Photic maculopathy: A review of the literature (I) | Archivos de la Sociedad Española de Oftalmología (English Edition)

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During the chronic phase the presence of window defects translating the atrophy of the retinal pigment epithelium is typical." ] ] ] "textoCompleto" => "IntroductionThe potential of light to produce ocular damages has been well known for millenia. In recent decades, the appearance of a new entity (laser pointer maculopathy) and the development of optical coherence tomography have again brought this pathology into the limelight.<a class="elsevierStyleCrossRef" href="#bib0480">1</a>The first form of described photic maculopathy is solar maculopathy because for thousands of years sunlight was the only available light and on many occasions said maculopathy broke out in epidemics due to the observation of solar eclipses. The first description of said pathology was made by Bonetus, a Swedish physician, who described it in the 17th century.<a class="elsevierStyleCrossRefs" href="#bib0485">2,3</a>Apparently, the oldest recorded total solar eclipse occurred in ancient Egypt, dated October 30, 1207 BC. This eclipse was also mentioned in the Bible and may have had significant consequences in the ancient world. Since then, this astronomical event has been recorded on many occasions. According to popular belief, a full solar eclipse is a rare and infrequent occurrence, but this is not so because every 18 months a full solar eclipse takes place in some part of the planet. Partial eclipses, i.e., when the moon does not entirely hide the sun, occur at least twice a year somewhere on the surface of the Earth.<a class="elsevierStyleCrossRefs" href="#bib0495">4,5</a>However, due to the very nature of eclipses, the small size of the moon's shadow on the Earth surface and the specific alignment of the planets involved, a full solar eclipse occurs on the same area of the Earth very infrequently, with an average of approximately 375 years.<a class="elsevierStyleCrossRefs" href="#bib0495">4,5</a>Since the 19th century, pathologies caused by exposure to light have evolved together with technology. In the first years of the 20th century, damage caused by welding equipment was described (welders arc maculopathy) and photic maculopathy reached a new dimension as an occupational hazard.In the decade of the 1940s, the first animal models were developed for studying cellular and tissue damage caused by exposure to nuclear blast radiations. At that time, a new in-depth understanding was obtained about the complex mechanisms by means of which light damages tissues.More recently, a novel technological development has brought photic damage into the limelight once again. The first cases of laser-induced maculopathy were reported as labor accidents in military, industrial or laboratory environments.<a class="elsevierStyleCrossRef" href="#bib0505">6</a> However, in the past 2 decades the extension of laser technology took laser devices into the homes and hands of children and teenagers. The inevitable consequence was an increase in the number of retinal lesions caused by laser beams. This is particularly relevant because this form of photic maculopathy is more severe than solar-induced maculopathy and affects young children with greater frequency.The objective of this review is to provide a comprehensive overview of the various types of photic maculopathy. Searches for this review were conducted in Pubmed utilizing the following algorithms: “photic maculopathy” or “solar maculopathy” or “eclipse maculopathy” or “welding maculopathy” or “laser pointer maculopathy” or “handheld laser maculopathy” or “lightning maculopathy” or (welder and macula) or (welder and retina) or (“arc welding” and macula) or (“arc welding” and retina) or (eclipse and retina) or (eclipse and macula). Said algorithm produced 173 articles. The references of said articles were utilized to increase the search.Solar retinopathy: photic maculopathy secondary to exposure to sunlightSince ancient times it has been known that direct exposure to sunlight could damage eyesight. Sources from ancient Greece and Rome reported that even indirect observation of a solar eclipse through water or a mirror could produce blindness. Some authors reported that one of the most severe punishments in the past consisted in exposing victims to high intensity light with the aim of leaving them blind.<a class="elsevierStyleCrossRef" href="#bib0510">7</a> Even though it cannot be proved, it has been suggested that Galileo Galilei might have endured visual loss secondary to the observation of the Sun.<a class="elsevierStyleCrossRefs" href="#bib0515">8–10</a>The first cases of photic maculopathy described in modern times were also secondary to the observation of the Sun, usually solar eclipses, and for this reason the terms “solar retinopathy” and “eclipse retinopathy” were applied indistinctly. Another term applied in this context is “foveomacular retinitis”.<a class="elsevierStyleCrossRef" href="#bib0530">11</a> This confusing term was applied to refer to the pathology of patients with morphological changes and clinic compatible with photic maculopathy without documenting exposure to light that could explain the presence of said lesions.<a class="elsevierStyleCrossRefs" href="#bib0535">12–14</a>EpidemiologyIt is difficult to assess the prevalence of solar retinopathy in the general population. In relation to the observation of eclipses, said pathology could sometimes exhibit epidemic proportions with low prevalence and peaks of outbreaks matching astronomical events. Epidemics have been reported involving hundreds of individuals such as the epidemic described by Patel and Bavishi<a class="elsevierStyleCrossRef" href="#bib0550">15</a> in India in 1990. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the main published series. However, the majority of articles refer individual cases or small series.<a class="elsevierStyleCrossRefs" href="#bib0555">16,17</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Some fruitless attempts were made to assess the incidence of photic maculopathy. Kabra<a class="elsevierStyleCrossRef" href="#bib0565">18</a> analyzed 42 patients who in 1980 had observed an eclipse in India. Only one exhibited retinal impairment. Other authors attempted to calculate incidence by counting affected individuals by means of ad hoc questionnaires given to people who had watched an eclipse.<a class="elsevierStyleCrossRef" href="#bib0570">19</a> However, it is impossible to determine the number of actually exposed individuals, which probably involves a significant imprint diagnosis because it is likely that individuals with only one impaired eye will not visit an ophthalmologist.If it is not possible to establish incidence, not even after a well-defined event such as an eclipse, it is even more difficult to determine prevalence. When a patient exhibiting said pathology is assessed by an ophthalmologist in the chronic phase, it is difficult to make a diagnostic. For these reasons, prevalence or incidence data are not reliable. Stokkermans and Dunbar<a class="elsevierStyleCrossRef" href="#bib0575">20</a> found an incidence of 0.14% in patients who visited seeking unspecialized ophthalmic care. In a series of predominantly male (75%) and middle-aged patients (mean 43years of age), 80% exhibited antecedents consistent with photic retinopathy, in 80% of cases due to solar exposure and 50% due to the use of welding equipment without adequate protection. In 15% of cases, patients had consumed psychotropic substances and 5% exhibited psychiatric pathology. In addition, 40% of patients exhibited lesions in both eyes.It is likely that individual susceptibility plays a significant role and that the threshold is different in each individual. Long exposures centered on the fovea, pupil dilatation, repeated exposure and the use of telescopes have also been associated to higher risk. In addition, pigmentation, transparency and temperature could also play a role (greater risk in hypothermia situations induced by exercise or fever).It appears that short exposure times can also cause damages. Chang and Cavuoto<a class="elsevierStyleCrossRef" href="#bib0580">21</a> recently published the case of a girl who developed said complication after solar exposure of only one minute. An acute pathology is described in the literature with greater frequency, as well as cases related to chronic exposure to the sun.<a class="elsevierStyleCrossRefs" href="#bib0585">22,23</a> Said chronic forms would be similar to those reported as “professional welder disease”.<a class="elsevierStyleCrossRef" href="#bib0595">24</a>Eclipse-induced photic maculopathy is generally bilateral but frequently asymmetric, unfortunately causing more severe damage in the dominant eye.<a class="elsevierStyleCrossRef" href="#bib0530">11</a> Kamali et al.<a class="elsevierStyleCrossRef" href="#bib0600">25</a> found that the right eye is more frequently affected, above all when the eclipse is observed through a handheld object considering that the majority of people are right-handed. As with the majority of traumatic pathology, this entity more frequently affects young males who are more accident prone and have greater lens transparency and larger pupil diameter.<a class="elsevierStyleCrossRef" href="#bib0605">26</a> It seems that, in addition to optical transparency, refractive error could play a role, with risk being higher in emmetropics and moderately farsighted individuals.<a class="elsevierStyleCrossRef" href="#bib0530">11</a>After studying an epidemic among the US military population in Hawaii, Penner and McNair<a class="elsevierStyleCrossRef" href="#bib0610">27</a> concluded that some meteorological factors such as the height of the Sun, the type of eclipse (total or partial) and the amount of clouds could play a role in the probability and severity of damages. It has also been speculated that risk could be higher in regions with greater transmissibility of ultraviolet-B radiation.<a class="elsevierStyleCrossRefs" href="#bib0530">11,23</a> Yannuzzi et al.<a class="elsevierStyleCrossRef" href="#bib0490">3</a> reported 10 photic retinopathy cases in patients who had sunbathed without looking directly at the Sun in the northern United States. After requesting information from several federal US agencies to analyze geophysical variables, said authors reach the conclusion that the damages could have been caused by increased ultraviolet radiation levels due to diminished ozone levels.Solar retinopathy has also been described in individuals gazing at the Sun for long periods of times without an eclipse, known as sungazers.<a class="elsevierStyleCrossRef" href="#bib0590">23</a> This strange behavior seems to be linked to mental disorders, religious ceremonies<a class="elsevierStyleCrossRefs" href="#bib0615">28,29</a> or the use of psychotropic drugs, some of which have midriatics and possibly photosensitizing effects. Accordingly, it has been speculated that some drugs could produce increased sensitivity and diminish sensitivity thresholds in individuals, although this has not been demonstrated.