7.-²³23 Fuller DG. Severe solar maculopathy associated with the use of lysergic acid diethylamide (LSD). Am J Ophthalmol. 1976 Apr;81(4):413-6.) However, the history of sun gazing is not always present.(²⁴24 Gladstone GJ, Tasman W. Solar retinitis after minimal exposure. Arch Ophthalmol. 1978;96(8):1368-9.,²⁵25 Stock RA, Savaris SL, Lima Filho EC, Bonamigo EL. Retinopatia solar sem exposição anormal: relato de caso. Arq Bras Oftalmol. 2013;76(2):118-20.)

With the advancement of humanity, other forms of light injury maculopathy have emerged, increasing the group of photic maculopathies that includes Laser Pointer Maculopathy, Welder's Maculopathy and iatrogenic maculopathy from operating microscopes/endoilluminators in eye surgeries. Laser pointers are instruments that can also mimic the action of sun exposure, causing lesions that are often more severe, commonly unilateral, and with a worse prognosis.(²⁶26 Barkana Y, Belkin M. Laser eye injuries. Surv Ophthalmol. 2000;44(6):459-78.) Welding maculopathy is similar to solar maculopathy, differing only in the history of welding and possible presence of welder's keratitis. Maculopathy from operating microscopes/endoilluminators is usually superior or inferior to the fovea and involves an area larger than all other types of photic injuries.(²⁷27 Comander J, Gardiner M, Loewenstein J. High-resolution optical coherence tomography findings in solar maculopathy and the differential diagnosis of outer retinal holes. Am J Ophthalmol. 2011;152(3):413-419.e6.)

In this report, we describe five patients treated at Hospital de Olhos do Paraná where a diagnosis of PM was made based on the anamnesis, clinical findings, and complementary exams that will be shared below.

CASE SERIES

CASE 1

Female patient, 21 years old. She reported worsening visual acuity (VA) in both eyes (AO) a week before the examination, especially in central vision. She reported that she had looked at a solar eclipse without adequate protection just before symptom onset. She denied pain or other associated symptoms. She denied comorbidities or an ophthalmic history other than myopia corrected with glasses.

At the examination, the best corrected visual acuity (BCVA) was 20/50 in the right eye (OD) and 20/70 in the left eye (OS). Slit lamp examination results and intraocular pressure were normal. At fundus examination of AO, there was a well-circumscribed lesion in the foveal region of AO, without other significant changes (Figure 1).

Optical coherence tomography (OCT) analysis showed disruption of the outer layers of the retina and retinal pigment epithelium (Figure 2). Upon return, there was a gradual improvement in VA. After 6 months, the VA was 20/30 and 20/20 in the OD and OS, respectively.

CASE 2

Male patient, 42 years old, diabetic for 2 years on regular metformin use, denies other comorbidities. The patient reported worsening of central vision for approximately 4 weeks in AO, with no other complaints. He denies events related to the onset of the low acuity episode, even sun gazing.

Ophthalmological examination showed BCVA 20/40 in OD and 20/50 in OS. Slit lamp exam was normal, normotensive in AO, and fundoscopy showed a hypopigmented lesion in the foveal region in AO, without other significant changes (Figure 3).

When analyzing the OCT images, there was an ellipsoid zone disruption underneath the fovea in AO, compatible with an external macular hole, worse in the LE (Figures 4 and 5). According to our follow-up, after 6 months, the patient achieved a BCVA of 20/20 in AO.

CASE 3

Male patient, 55 years old, white, was seen at our hospital reporting low VA in AO, but more intense in the OD for approximately 3 months, without other complaints. He mentions that he works as a bricklayer with sun exposure at various times of the day and without using eyeglasses to protect him from sun exposure. However, no particular moment of sungazing was cited. He denied traumatic systemic and ocular antecedents. He refers to previous cataract surgery of the OS 3 years ago.

On examination, he had BCVA of 20/50 in OD and BCVA of 20/30 in OS. Biomicroscopy showed 2+/6+ nuclear cataracts in the OD, and in the OS, pseudophakic with a well-positioned intraocular lens, and no other changes. Fundoscopy showed a mild decrease in foveal reflex in AO (Figure 6). OCT images of both eyes showed an image of an ellipsoid zone disruption underneath the fovea (Figure 7 and 8). After 6 months of follow-up, he improved VA to 20/30 and 20/25 in OD and OS, respectively.

CASE 4

Male patient, 8 years old, white, was seen at our hospital reporting low VA in the OD on the day as the appointment. His mother reports exposure to a laser pointer for 2 seconds just before the low vision symptom.

On examination, he had BCVA of 20/20 in AO but mentioned some blurring in the OD. Slit lamp examination results and intraocular pressure were normal. At fundus examination of the OD, there was a tiny well-circumscribed lesion in the foveal region (Figure 9). OCT analysis showed disruption of the outer layers of the retina and retinal pigment epithelium in the OD, and OS without changes (Figure 10 and 11). This case is the most recent and we have not had follow-up data yet.

