What are the next steps after photocoagulation if I see shimmering dots in light?

Management of Shimmering Dots After Photocoagulation

If you experience shimmering dots in light after photocoagulation, you should undergo immediate OCT imaging to assess for macular edema or choroidal neovascularization, which are treatable complications of the procedure. 1

Diagnostic Evaluation

When patients report visual symptoms such as shimmering dots (scotomas) after laser photocoagulation, a thorough evaluation is necessary to rule out complications:

1. Complete ocular examination:

   • Visual acuity testing
   • Pupillary assessment for relative afferent pupillary defect
   • Dilated fundus examination with careful peripheral retina assessment
   • Slit-lamp biomicroscopy 2, 1

2. Advanced imaging:

   • Optical Coherence Tomography (OCT) to assess for:
     • Macular edema
     • Choroidal neovascularization (CNV)
     • Retinal structural changes 1
   • Consider fluorescein angiography if leakage or neovascularization is suspected 1

Common Causes of Shimmering Scotomas After Photocoagulation

• Normal post-laser scotomas: Some scotomas are expected after photocoagulation and may persist
• Macular edema: Fluid accumulation in the central retina
• Choroidal neovascularization: Abnormal blood vessel growth
• Vitreous debris: Cells or pigment in the vitreous 2
• Chorioretinal adhesions with secondary intraretinal cystoid fluid 1

Treatment Approach

Based on the findings from your diagnostic evaluation:

1. If macular edema or CNV is detected:

   • Anti-VEGF injections are the primary treatment
   • Follow-up OCT imaging at 1 month after treatment 1

2. If persistent central serous chorioretinopathy is present:

   • Consider photodynamic therapy (PDT) due to its excellent safety profile 1

3. If diabetic macular edema is detected:

   • Anti-VEGF therapy is recommended as first-line treatment 1

4. If vitreous hemorrhage is present:

   • Close monitoring
   • Consider vitrectomy if dense and persistent 2

5. If no treatable pathology is found:

   • Reassurance that some scotomas are expected after photocoagulation
   • Regular follow-up examinations (initially every 1-2 weeks) 2

Follow-up Schedule

• Initial follow-up: 1-2 weeks after reporting symptoms
• If macular edema or CNV is treated: 1 month after treatment
• Subsequent follow-up: Based on clinical findings and treatment response 2, 1

Important Considerations

• Avoid additional laser treatments near the foveal vasculature (within 500 μm of the center of the macula) to prevent further central vision damage 1
• If additional laser treatment is needed, consider modified protocols with less intense treatment and greater spacing to minimize complications 1
• Report any worsening of symptoms or new visual changes immediately 1

Prevention of Future Complications

For future laser treatments, if needed:

• Use modified laser protocols with less intense burns
• Maintain greater spacing between laser spots
• Avoid treatment near the foveal center 1

Shimmering scotomas after photocoagulation may be normal or indicate complications requiring treatment. Prompt evaluation with OCT imaging is essential to determine the appropriate management strategy and preserve vision.