<a class="elsevierStyleCrossRef" href="#bib0590">23</a> As discussed above, said entity has exceptionally been described in sunbathers,<a class="elsevierStyleCrossRefs" href="#bib0625">30,31</a> also among military personnel watching the sky with prismatics during long periods of time,<a class="elsevierStyleCrossRef" href="#bib0600">25</a> in mountain climbers due to solar reflection in the snow,<a class="elsevierStyleCrossRef" href="#bib0585">22</a> or in sailors watching sunsets at sea.PathogenyThe design of the eye allows the retina to receive radiance 100,000 times higher than that received by the cornea.<a class="elsevierStyleCrossRef" href="#bib0635">32</a> Initially, thermal damage was proposed as the main mechanism, according to which the retina would “burn out” in the same way a paper burns under a focused magnifying glass. However, nowadays we have evidence allowing us to reject this theory. The increase of temperature produced by solar exposure is estimated to be only of 2°C, while the denaturation of proteins would require a temperature increase of at least 10°C.<a class="elsevierStyleCrossRefs" href="#bib0480">1,33</a>The author of the theory proposing that the damage occurs due to non-thermal mechanisms is Vos.<a class="elsevierStyleCrossRef" href="#bib0645">34</a> In 1962, he published an article proposing for the first time that a non-thermal mechanism could account for said damages. The article developed a mathematical model to determine the critical amount necessary to induce protein coagulation and the formation of water steam, and concludes that this threshold is not reached, therefore proposing metabolic poisoning, i.e., that metabolic acceleration induced by exposure to light produces toxic metabolites that cannot be removed from tissue.In 1966, Noell et al.<a class="elsevierStyleCrossRef" href="#bib0650">35</a> described phototoxicity as the main mechanism in rats, and shortly thereafter confirmed this theory in primates.At present, 3 types of light-induced retinal damages have been identified. These are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The experiments carried out by Noell et al.<a class="elsevierStyleCrossRef" href="#bib0650">35</a> in rats in which hyperthermia increased and accelerated phototoxicity suggest that the thermal mechanism could increase photochemical damages. However, there is still a lot to be understood. The fact is that millions watch eclipses every year, frequently without adequate protection, and only a few develop solar retinopathy. Yannuzzi et al. published a number of articles developing a multivariate model in an attempt to explain said paradox. Said model includes individual susceptibility as well as geophysical factors.<a class="elsevierStyleCrossRefs" href="#bib0485">2,3,36</a>Animal modelsDoubtlessly, the technological development which most increased the understanding of photic maculopathy is optical coherence tomography (OCT), before which our understanding was very limited due to the necessity of histological studies, which meant that the majority of research was carried out in animals. Some authors reported cases in which a human eye to be enucleated due to a tumor was intentionally submitted to extended exposure to light in order to subsequently carry out a histological study of its effect on the retina.<a class="elsevierStyleCrossRefs" href="#bib0660">37,38</a> The various animal models developed in the course of the 20th century are discussed below.The first studies were carried out in rabbits in the 50s, in the context of the first nuclear tests. These experiments consisted in placing and alarm to wake up rabbits one second before the nuclear blast. The animals were located at different distances from the site and were subsequently sacrificed to study the effect of the intense light on the retina. The conclusion was that damages were induced mainly by a thermal and photodisruptive mechanism. Exposure to an extremely high amount of heat in a few milliseconds causes water in tissue to boil and to coagulate proteins and producing tissue cavitation.<a class="elsevierStyleCrossRefs" href="#bib0670">39,40</a>A new animal model was developed in the 70s. Indirect ophthalmoscopy was utilized to project light continuously on the retina through a 20-diopter lens. This new model demonstrated that the application of low intensity light for extended periods of time can also induce damage. However, in these experiments damages would not be due to thermal mechanisms,<a class="elsevierStyleCrossRefs" href="#bib0680">41–43</a> although they demonstrated the appearance of retinal edema followed by disorganization of pigment epithelium photoreceptors, and finally the repair and reorganization of both.<a class="elsevierStyleCrossRef" href="#bib0685">42</a> This regenerative capacity would explain the positive prognosis demonstrated in several series studying eclipse-induced retinopathies.Pathological anatomyIn 1974, Tso et al. published studies based on Rhesus monkey animal models. After 2h of exposure to indirect ophthalmoscopy light projected through a 20-diopter lens, damage was mainly located in photoreceptors and these cells have the ability to regenerate provided that the nucleus is not compromised.<a class="elsevierStyleCrossRefs" href="#bib0680">41,44</a>In the following years, said findings were replicated in human beings. In 1975, Tso and La Piana published a series of 3 patients who were scheduled for enucleation for uveal melanoma and were asked to gaze at the sun during one hour. Clinic evolution was analyzed in detail as well as macular histology after enucleation, finding thickened Bruch membrane and necrosis of the retina pigment epithelium without significant compromise of photoreceptors.<a class="elsevierStyleCrossRef" href="#bib0660">37</a> In 1993, Hope-Ross et al.<a class="elsevierStyleCrossRef" href="#bib0665">38</a> published a similar paper reporting that damages were mainly limited to the retina pigment epithelium with subtle alterations in external photoreceptor segments, the nature of which were not explained. The findings of both authors are contradictory because, while Tso reported RPE necrosis,<a class="elsevierStyleCrossRef" href="#bib0660">37</a> Hope-Ross et al.<a class="elsevierStyleCrossRef" href="#bib0665">38</a> found that RPE had very few alterations and reported swelling of external photoreceptor segments, with fragmentation and vesiculation of discs. The presence of swollen mitochondria was also demonstrated in said external segments, which would support the theory of metabolic overload.<a class="elsevierStyleCrossRef" href="#bib0665">38</a>In 2000, Bechmann et al. published a letter reporting for the first time the usefulness of OCT for diagnosing said entity, confirming in vivo that the findings seemed to be limited to the external retina.<a class="elsevierStyleCrossRef" href="#bib0700">45</a>ClinicFrequently, presentation is bilateral but asymmetric, with the dominant eye being more compromised.<a class="elsevierStyleCrossRef" href="#bib0530">11</a> Patients generally refer blurred vision, followed a few hours later by the appearance of scotoma.<a class="elsevierStyleCrossRef" href="#bib0610">27</a> Some referred the perception of a point of light close to fixation<a class="elsevierStyleCrossRef" href="#bib0705">46</a> that preceded the appearance of scotoma or metamorphopsia.<a class="elsevierStyleCrossRef" href="#bib0710">47</a> The appearance of color vision defects mainly affecting the blue-yellow line have been described. This finding was related to the fact that the phototoxic effect of blue light is higher.<a class="elsevierStyleCrossRef" href="#bib0710">47</a>The majority of published cases focus almost exclusively on visual acuity (VA). The 3-case series published by Kamali et al.<a class="elsevierStyleCrossRef" href="#bib0600">25</a> in 1975 includes a very detailed description. In many cases, the patient does not notice anything apart from a certain feeling of glare, but shortly afterwards a sort of cloud is perceived associated to the appearance of afterimages, photophobia and sometimes photopsia or chromatopsia (visual perception with a stained shade). Twenty-four hours after the event, said cloud becomes more dense and turns into a scotoma that can remain during hours or weeks, although it can also become permanent. Scotoma can be absolute or relative, in some cases being initially absolute and subsequently becoming relative. Generally, VA reduction is moderate (in the area of 6/12) and metamorphopsia could appear, initially due to the displacement of photoreceptors caused by edema and in later stages due to degenerative changes.<a class="elsevierStyleCrossRef" href="#bib0600">25</a>Exceptionally, corneal compromise has been described in the form of superficial keratitis,<a class="elsevierStyleCrossRef" href="#bib0715">48</a> retina detachment without specifying the mechanism,<a class="elsevierStyleCrossRef" href="#bib0720">49</a> central serous maculopathy,<a class="elsevierStyleCrossRef" href="#bib0725">50</a> and choroidal folds<a class="elsevierStyleCrossRef" href="#bib0730">51</a> and a condition similar to placoid pigmented multifocal epitheliopathy.<a class="elsevierStyleCrossRef" href="#bib0735">52</a> Li et al.<a class="elsevierStyleCrossRef" href="#bib0740">53</a> described the case of a patient who developed epiretinal membrane. Said author believed that the inflammation induced by phototoxic damage precipitated the appearance of said membrane in a 63-year-old patient, that is a lot older than the majority of patients with said pathology. Evolution toward macular hole is infrequent in solar retinopathy but relatively frequent in other more severe forms of photic retinopathy such as those produced by laser pointer beams.DiagnosticTypically, diagnostic was based exclusively on ocular fundus examinations, which initially show a darker macula. This is due to the congestion of the choroids. Subsequently, retinal edema adopts the appearance of a yellowish spot surrounded in many cases by a grayish area. Some patients could also exhibit small hemorrhages. This vitelliform lesion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), considered by Gass as pathognomic of photic maculopathy, disappears to be substituted by a hypo-pigmented area.<a class="elsevierStyleCrossRefs" href="#bib0600">25,53</a> Some authors described that in some cases an imprint in the form of the silhouette of the portion of the Sun that was not hidden by the moon can be observed in the ocular fundus<a class="elsevierStyleCrossRefs" href="#bib0745">54–56</a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>For several decades, fluorescein angiography (FA) was the gold standard for diagnosing said pathology. Stain exudation can be observed during the acute phase in the injured area, while in the chronic phase the appearance of a window effect defect is characteristic (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<a class="elsevierStyleCrossRef" href="#bib0660">37</a><elsevierMultimedia ident="fig0015"></elsevierMultimedia>The first description of the usefulness of OTC for diagnosing said pathology was published by Bechmann et al.