CASE 5

Male patient, 13 years old, white, was seen at our hospital reporting low VA in the OD on the day of consultation. The patient was accompanied by his mother, who reported exposure to the green laser two hours before the appointment. She reported that the exposure was by aiming the laser at the mirror and hitting the eye. At the appointment, the patient reported a black spot in the OD, and no complaints in the OS. On examination, he presented with BCVA of 20/30 in the OD with +6.75 ESF -0.25 CYL and 20/20 in the OS with +6.25 ESF -0.25 CYL but reported that he was unable to see the entire line in the OS, that is, with decreased paracentral acuity.

Upon fundus examination, he presented the classic yellowish stain in the macular area on both sides, being slightly paracentral in the left eye (Figure 12). On OCT, he presented interruption of the ellipsoid zone on both sides, with the right eye having a central macular interruption and the left eye paramacular (Figure 13 and 14).

After 4 months of follow-up of this patient, we have the macular finding of the characteristic hole defect without the yellowish spot in the acute setting and corrected visual acuity of 20/25 in the OD and 20/20 in the OS. The patient reports that he still notices the defect in his right eye, although reporting improvement.

DISCUSSION

The lesions are frequently bilateral, asymmetric, and more prominent in the dominant eye.(²⁸28 Huang SJ, Gross NE, Costa DL, Yannuzzi LA. Optical coherence tomography findings in photic maculopathy. Retina. 2003;23(6):863-6.) On initial funduscopic examination, findings may be mild, such as only a decrease in the foveal reflex, or visualization of a yellowish-white spot on the fovea that suggests acute onset, often surrounded by granular pigmentation.(²⁷27 Comander J, Gardiner M, Loewenstein J. High-resolution optical coherence tomography findings in solar maculopathy and the differential diagnosis of outer retinal holes. Am J Ophthalmol. 2011;152(3):413-419.e6.) In cases 1, 4, and 5, hypopigmentation was seen in the foveal area, although with a more yellowish hypopigmentation compared to case 2, probably meaning a more acute condition. Case 3 had a milder presentation with foveal reflex attenuation, corroborating the findings of a more chronic involvement.

In longstanding PM, there is a small multifaceted outer retinal hole (or holes) with a pigment halo. At first glance, these holes may appear to be small, full-thickness macular holes because of their reddish center. However, on closer inspection, the holes are restricted to the outer retina stereoscopically, and the foveal reflex is often present.(⁴4 Gass JD. Stereoscopic atlas of macular diseases. 4th ed. St. Louis: Mosby; 1997. Photic maculopathy. p. 760-5.) Case 3 depicts this more chronic involvement in which the classic yellow dot on the fovea is no longer seen, but a small macular hole, which on OCT leads to the conclusion that it is an involvement of the outermost layers of the retina.

Visual acuity at diagnosis of our reported patients ranged from 20/20 to 20/70, with a higher prevalence of mild to moderate visual impairment. The finding agrees with the information in the literature. In solar maculopathy, VA commonly ranges from 20/40 to 20/60, although it can range from 20/20 to CF.(²¹21 Schatz H, Mendelblatt F. Solar retinopathy from sun-gazing under the influence of LSD. Br J Ophthalmol. 1973;57(4):270-3.,²⁹29 Pinheiro A, Souza EC, Moura FC, Vessani RM, Takahashi W. Optical coherence tomography study in patients with solar retinopathy. Rev Bras Oftal. 2004;63(5-6): 310-4.,³⁰30 González Martín-Moro J, Hernández Verdejo JL, Zarallo Gallardo J. Photic maculopathy: A review of the literature. Arch Soc Esp Oftalmol. 2018;93(11):542-550.) In laser pointer maculopathy, VA is typically worse than what we saw in our patient 4, commonly being 20/200 or worse.(²⁶26 Barkana Y, Belkin M. Laser eye injuries. Surv Ophthalmol. 2000;44(6):459-78.) In patient 5, we see again a tendency for paramacular lesions to come to the office with 20/20, and the central lesion with worse vision, although better than other studies(²⁶26 Barkana Y, Belkin M. Laser eye injuries. Surv Ophthalmol. 2000;44(6):459-78.). As mentioned in the same study(²⁶26 Barkana Y, Belkin M. Laser eye injuries. Surv Ophthalmol. 2000;44(6):459-78.), patients with paramacular involvement usually have a VA of 20/40 or better, as was the case with our patient 4 and the OD of patient 5.