<a class="elsevierStyleCrossRef" href="#bib0700">45</a> in 2000. The quasi-histological information provided by this technology has displaced FA as the most sensitive technique.<a class="elsevierStyleCrossRef" href="#bib0760">57</a> Even first-generation time domain OCT devices demonstrated superiority against FA. In an article published in 2009, Jain et al.<a class="elsevierStyleCrossRef" href="#bib0765">58</a> compared the diagnostic capacity of FA and Stratus OCT in 21 eyes affected by solar retinopathy. The OCT device identified alterations in all patients, although 2 of them did not exhibit the typical window defect. The authors proposed that OCT could have a prognostic value. The reduction of central macular thickness and the presence of total width cystic lesions under the fovea were associated to poorer levels of VA.<a class="elsevierStyleCrossRefs" href="#bib0765">58,59</a>The tomographic evolution of photic maculopathy is as follows: in the acute phase, hyper-reflective areas appear which are subsequently substituted by hypo-reflective cystic spaces. Said cyst occupied the area corresponding to lost receptors, usually adopting a rectangular shape.<a class="elsevierStyleCrossRef" href="#bib0775">60</a> Spectral domain OCT is considerably more sensitive than time domain OCT.<a class="elsevierStyleCrossRef" href="#bib0780">61</a> It is frequent to find a disruption of the Verhoeff membrane (the interdigitation zone between photoreceptors and the retinal pigment epithelium). Usually, disruption also occurs in the ellipsoid line (between the internal and external photoreceptor segments).<a class="elsevierStyleCrossRef" href="#bib0785">62</a> It seems that these small changes are present in all cases (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). In eyes with poor vision a disruption of the external nuclear layer and the external limiting membrane occurs even though it is not clear whether these are artifacts or actual damages.<a class="elsevierStyleCrossRef" href="#bib0790">63</a><elsevierMultimedia ident="fig0020"></elsevierMultimedia>In the chronic phase, a broad hypo-reflective area appears at the interface between the external and internal photoreceptor segments. Even though this image is not pathognomic of the entity, it is relatively specific.<a class="elsevierStyleCrossRefs" href="#bib0590">23,64</a>Autofluorescence is highly sensitive for detecting this type of lesions. It is based on the properties of natural fluorophores. It is considered to originate mainly in the lipofuscin contained in the retina pigment epithelium cells.<a class="elsevierStyleCrossRef" href="#bib0800">65</a> The characteristic pattern is the presence of small hypo-fluorescence areas surrounded by an uneven ring of hyper-fluorescence. Autofluorescence is not as sensitive as OCT because, in order to show relevant changes, a window defect must be present in the retinal pigment epithelium.<a class="elsevierStyleCrossRef" href="#bib0805">66</a>The autofluorescence technique in the near infrared could also be useful.<a class="elsevierStyleCrossRef" href="#bib0620">29</a> Although it is still necessary to determine its reliability and reproducibility, it could prove to be very useful in the future. In this case, autofluorescence originates in the melanin contained in the RPE and to a lesser extent in the choroids, because RPE is probably one of the cell types that is primarily affected in this entity.Scotoma produced by said entity are usually small and cannot be detected by conventional perimetry. However, numerous authors have reported the usefulness of microperimetry.<a class="elsevierStyleCrossRef" href="#bib0810">67</a>In general, electrophysiology contributes very little to the diagnostic of photic maculopathy.<a class="elsevierStyleCrossRef" href="#bib0815">68</a> Some articles have reported a reduction of central response amplitude in multifocal electroretinogram.<a class="elsevierStyleCrossRefs" href="#bib0815">68–71</a>Amsler grid is a classic test that enables the detection and follow-up of scotomae and metamorphopsia.<a class="elsevierStyleCrossRef" href="#bib0835">72</a>Some authors have demonstrated the existence of tritan-type defects (dyschromatopsia in the blue-yellow axis) in these patients. This would suggest that the photochemical mechanism is probably the most important one because blue cones are more sensitive than red or green to shorter wavelengths.<a class="elsevierStyleCrossRef" href="#bib0710">47</a> However, this pattern could also be explained due to the existence of a smaller number of blue cones.<a class="elsevierStyleCrossRef" href="#bib0710">47</a>Differential diagnosticEven though Gass believed that photic maculopathy produces a pathognomic pattern, the fact is that many entities could produce similar changes. A series recently published by Raoof et al.<a class="elsevierStyleCrossRef" href="#bib0840">73</a> discusses differential diagnostic of photic maculopathy secondary to laser beams. Even though this form has a severe presentation, in essence it is the same entity. Said authors considered that a differential diagnostic includes so many entities that they define this entity as the “new simulator”.In the acute phase, the appearance of a vitelliform lesion could give rise to a differential diagnostic with Best's disease because it also can produce external retinal disruption. However, in contrast with Best's disease, photic retinopathy does not produce subretinal deposits. Of course, in the case of doubt EOG is a recourse. In the acute phase, differential diagnostic is easier because the patient is more likely to remember and recognize the exposure.<a class="elsevierStyleCrossRef" href="#bib0840">73</a>However, in the chronic phase differential diagnostic could be much more complicated because the patient may not remember or admit solar exposure, and the appearance of the retina is shared by many pathologies. In the chronic phase, differential diagnostic would include retinopathy due to tamoxifen (although crystalline deposits would be present in the internal retina), juxtafoveolar telangiectasiae (that can be evidenced with FA) (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>), macular traction syndrome, achromatopsia, acute retinal epithelitis, Stargardt's disease (although, in contrast with photic retinopathy, this entity is progressive) or the consumption of nitrites.<a class="elsevierStyleCrossRef" href="#bib0775">60</a><elsevierMultimedia ident="fig0025"></elsevierMultimedia>Photic retinopathy is the great simulator of retinal dystrophies. Recently, Zhang et al.<a class="elsevierStyleCrossRef" href="#bib0805">66</a> published a series of 5 children referred for genetic study due to suspected retinal dystrophy who finally had laser pointer maculopathy. Photic maculopathy could “phenocopy” a retinal dystrophy coursing with a foveal gap, such as rod monochromatism or Stargardt's disease. Accordingly, before initiating genetic study of possible retinal dystrophy a complete clinic history should be performed to discard said possibility as much as possible.PrognosisPrognostic is good and considerably better for solar maculopathy than laser pointer maculopathy. The majority of visual recovery occurs in the first weeks after exposure.<a class="elsevierStyleCrossRefs" href="#bib0530">11,17</a> This improvement is possible because even though primate cones and rods do not have reproductive capacity<a class="elsevierStyleCrossRef" href="#bib0765">58</a> they do have regenerative capacity, which is possible provided that the nucleus of the cell is not damaged.<a class="elsevierStyleCrossRef" href="#bib0695">44</a>In a series of 15 eyes of 15 patients who had suffered solar retinopathy in Sweden during an eclipse in 1999, Källmark and Ygge et al.<a class="elsevierStyleCrossRef" href="#bib0845">74</a> reported that most of the recovery occurred in the first 3 months. A British series with 20 patients, also published in 1999, reported that only 4 perceived the presence of scotoma after 7 months.<a class="elsevierStyleCrossRefs" href="#bib0850">75–77</a>It is likely that the prognosis of this entity has improved due to awareness raising campaigns. However, this subjective improvement contrasts with the presence of irreversible alterations in the external retina, easily demonstrable with OCT. The majority of patients will have a small defect in the ellipsoid zone.<a class="elsevierStyleCrossRef" href="#bib0865">78</a> These sequels have been documented even 51 years after the initial exposure.<a class="elsevierStyleCrossRef" href="#bib0870">79</a>The appearance of long-term complications, such as choroidal neovascularization, seems to be low in eclipse-associated maculopathy but have been described with relative frequency after exposure to laser pointers and with significant frequency after exposure to YAG laser.<a class="elsevierStyleCrossRef" href="#bib0875">80</a> As described above, other complications have been described exceptionally such as the appearance of epiretinal membranes.<a class="elsevierStyleCrossRef" href="#bib0740">53</a>It has been suggested that, in addition to having a diagnostic value, OCT also has a prognostic value. VA is correlated with foveal thickness.<a class="elsevierStyleCrossRef" href="#bib0765">58</a> Other authors have correlated VA with the tissue disruption pattern. Two classifications have been proposed correlating the histological pattern with the prognostic.<a class="elsevierStyleCrossRefs" href="#bib0770">59,81</a> After examining 21 affected patients, Gulkilik et al.<a class="elsevierStyleCrossRef" href="#bib0770">59</a> found that the involvement of the entire photoreceptor width is associated to poor prognosis. They also found that eyes with cystic lesions in the external retina have a worse prognosis than eyes without said lesions.<a class="elsevierStyleCrossRef" href="#bib0770">59</a> Jorge et al.<a class="elsevierStyleCrossRef" href="#bib0880">81</a> differentiated 3 patterns and suggested that the prognostic is worse when the entire photoreceptor layer is compromised.No articles have been published about the potential prognostic value of in face technology, although it presumably has this potential because it is able to determine with great precision the area in which photoreceptors have disappeared as well as the existence of foveal compromise.TreatmentEven though the use of oral steroids have been proposed for this and other forms of photic maculopathy, there is no scientific evidence that they can improve prognosis.<a class="elsevierStyleCrossRef" href="#bib0600">25</a> Some authors have proposed consuming vitamin A and aspirin.<a class="elsevierStyleCrossRef" href="#bib0820">69</a>Prevention: safe eclipse observationAn eclipse is a highly infrequent event and nobody has sufficient experience regarding its safe observation. Large amount of solar retinopathy cases have been described in patients utilizing spontaneous protection devices such as smoked glass, dark plastic, film negatives or compact discs.<a class="elsevierStyleCrossRefs" href="#bib0640">33,55</a> The truth is that it is difficult to assess the protective efficacy of a method because, in order to achieve certainty the observer would have to gaze the eclipse 100% of the time through the device, and many patients referred using protective devices only part of the time.<a class="elsevierStyleCrossRefs" href="#bib0570">19,82</a>Direct sungazing is an extreme risk for vision except during the short period of time of the total eclipse, when the moon completely hides the surface of the Sun. This only occurs during the short period of a total Sun eclipse. The only safe way to gaze a non-eclipsed part of the Sun or a partial solar eclipse is through sunglasses specifically designed for this purpose or with handheld solar filters. In any case, said products should comply with the international ISO12312-2<a class="elsevierStyleCrossRef" href="#bib0890">83</a> safety standard. Home made filters or conventional eyeglasses, even the dark ones, are unsafe because they still allow an excessive amount of light to pass through. <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> describes the instructions for safe observation utilizing solar glasses or handheld filters.<a class="elsevierStyleCrossRef" href="#bib0895">84</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>The American Association of Astronomy (AAS), together with the National Science Foundation (NSF) of the United States, include in their websites a list of companies and manufacturers of filters and sunglasses for watching eclipses which fulfill the above mentioned international safety roles. Many of said companies have distributors throughout the world and are therefore easily accessible for the majority of the population.<a class="elsevierStyleCrossRef" href="#bib0900">85</a>Probably, one of the safest methods is the use of welding goggles that include specific filters. Indirect observation projecting the eclipse through a “stenopeic hole” on a screen is very safe<a class="elsevierStyleCrossRef" href="#bib0600">25</a> and can be done making a small hole in a sheet of paper or using both hands. Giving the back to the Sun, the light that passes through the small hole is projected on the ground, reproducing the shadow of the partially eclipsed Sun. Another way to observe an eclipse is observing the shadow that forms when the eclipsed Sun passes through the leaves of a tree. This shadow will comprise a large amount of solar crescents projected by the small spaces between leaves.Arc welding maculopathyEpidemiologyThe second form of described photic maculopathy is that produced by exposure to welding devices. This entity was described by Terrien in 1902 who observed it in workers who were building the London underground.<a class="elsevierStyleCrossRef" href="#bib0905">86</a> The most common lesion caused by exposure to welding devices is actinic keratitis. Retinal compromise is very infrequent.Difference methods can be associated to different risks. Risk is particularly high with carbon dioxide arc welding.<a class="elsevierStyleCrossRef" href="#bib0910">87</a> At present, this pathology is highly infrequent at least in the Western world. Some articles suggested that this occupational disease was more frequent in Eastern block countries during the communist era,<a class="elsevierStyleCrossRef" href="#bib0705">46</a> and that the pathology is more frequent in countries having unsophisticated labor laws.<a class="elsevierStyleCrossRefs" href="#bib0915">88,89</a> A study carried out in Nigeria to assess the impact of this professional activity on ocular health reported that over half of the surveyed workers admitted to never using protection and the vast majority of the remaining half used protection only occasionally.<a class="elsevierStyleCrossRef" href="#bib0915">88</a>It is surprising that no cohort study has been published to date assessing said occupational hazard. A recent study carried out in China among 86 welders reported that photic maculopathy affected 32% of workers. The authors found a correlation between the duration of exposure, the consumption of lutein and the use of protective measures.<a class="elsevierStyleCrossRef" href="#bib0920">89</a> In contrast with eclipse-induced maculopathy, the subject of a significant amount of small series, virtually all studies on welders maculopathy refer to individual cases. Even though said entity has been regarded as a professional disease, the diminished price of these devices have made them available to the general public, to the point that some phototoxicity cases were reported among welding enthusiasts.<a class="elsevierStyleCrossRefs" href="#bib0510">7,72</a>Acute toxicity caused by exposure to welding is very rare.<a class="elsevierStyleCrossRef" href="#bib0925">90</a> However, some cases have been described after exposures as short as 30s.<a class="elsevierStyleCrossRef" href="#bib0930">91</a>Retinal toxicity secondary to chronic exposure is more frequent, with some authors believing that this is an underestimated occupational hazard.<a class="elsevierStyleCrossRef" href="#bib0935">92</a> In fact, in a recent case-control study, Yang et al.<a class="elsevierStyleCrossRef" href="#bib0595">24</a> demonstrated the presence of macular changes in 3 out of 80 studied eyes of professional welders in the region of Guangzhou (China). This high incidence of 38% can be explained due to the high sensitivity of OCT for detecting subclinic damages.Phototoxic maculopathy is not recognized as an occupational hazard in the majority of countries, probably because in most cases damages are subclinic. In fact, the authors of the above-mentioned series did not demonstrate significant VA differences between welders and controls.<a class="elsevierStyleCrossRef" href="#bib0595">24</a>Radiations emitted by said devices expand through a broad spectrum, from infrared to beyond ultraviolet. Exposure to ultraviolet is regarded as responsible for actinic keratitis, whereas exposure to longer wavelengths produces photochemical damages in the retina.ClinicAcute toxicity due to exposure to welding is very rare.<a class="elsevierStyleCrossRef" href="#bib0925">90</a> Most articles report cases produced by chronic exposure. Even though retinal changes are not infrequent, they usually course with hardly any repercussion on the visual function.<a class="elsevierStyleCrossRef" href="#bib0595">24</a>DiagnosticDiagnostic considerations are not significantly different in comparison to other forms of photic retinopathy.<a class="elsevierStyleCrossRefs" href="#bib0825">70,86,92</a>PrognosisPrognosis is good. Many of the described cases had subclinic expression although severe cases have been described evolving into the formation of lamellar macular holes.<a class="elsevierStyleCrossRef" href="#bib0925">90</a>TreatmentAs in other forms of photic maculopathy, some authors administer systemic corticoids although the usefulness thereof is not demonstrated.<a class="elsevierStyleCrossRefs" href="#bib0510">7,90</a>PreventionObservation of labor laws is crucial. As discussed above, in less developed countries many workers admit to not using protection.<a class="elsevierStyleCrossRef" href="#bib0915">88</a> However, even in Western countries with highly developed labor legislations, the implementation of these prevention measures is difficult. Even though workers are advised to wear protection all the time, the fact is that total protection is not possible because in some cases they must weld in areas with very little lighting<a class="elsevierStyleCrossRef" href="#bib0835">72</a> and in uncomfortable positions in which protection is difficult, in addition to being inevitably exposed to the “friendly fire” of other workers.<a class="elsevierStyleCrossRefs" href="#bib0595">24,93</a>It has been speculated that the use of vitamin A and aspirin could have protective effects.<a class="elsevierStyleCrossRef" href="#bib0905">86</a> Similarly, the use of medicaments such as fluphenazine should be avoided as they exhibit a potential effect that increases sensitivity to light.<a class="elsevierStyleCrossRefs" href="#bib0705">46,94,95</a>Legal considerationsDue to the sensitivity of OCT to identify photic damage, it would probably be recommendable to carry out a macular OCT before individuals and start working as welders.ConclusionSolar maculopathy is the oldest form of photic maculopathy. In some cases it expresses as small epidemics related to the observation of solar eclipses although it can also be related to the consumption of drugs and religious ceremonies. It was initially proposed that the lesion occurred due to thermal mechanisms, but nowadays it is clear that photochemical mechanisms are probably the main culprits. Some histological studies have been carried out in animals and also in humans scheduled for enucleation due to intraocular tumors. It is believed that if the nucleus is not damaged, photoreceptors have a degree of regenerative capacity. This explains that some degree of recovery frequently occurs. For a long time, the gold standard in the diagnostic of this pathology was FA, but now it has been clearly replaced by OCT. The visual prognosis of solar maculopathy is good, as the majority of patients recover most of the lost VA. Some authors have utilized corticoids for treating this entity, without scientific evidence supporting this treatment.Maculopathy associated to the use of welding devices is an infrequent entity, at least in more developed countries. On many occasions, OCT reveals morphological changes in welders but these do not usually compromise VA. From the diagnostic viewpoint, welders maculopathy is not different to solar maculopathy. There is no treatment but it is recommendable to advise these patients to avoid the use of medicaments that have the potential of increasing sensitivity to light.FundingThe research for this review has not received any specific ground from agencies of the public, commercial or nonprofit sectors.