Regarding light exposure history, we had case 1 with proven exposure to the eclipse, case 4 and 5 with proven exposure to the laser pointer, and case 2 and 3 without reporting an acute moment exposure. Patient 3 worked as a bricklayer with daily sun exposure, which may have led to a photic lesion, but we cannot be sure about the factor “acute sun exposure” in this case. In the literature, we classically have sungazing reports in solar maculopathy; however, we also have cases with no report of sun observation.(²⁴24 Gladstone GJ, Tasman W. Solar retinitis after minimal exposure. Arch Ophthalmol. 1978;96(8):1368-9.,²⁵25 Stock RA, Savaris SL, Lima Filho EC, Bonamigo EL. Retinopatia solar sem exposição anormal: relato de caso. Arq Bras Oftalmol. 2013;76(2):118-20.) For those cases of external retinal disruption with no history of exposure to sunlight, we could open the diagnostic reasoning to another etiology, “Foveomacular retinitis”, which has been described a few times in the literature as a form of primary maculopathy distinct from solar maculopathy where there is no sun exposure.(³¹31 Kuming BS. Foveomacular retinitis. Br J Ophthalmol. 1986;70:816-8.,³²32 Cordes FC. A type of foveomacular retinitis observed in the U.S. Navy. Am J Ophthalmol. 1944;27:803.) The disease can be viral in etiology and is usually self-limiting.(³¹31 Kuming BS. Foveomacular retinitis. Br J Ophthalmol. 1986;70:816-8.) However, Wergeland et al. compared 36 patients in clinical history and examination findings and concluded that, apart from the report of sun exposure, they are identical diseases, if not the same disease.(³³33 Wergeland FL, Brenner EH. Solar retinopathy and foveomacular retinitis. Ann Ophthalmol. 1975;7(4):495-8.) In fact, some studies report both diseases as synonyms, even though some studies report some differences.(²⁷27 Comander J, Gardiner M, Loewenstein J. High-resolution optical coherence tomography findings in solar maculopathy and the differential diagnosis of outer retinal holes. Am J Ophthalmol. 2011;152(3):413-419.e6.)

Fluorescein angiography may demonstrate punctate window defects in the foveal area, a finding common to other retinal diseases. However, images with fluorescein or indocyanine angiography are not very useful since the RPE in the foveal area is more pigmented than elsewhere in the fundus, reducing light transmission from the choroid.(²⁸28 Huang SJ, Gross NE, Costa DL, Yannuzzi LA. Optical coherence tomography findings in photic maculopathy. Retina. 2003;23(6):863-6.)

Optical coherence tomography is the exam that brings more clarity in these cases. It presents with an interruption of the outer limiting membrane and the junctions of the inner and outer segments, justafoveal microcysts, and increased foveal hyperreflectivity.(²⁸28 Huang SJ, Gross NE, Costa DL, Yannuzzi LA. Optical coherence tomography findings in photic maculopathy. Retina. 2003;23(6):863-6.) An outer lamellar cystic change is believed to be produced by either the thermal or the thermally enhanced phototoxic reaction at the photoreceptor level and surface of the retinal pigment epithelium.(¹1 Yannuzzi LA, Fisher YL, Slakter JS, Krueger A. Solar retinopathy: a photobiologic and geophysical analysis. 1989. Retina. 2012;32 Suppl 1:28-43.) All five patients in this report showed disruption of the outer layers of the retina in agreement with the literature.

Regarding visual recovery, the first, third, and fifth cases had partial recovery, while the second case had a complete recovery. There seems to be much individual variation in the susceptibility to developing permanent vision loss.(²⁷27 Comander J, Gardiner M, Loewenstein J. High-resolution optical coherence tomography findings in solar maculopathy and the differential diagnosis of outer retinal holes. Am J Ophthalmol. 2011;152(3):413-419.e6.) Correlating with the OCT findings, full-thickness involvement of the photoreceptor layer of the entire fovea indicates an association with permanent vision loss, whereas isolated involvement of the outer or inner segments or a lesion outside the center of the fovea results in a better visual outcome.(³⁴34 Tabatabaei SA, Soleimani M, Bohrani B, Banafsheafshan A, Faghihi S, Faghihi H. Multimodal imaging in photic retinopathy. Int J Ophthalmol. 2019;12(3):523-5.) We can see that the OD of patient 1, which had a wider disruption of the outer layers of the retina, had a worse recovery than the OS. This greater involvement of the outer layers of the retina may be related to the lower visual recovery in this case. In case 3, we have a slight asymmetry of visual recovery, worse in the OD; however, it can be explained by the nuclear cataract present only in that eye. Patients 4 and 5 are recent cases that we do not have a big follow-up data, probably able to improve with more months of recovery. We can infer that we will have a better recovery in the right eye of patient 4 and in the left eye of patient 5 who had paramacular disorders. Patient 5 reports that the black spot in his right eye is recovering well, but in the follow-up appointments, we still have the central defect with partial vision of 20/25.

In conclusion, we show here five cases that were diagnosed with PM, with variations concerning types of light exposure or even presence of exposure, symptom duration, retinography findings, and visual recovery.

REFERENCES

Publication Dates

History