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1099731" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1040913" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1099732" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1040914" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Solar retinopathy: photic maculopathy secondary to exposure to sunlight" "secciones" => array:10 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Epidemiology" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Pathogeny" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Animal models" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Pathological anatomy" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Clinic" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Diagnostic" ] 6 => array:2 [ "identificador" => "sec0045" "titulo" => "Differential diagnostic" ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Prognosis" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Treatment" ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Prevention: safe eclipse observation" ] ] ] 6 => array:3 [ "identificador" => "sec0065" "titulo" => "Arc welding maculopathy" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0070" "titulo" => "Epidemiology" ] 1 => array:2 [ "identificador" => "sec0075" "titulo" => "Clinic" ] 2 => array:2 [ "identificador" => "sec0080" "titulo" => "Diagnostic" ] 3 => array:2 [ "identificador" => "sec0085" "titulo" => "Prognosis" ] 4 => array:2 [ "identificador" => "sec0090" "titulo" => "Treatment" ] 5 => array:2 [ "identificador" => "sec0095" "titulo" => "Prevention" ] 6 => array:2 [ "identificador" => "sec0100" "titulo" => "Legal considerations" ] ] ] 7 => array:2 [ "identificador" => "sec0105" "titulo" => "Conclusion" ] 8 => array:2 [ "identificador" => "sec0110" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0115" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-04-21" "fechaAceptado" => "2018-06-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1040913" "palabras" => array:6 [ 0 => "Photic maculopathy" 1 => "Solar maculopathy" 2 => "Eclipse maculopathy" 3 => "Arc welding maculopathy" 4 => "Handheld laser maculopathy" 5 => "Macular dystrophy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1040914" "palabras" => array:6 [ 0 => "Maculopatía fótica" 1 => "Maculopatía solar" 2 => "Maculopatía por eclipse" 3 => "Maculopatía por dispositivos de soldar" 4 => "Maculopatía por puntero láser" 5 => "Distrofia macular" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The human retina, as transducer of light energy, is especially exposed to light toxicity. Solar maculopathy has been the only form of photic maculopathy for millennia, often secondary to the observation of an eclipse. During the last century, technological advances have led to the appearance of new forms of photic maculopathy, related to the exposure to new forms of artificial light, such as welding devices and lasers. In recent years, the general use of laser pointers has led to an upturn in interest in this pathology. The aim of this review is to offer an integrated view of the different types of photic maculopathy. Due to the extension of this topic, the review is presented divided into two parts. In this first part solar maculopathy and welding arc maculopathy are presented." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "La retina humana, como tejido transductor de la energía lumínica, está especialmente expuesta a la toxicidad inducida por la exposición a la luz. La maculopatía solar ha sido durante milenios la única forma de maculopatía fótica, muchas veces en relación con la observación de un eclipse. Durante el último siglo los avances tecnológicos han conducido a la aparición de nuevas formas de retinopatía fótica, en relación con la exposición a nuevas formas de luz artificial como los dispositivos de soldar o emisores de láser. En los últimos años la generalización del uso de punteros láser ha hecho que repunte el interés por esta patología. El objetivo de esta revisión es ofrecer una visión integrada de los diversos tipos de maculopatía fótica. La revisión se presenta dividida en dos partes, debido a la extensión del tema tratado. En esta primera parte se trata la maculopatía solar y la maculopatía producida por exposición a los dispositivos de soldar." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: González Martín-Moro J, Hernández Verdejo JL, Zarallo Gallardo J. Maculopatía fótica: revisión de la literatura (I). Arch Soc Esp Oftalmol. 2018;93:530–541." ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 662 "Ancho" => 1000 "Tamanyo" => 58570 ] ] "descripcion" => array:1 [ "en" => "Vitelliform lesion that appeared several days after exposure." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1693 "Ancho" => 2167 "Tamanyo" => 233521 ] ] "descripcion" => array:1 [ "en" => "Lesion reproducing the shape of the Sun that is not hidden by the moon. Image shown with the authorization of Sutter et al.<a class="elsevierStyleCrossRef" href="#bib0755">56</a>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 671 "Ancho" => 1000 "Tamanyo" => 35992 ] ] "descripcion" => array:1 [ "en" => "FA. During the chronic phase the presence of window defects translating the atrophy of the retinal pigment epithelium is typical." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1219 "Ancho" => 2167 "Tamanyo" => 243500 ] ] "descripcion" => array:1 [ "en" => "Changes in OCT during the chronic photic maculopathy phase, showing the way in which the interruption of the retinal strata affects the retinal pigment epithelium, the Verhoeff line (interdigitation of the retina pigment epithelium and photoreceptors) and the photoreceptor integrity line (joining of the external and internal photoreceptor segments)." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 732 "Ancho" => 1300 "Tamanyo" => 80218 ] ] "descripcion" => array:1 [ "en" => "Even though Gass initially proposed that the image was pathognomic, numerous dystrophies could simulate this pattern. The image shows idiopathic macular telangiectasia exhibiting a similar image." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author, publication date \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Date of eclipse \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">No. of eyes/no. of patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Conclusion \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kabra, 1982 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16-02-1980. Hyderabad, India \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">84 eyes; 42 patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Only one solar retinopathy case \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Penner, 1966 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4-02-1962, Hawaii, USA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52 eyes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Only in 3 eyes the visual prognostic was worse than 20/50. The dominant eye is more compromised. Many homemade devices do not provide sufficient protection for observing eclipses \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jain, 2009 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Does not match a specific eclipse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 eyes; 11 patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">OCT is more sensitive than retinography \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Källmark, 2005 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11-08-1999. Stockholm, Sweden \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 eyes; 15 patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Significant improvement in 14 out of 15 cases \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1880917.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Main solar retinopathy series." ] ] 6 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Class \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Wavelength and pigment \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mechanism \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Situations \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 1 Thermal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The entire spectrum. Melanin Almost immediate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Heat is generated faster than it can be dissipated. Protein denaturation and coagulation. In extreme cases, tissue vacuolization due to formation of water steam. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Laser Argon and Krypton. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 2 Photochemical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Blue light Rhodopsine Hours of delay \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No heating. Damage occurs at the molecular level due to oxidation (proteins and nucleic acids). Mechanism equivalents to that of Sun damages on skin. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Very important mechanism in various forms of photic maculopathy. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 3 Photodisruption \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mechanical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fast absorption preventing dissipation of energy. Tissue is disintegrated in ions and electrons (plasma). The formation of water steam contributes to cavitation. Not dependent on pigmentation. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Laser YAG \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1880919.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Light produces toxicity in the retina through at least 3 mechanisms." ] ] 7 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Inspect the sun filder before use. If folds, scrapes or other damages are found, do not use. In addition, read and follow the printed instructions on the filter packaging \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Always supervise children while they use the filters \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• If using ammetropia corrective spectacles do not remove them, placing the filters over them or maintaining the hand filter in front of the spectacles. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Never gaze at the uneclipsed part of the Sun, or a partial eclipse through an unfiltered photo camera, telescope or binoculars. Also, do not gaze at the Sun through said devices with filters in place because the concentration of energy amplified by optical devices could damage the eyes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• When the eclipse is total, it is possible to gaze without the filters, but when the Sun begins to emerge place the filters in front of the eyes to watch the partial eclipse phases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• If the “eclipse goggles” or filters are not damaged they can be reutilized many times as they do not “wear out”. In fact, reuse is included in the update of the ISO 12312-2 standard adapted in 2015 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1880918.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Recommendations for watching an eclipse." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:95 [ 0 => array:3 [ "identificador" => "bib0480" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Light damage to the retina: an historical approach" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ …2] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eye (Lond)" "fecha" => "2016" "volumen" => "30" "paginaInicial" => "169" "paginaFinal" => "172" "itemHostRev" => array:3 [ "pii" => "S0302283817302531" "estado" => "S300" "issn" => "03022838" ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0485" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Solar retinopathy: a photobiological and geophysical analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ …4] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Trans Am Ophthalmol Soc" "fecha" => "1987" "volumen" => "85" "paginaInicial" => "120" "paginaFinal" => "158" "link" => array:1 [ 0 => array:2 [ …2] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0490" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Solar retinopathy. 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Photic maculopathy: A review of the literature (I)

Maculopatía fótica: revisión de la literatura (I)

J. González Martín-Moroa,b,

Corresponding author

juliogmm@yahoo.es

Corresponding author.

, J.L. Hernández Verdejoc, J. Zarallo Gallardoa,b

a Servicio de Oftalmología, Hospital Universitario del Henares, Coslada, Madrid, Spain

b Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain

c Facultad de Óptica y Optometría, Universidad Complutense de Madrid, Madrid, Spain

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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">FA&#46; During the chronic phase the presence of window defects translating the atrophy of the retinal pigment epithelium is typical&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The potential of light to produce ocular damages has been well known for millenia&#46; In recent decades&#44; the appearance of a new entity &#40;laser pointer maculopathy&#41; and the development of optical coherence tomography have again brought this pathology into the limelight&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The first form of described photic maculopathy is solar maculopathy because for thousands of years sunlight was the only available light and on many occasions said maculopathy broke out in epidemics due to the observation of solar eclipses&#46; The first description of said pathology was made by Bonetus&#44; a Swedish physician&#44; who described it in the 17th century&#46;<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Apparently&#44; the oldest recorded total solar eclipse occurred in ancient Egypt&#44; dated October 30&#44; 1207 BC&#46; This eclipse was also mentioned in the Bible and may have had significant consequences in the ancient world&#46; Since then&#44; this astronomical event has been recorded on many occasions&#46; According to popular belief&#44; a full solar eclipse is a rare and infrequent occurrence&#44; but this is not so because every 18 months a full solar eclipse takes place in some part of the planet&#46; Partial eclipses&#44; i&#46;e&#46;&#44; when the moon does not entirely hide the sun&#44; occur at least twice a year somewhere on the surface of the Earth&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">However&#44; due to the very nature of eclipses&#44; the small size of the moon&#39;s shadow on the Earth surface and the specific alignment of the planets involved&#44; a full solar eclipse occurs on the same area of the Earth very infrequently&#44; with an average of approximately 375 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0495"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Since the 19th century&#44; pathologies caused by exposure to light have evolved together with technology&#46; In the first years of the 20th century&#44; damage caused by welding equipment was described <span class="elsevierStyleItalic">&#40;welders arc maculopathy&#41;</span> and photic maculopathy reached a new dimension as an occupational hazard&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the decade of the 1940s&#44; the first animal models were developed for studying cellular and tissue damage caused by exposure to nuclear blast radiations&#46; At that time&#44; a new in-depth understanding was obtained about the complex mechanisms by means of which light damages tissues&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">More recently&#44; a novel technological development has brought photic damage into the limelight once again&#46; The first cases of laser-induced maculopathy were reported as labor accidents in military&#44; industrial or laboratory environments&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">6</span></a> However&#44; in the past 2 decades the extension of laser technology took laser devices into the homes and hands of children and teenagers&#46; The inevitable consequence was an increase in the number of retinal lesions caused by laser beams&#46; This is particularly relevant because this form of photic maculopathy is more severe than solar-induced maculopathy and affects young children with greater frequency&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The objective of this review is to provide a comprehensive overview of the various types of photic maculopathy&#46; Searches for this review were conducted in Pubmed utilizing the following algorithms&#58; &#8220;photic maculopathy&#8221; or &#8220;solar maculopathy&#8221; or &#8220;eclipse maculopathy&#8221; or &#8220;welding maculopathy&#8221; or &#8220;laser pointer maculopathy&#8221; or &#8220;handheld laser maculopathy&#8221; or &#8220;lightning maculopathy&#8221; or &#40;welder and macula&#41; or &#40;welder and retina&#41; or &#40;&#8220;arc welding&#8221; and macula&#41; or &#40;&#8220;arc welding&#8221; and retina&#41; or &#40;eclipse and retina&#41; or &#40;eclipse and macula&#41;&#46; Said algorithm produced 173 articles&#46; The references of said articles were utilized to increase the search&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Solar retinopathy&#58; photic maculopathy secondary to exposure to sunlight</span><p id="par0045" class="elsevierStylePara elsevierViewall">Since ancient times it has been known that direct exposure to sunlight could damage eyesight&#46; Sources from ancient Greece and Rome reported that even indirect observation of a solar eclipse through water or a mirror could produce blindness&#46; Some authors reported that one of the most severe punishments in the past consisted in exposing victims to high intensity light with the aim of leaving them blind&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">7</span></a> Even though it cannot be proved&#44; it has been suggested that Galileo Galilei might have endured visual loss secondary to the observation of the Sun&#46;<a class="elsevierStyleCrossRefs" href="#bib0515"><span class="elsevierStyleSup">8&#8211;10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The first cases of photic maculopathy described in modern times were also secondary to the observation of the Sun&#44; usually solar eclipses&#44; and for this reason the terms &#8220;solar retinopathy&#8221; and &#8220;eclipse retinopathy&#8221; were applied indistinctly&#46; Another term applied in this context is &#8220;foveomacular retinitis&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">11</span></a> This confusing term was applied to refer to the pathology of patients with morphological changes and clinic compatible with photic maculopathy without documenting exposure to light that could explain the presence of said lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">12&#8211;14</span></a></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Epidemiology</span><p id="par0055" class="elsevierStylePara elsevierViewall">It is difficult to assess the prevalence of solar retinopathy in the general population&#46; In relation to the observation of eclipses&#44; said pathology could sometimes exhibit epidemic proportions with low prevalence and peaks of outbreaks matching astronomical events&#46; Epidemics have been reported involving hundreds of individuals such as the epidemic described by Patel and Bavishi<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">15</span></a> in India in 1990&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the main published series&#46; However&#44; the majority of articles refer individual cases or small series&#46;<a class="elsevierStyleCrossRefs" href="#bib0555"><span class="elsevierStyleSup">16&#44;17</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">Some fruitless attempts were made to assess the incidence of photic maculopathy&#46; Kabra<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">18</span></a> analyzed 42 patients who in 1980 had observed an eclipse in India&#46; Only one exhibited retinal impairment&#46; Other authors attempted to calculate incidence by counting affected individuals by means of <span class="elsevierStyleItalic">ad hoc</span> questionnaires given to people who had watched an eclipse&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">19</span></a> However&#44; it is impossible to determine the number of actually exposed individuals&#44; which probably involves a significant imprint diagnosis because it is likely that individuals with only one impaired eye will not visit an ophthalmologist&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">If it is not possible to establish incidence&#44; not even after a well-defined event such as an eclipse&#44; it is even more difficult to determine prevalence&#46; When a patient exhibiting said pathology is assessed by an ophthalmologist in the chronic phase&#44; it is difficult to make a diagnostic&#46; For these reasons&#44; prevalence or incidence data are not reliable&#46; Stokkermans and Dunbar<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">20</span></a> found an incidence of 0&#46;14&#37; in patients who visited seeking unspecialized ophthalmic care&#46; In a series of predominantly male &#40;75&#37;&#41; and middle-aged patients &#40;mean 43<span class="elsevierStyleHsp" style=""></span>years of age&#41;&#44; 80&#37; exhibited antecedents consistent with photic retinopathy&#44; in 80&#37; of cases due to solar exposure and 50&#37; due to the use of welding equipment without adequate protection&#46; In 15&#37; of cases&#44; patients had consumed psychotropic substances and 5&#37; exhibited psychiatric pathology&#46; In addition&#44; 40&#37; of patients exhibited lesions in both eyes&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">It is likely that individual susceptibility plays a significant role and that the threshold is different in each individual&#46; Long exposures centered on the fovea&#44; pupil dilatation&#44; repeated exposure and the use of telescopes have also been associated to higher risk&#46; In addition&#44; pigmentation&#44; transparency and temperature could also play a role &#40;greater risk in hypothermia situations induced by exercise or fever&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">It appears that short exposure times can also cause damages&#46; Chang and Cavuoto<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">21</span></a> recently published the case of a girl who developed said complication after solar exposure of only one minute&#46; An acute pathology is described in the literature with greater frequency&#44; as well as cases related to chronic exposure to the sun&#46;<a class="elsevierStyleCrossRefs" href="#bib0585"><span class="elsevierStyleSup">22&#44;23</span></a> Said chronic forms would be similar to those reported as &#8220;professional welder disease&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">24</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Eclipse-induced photic maculopathy is generally bilateral but frequently asymmetric&#44; unfortunately causing more severe damage in the dominant eye&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">11</span></a> Kamali et al&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">25</span></a> found that the right eye is more frequently affected&#44; above all when the eclipse is observed through a handheld object considering that the majority of people are right-handed&#46; As with the majority of traumatic pathology&#44; this entity more frequently affects young males who are more accident prone and have greater lens transparency and larger pupil diameter&#46;<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">26</span></a> It seems that&#44; in addition to optical transparency&#44; refractive error could play a role&#44; with risk being higher in emmetropics and moderately farsighted individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">11</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">After studying an epidemic among the US military population in Hawaii&#44; Penner and McNair<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">27</span></a> concluded that some meteorological factors such as the height of the Sun&#44; the type of eclipse &#40;total or partial&#41; and the amount of clouds could play a role in the probability and severity of damages&#46; It has also been speculated that risk could be higher in regions with greater transmissibility of ultraviolet-B radiation&#46;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">11&#44;23</span></a> Yannuzzi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">3</span></a> reported 10 photic retinopathy cases in patients who had sunbathed without looking directly at the Sun in the northern United States&#46; After requesting information from several federal US agencies to analyze geophysical variables&#44; said authors reach the conclusion that the damages could have been caused by increased ultraviolet radiation levels due to diminished ozone levels&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Solar retinopathy has also been described in individuals gazing at the Sun for long periods of times without an eclipse&#44; known as <span class="elsevierStyleItalic">sungazers</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">23</span></a> This strange behavior seems to be linked to mental disorders&#44; religious ceremonies<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">28&#44;29</span></a> or the use of psychotropic drugs&#44; some of which have midriatics and possibly photosensitizing effects&#46; Accordingly&#44; it has been speculated that some drugs could produce increased sensitivity and diminish sensitivity thresholds in individuals&#44; although this has not been demonstrated&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">23</span></a> As discussed above&#44; said entity has exceptionally been described in sunbathers&#44;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">30&#44;31</span></a> also among military personnel watching the sky with prismatics during long periods of time&#44;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">25</span></a> in mountain climbers due to solar reflection in the snow&#44;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">22</span></a> or in sailors watching sunsets at sea&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pathogeny</span><p id="par0095" class="elsevierStylePara elsevierViewall">The design of the eye allows the retina to receive radiance 100&#44;000 times higher than that received by the cornea&#46;<a class="elsevierStyleCrossRef" href="#bib0635"><span class="elsevierStyleSup">32</span></a> Initially&#44; thermal damage was proposed as the main mechanism&#44; according to which the retina would &#8220;burn out&#8221; in the same way a paper burns under a focused magnifying glass&#46; However&#44; nowadays we have evidence allowing us to reject this theory&#46; The increase of temperature produced by solar exposure is estimated to be only of 2<span class="elsevierStyleHsp" style=""></span>&#176;C&#44; while the denaturation of proteins would require a temperature increase of at least 10<span class="elsevierStyleHsp" style=""></span>&#176;C&#46;<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">1&#44;33</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The author of the theory proposing that the damage occurs due to non-thermal mechanisms is Vos&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">34</span></a> In 1962&#44; he published an article proposing for the first time that a non-thermal mechanism could account for said damages&#46; The article developed a mathematical model to determine the critical amount necessary to induce protein coagulation and the formation of water steam&#44; and concludes that this threshold is not reached&#44; therefore proposing metabolic poisoning&#44; i&#46;e&#46;&#44; that metabolic acceleration induced by exposure to light produces toxic metabolites that cannot be removed from tissue&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">In 1966&#44; Noell et al&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">35</span></a> described phototoxicity as the main mechanism in rats&#44; and shortly thereafter confirmed this theory in primates&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">At present&#44; 3 types of light-induced retinal damages have been identified&#46; These are summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0115" class="elsevierStylePara elsevierViewall">The experiments carried out by Noell et al&#46;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">35</span></a> in rats in which hyperthermia increased and accelerated phototoxicity suggest that the thermal mechanism could increase photochemical damages&#46; However&#44; there is still a lot to be understood&#46; The fact is that millions watch eclipses every year&#44; frequently without adequate protection&#44; and only a few develop solar retinopathy&#46; Yannuzzi et al&#46; published a number of articles developing a multivariate model in an attempt to explain said paradox&#46; Said model includes individual susceptibility as well as geophysical factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">2&#44;3&#44;36</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Animal models</span><p id="par0120" class="elsevierStylePara elsevierViewall">Doubtlessly&#44; the technological development which most increased the understanding of photic maculopathy is optical coherence tomography &#40;OCT&#41;&#44; before which our understanding was very limited due to the necessity of histological studies&#44; which meant that the majority of research was carried out in animals&#46; Some authors reported cases in which a human eye to be enucleated due to a tumor was intentionally submitted to extended exposure to light in order to subsequently carry out a histological study of its effect on the retina&#46;<a class="elsevierStyleCrossRefs" href="#bib0660"><span class="elsevierStyleSup">37&#44;38</span></a> The various animal models developed in the course of the 20th century are discussed below&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The first studies were carried out in rabbits in the 50s&#44; in the context of the first nuclear tests&#46; These experiments consisted in placing and alarm to wake up rabbits one second before the nuclear blast&#46; The animals were located at different distances from the site and were subsequently sacrificed to study the effect of the intense light on the retina&#46; The conclusion was that damages were induced mainly by a thermal and photodisruptive mechanism&#46; Exposure to an extremely high amount of heat in a few milliseconds causes water in tissue to boil and to coagulate proteins and producing tissue cavitation&#46;<a class="elsevierStyleCrossRefs" href="#bib0670"><span class="elsevierStyleSup">39&#44;40</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">A new animal model was developed in the 70s&#46; Indirect ophthalmoscopy was utilized to project light continuously on the retina through a 20-diopter lens&#46; This new model demonstrated that the application of low intensity light for extended periods of time can also induce damage&#46; However&#44; in these experiments damages would not be due to thermal mechanisms&#44;<a class="elsevierStyleCrossRefs" href="#bib0680"><span class="elsevierStyleSup">41&#8211;43</span></a> although they demonstrated the appearance of retinal edema followed by disorganization of pigment epithelium photoreceptors&#44; and finally the repair and reorganization of both&#46;<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">42</span></a> This regenerative capacity would explain the positive prognosis demonstrated in several series studying eclipse-induced retinopathies&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Pathological anatomy</span><p id="par0135" class="elsevierStylePara elsevierViewall">In 1974&#44; Tso et al&#46; published studies based on <span class="elsevierStyleItalic">Rhesus</span> monkey animal models&#46; After 2<span class="elsevierStyleHsp" style=""></span>h of exposure to indirect ophthalmoscopy light projected through a 20-diopter lens&#44; damage was mainly located in photoreceptors and these cells have the ability to regenerate provided that the nucleus is not compromised&#46;<a class="elsevierStyleCrossRefs" href="#bib0680"><span class="elsevierStyleSup">41&#44;44</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">In the following years&#44; said findings were replicated in human beings&#46; In 1975&#44; Tso and La Piana published a series of 3 patients who were scheduled for enucleation for uveal melanoma and were asked to gaze at the sun during one hour&#46; Clinic evolution was analyzed in detail as well as macular histology after enucleation&#44; finding thickened Bruch membrane and necrosis of the retina pigment epithelium without significant compromise of photoreceptors&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">37</span></a> In 1993&#44; Hope-Ross et al&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">38</span></a> published a similar paper reporting that damages were mainly limited to the retina pigment epithelium with subtle alterations in external photoreceptor segments&#44; the nature of which were not explained&#46; The findings of both authors are contradictory because&#44; while Tso reported RPE necrosis&#44;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">37</span></a> Hope-Ross et al&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">38</span></a> found that RPE had very few alterations and reported swelling of external photoreceptor segments&#44; with fragmentation and vesiculation of discs&#46; The presence of swollen mitochondria was also demonstrated in said external segments&#44; which would support the theory of metabolic overload&#46;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">38</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">In 2000&#44; Bechmann et al&#46; published a letter reporting for the first time the usefulness of OCT for diagnosing said entity&#44; confirming <span class="elsevierStyleItalic">in vivo</span> that the findings seemed to be limited to the external retina&#46;<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">45</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Clinic</span><p id="par0150" class="elsevierStylePara elsevierViewall">Frequently&#44; presentation is bilateral but asymmetric&#44; with the dominant eye being more compromised&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">11</span></a> Patients generally refer blurred vision&#44; followed a few hours later by the appearance of scotoma&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">27</span></a> Some referred the perception of a point of light close to fixation<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">46</span></a> that preceded the appearance of scotoma or metamorphopsia&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">47</span></a> The appearance of color vision defects mainly affecting the blue-yellow line have been described&#46; This finding was related to the fact that the phototoxic effect of blue light is higher&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">47</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The majority of published cases focus almost exclusively on visual acuity &#40;VA&#41;&#46; The 3-case series published by Kamali et al&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">25</span></a> in 1975 includes a very detailed description&#46; In many cases&#44; the patient does not notice anything apart from a certain feeling of glare&#44; but shortly afterwards a sort of cloud is perceived associated to the appearance of afterimages&#44; photophobia and sometimes photopsia or chromatopsia &#40;visual perception with a stained shade&#41;&#46; Twenty-four hours after the event&#44; said cloud becomes more dense and turns into a scotoma that can remain during hours or weeks&#44; although it can also become permanent&#46; Scotoma can be absolute or relative&#44; in some cases being initially absolute and subsequently becoming relative&#46; Generally&#44; VA reduction is moderate &#40;in the area of 6&#47;12&#41; and metamorphopsia could appear&#44; initially due to the displacement of photoreceptors caused by edema and in later stages due to degenerative changes&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">25</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Exceptionally&#44; corneal compromise has been described in the form of superficial keratitis&#44;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">48</span></a> retina detachment without specifying the mechanism&#44;<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">49</span></a> central serous maculopathy&#44;<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">50</span></a> and choroidal folds<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">51</span></a> and a condition similar to placoid pigmented multifocal epitheliopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0735"><span class="elsevierStyleSup">52</span></a> Li et al&#46;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">53</span></a> described the case of a patient who developed epiretinal membrane&#46; Said author believed that the inflammation induced by phototoxic damage precipitated the appearance of said membrane in a 63-year-old patient&#44; that is a lot older than the majority of patients with said pathology&#46; Evolution toward macular hole is infrequent in solar retinopathy but relatively frequent in other more severe forms of photic retinopathy such as those produced by laser pointer beams&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Diagnostic</span><p id="par0165" class="elsevierStylePara elsevierViewall">Typically&#44; diagnostic was based exclusively on ocular fundus examinations&#44; which initially show a darker macula&#46; This is due to the congestion of the choroids&#46; Subsequently&#44; retinal edema adopts the appearance of a yellowish spot surrounded in many cases by a grayish area&#46; Some patients could also exhibit small hemorrhages&#46; This vitelliform lesion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; considered by Gass as pathognomic of photic maculopathy&#44; disappears to be substituted by a hypo-pigmented area&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">25&#44;53</span></a> Some authors described that in some cases an imprint in the form of the silhouette of the portion of the Sun that was not hidden by the moon can be observed in the ocular fundus<a class="elsevierStyleCrossRefs" href="#bib0745"><span class="elsevierStyleSup">54&#8211;56</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">For several decades&#44; fluorescein angiography &#40;FA&#41; was the gold standard for diagnosing said pathology&#46; Stain exudation can be observed during the acute phase in the injured area&#44; while in the chronic phase the appearance of a window effect defect is characteristic &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">37</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0175" class="elsevierStylePara elsevierViewall">The first description of the usefulness of OTC for diagnosing said pathology was published by Bechmann et al&#46;<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">45</span></a> in 2000&#46; The quasi-histological information provided by this technology has displaced FA as the most sensitive technique&#46;<a class="elsevierStyleCrossRef" href="#bib0760"><span class="elsevierStyleSup">57</span></a> Even first-generation time domain OCT devices demonstrated superiority against FA&#46; In an article published in 2009&#44; Jain et al&#46;<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">58</span></a> compared the diagnostic capacity of FA and <span class="elsevierStyleItalic">Stratus</span> OCT in 21 eyes affected by solar retinopathy&#46; The OCT device identified alterations in all patients&#44; although 2 of them did not exhibit the typical window defect&#46; The authors proposed that OCT could have a prognostic value&#46; The reduction of central macular thickness and the presence of total width cystic lesions under the fovea were associated to poorer levels of VA&#46;<a class="elsevierStyleCrossRefs" href="#bib0765"><span class="elsevierStyleSup">58&#44;59</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">The tomographic evolution of photic maculopathy is as follows&#58; in the acute phase&#44; hyper-reflective areas appear which are subsequently substituted by hypo-reflective cystic spaces&#46; Said cyst occupied the area corresponding to lost receptors&#44; usually adopting a rectangular shape&#46;<a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">60</span></a> Spectral domain OCT is considerably more sensitive than time domain OCT&#46;<a class="elsevierStyleCrossRef" href="#bib0780"><span class="elsevierStyleSup">61</span></a> It is frequent to find a disruption of the Verhoeff membrane &#40;the interdigitation zone between photoreceptors and the retinal pigment epithelium&#41;&#46; Usually&#44; disruption also occurs in the ellipsoid line &#40;between the internal and external photoreceptor segments&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0785"><span class="elsevierStyleSup">62</span></a> It seems that these small changes are present in all cases &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; In eyes with poor vision a disruption of the external nuclear layer and the external limiting membrane occurs even though it is not clear whether these are artifacts or actual damages&#46;<a class="elsevierStyleCrossRef" href="#bib0790"><span class="elsevierStyleSup">63</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0185" class="elsevierStylePara elsevierViewall">In the chronic phase&#44; a broad hypo-reflective area appears at the interface between the external and internal photoreceptor segments&#46; Even though this image is not pathognomic of the entity&#44; it is relatively specific&#46;<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">23&#44;64</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">Autofluorescence is highly sensitive for detecting this type of lesions&#46; It is based on the properties of natural fluorophores&#46; It is considered to originate mainly in the lipofuscin contained in the retina pigment epithelium cells&#46;<a class="elsevierStyleCrossRef" href="#bib0800"><span class="elsevierStyleSup">65</span></a> The characteristic pattern is the presence of small hypo-fluorescence areas surrounded by an uneven ring of hyper-fluorescence&#46; Autofluorescence is not as sensitive as OCT because&#44; in order to show relevant changes&#44; a window defect must be present in the retinal pigment epithelium&#46;<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">66</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">The autofluorescence technique in the near infrared could also be useful&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">29</span></a> Although it is still necessary to determine its reliability and reproducibility&#44; it could prove to be very useful in the future&#46; In this case&#44; autofluorescence originates in the melanin contained in the RPE and to a lesser extent in the choroids&#44; because RPE is probably one of the cell types that is primarily affected in this entity&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Scotoma produced by said entity are usually small and cannot be detected by conventional perimetry&#46; However&#44; numerous authors have reported the usefulness of microperimetry&#46;<a class="elsevierStyleCrossRef" href="#bib0810"><span class="elsevierStyleSup">67</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">In general&#44; electrophysiology contributes very little to the diagnostic of photic maculopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0815"><span class="elsevierStyleSup">68</span></a> Some articles have reported a reduction of central response amplitude in multifocal electroretinogram&#46;<a class="elsevierStyleCrossRefs" href="#bib0815"><span class="elsevierStyleSup">68&#8211;71</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Amsler grid is a classic test that enables the detection and follow-up of scotomae and metamorphopsia&#46;<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">72</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Some authors have demonstrated the existence of tritan-type defects &#40;dyschromatopsia in the blue-yellow axis&#41; in these patients&#46; This would suggest that the photochemical mechanism is probably the most important one because blue cones are more sensitive than red or green to shorter wavelengths&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">47</span></a> However&#44; this pattern could also be explained due to the existence of a smaller number of blue cones&#46;<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">47</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Differential diagnostic</span><p id="par0220" class="elsevierStylePara elsevierViewall">Even though Gass believed that photic maculopathy produces a pathognomic pattern&#44; the fact is that many entities could produce similar changes&#46; A series recently published by Raoof et al&#46;<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">73</span></a> discusses differential diagnostic of photic maculopathy secondary to laser beams&#46; Even though this form has a severe presentation&#44; in essence it is the same entity&#46; Said authors considered that a differential diagnostic includes so many entities that they define this entity as the &#8220;new simulator&#8221;&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">In the acute phase&#44; the appearance of a vitelliform lesion could give rise to a differential diagnostic with Best&#39;s disease because it also can produce external retinal disruption&#46; However&#44; in contrast with Best&#39;s disease&#44; photic retinopathy does not produce subretinal deposits&#46; Of course&#44; in the case of doubt EOG is a recourse&#46; In the acute phase&#44; differential diagnostic is easier because the patient is more likely to remember and recognize the exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">73</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">However&#44; in the chronic phase differential diagnostic could be much more complicated because the patient may not remember or admit solar exposure&#44; and the appearance of the retina is shared by many pathologies&#46; In the chronic phase&#44; differential diagnostic would include retinopathy due to tamoxifen &#40;although crystalline deposits would be present in the internal retina&#41;&#44; juxtafoveolar telangiectasiae &#40;that can be evidenced with FA&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#44; macular traction syndrome&#44; achromatopsia&#44; acute retinal epithelitis&#44; Stargardt&#39;s disease &#40;although&#44; in contrast with photic retinopathy&#44; this entity is progressive&#41; or the consumption of nitrites&#46;<a class="elsevierStyleCrossRef" href="#bib0775"><span class="elsevierStyleSup">60</span></a></p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0235" class="elsevierStylePara elsevierViewall">Photic retinopathy is the great simulator of retinal dystrophies&#46; Recently&#44; Zhang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0805"><span class="elsevierStyleSup">66</span></a> published a series of 5 children referred for genetic study due to suspected retinal dystrophy who finally had laser pointer maculopathy&#46; Photic maculopathy could &#8220;phenocopy&#8221; a retinal dystrophy coursing with a foveal gap&#44; such as rod monochromatism or Stargardt&#39;s disease&#46; Accordingly&#44; before initiating genetic study of possible retinal dystrophy a complete clinic history should be performed to discard said possibility as much as possible&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Prognosis</span><p id="par0240" class="elsevierStylePara elsevierViewall">Prognostic is good and considerably better for solar maculopathy than laser pointer maculopathy&#46; The majority of visual recovery occurs in the first weeks after exposure&#46;<a class="elsevierStyleCrossRefs" href="#bib0530"><span class="elsevierStyleSup">11&#44;17</span></a> This improvement is possible because even though primate cones and rods do not have reproductive capacity<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">58</span></a> they do have regenerative capacity&#44; which is possible provided that the nucleus of the cell is not damaged&#46;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">44</span></a></p><p id="par0245" class="elsevierStylePara elsevierViewall">In a series of 15 eyes of 15 patients who had suffered solar retinopathy in Sweden during an eclipse in 1999&#44; K&#228;llmark and Ygge et al&#46;<a class="elsevierStyleCrossRef" href="#bib0845"><span class="elsevierStyleSup">74</span></a> reported that most of the recovery occurred in the first 3 months&#46; A British series with 20 patients&#44; also published in 1999&#44; reported that only 4 perceived the presence of scotoma after 7 months&#46;<a class="elsevierStyleCrossRefs" href="#bib0850"><span class="elsevierStyleSup">75&#8211;77</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">It is likely that the prognosis of this entity has improved due to awareness raising campaigns&#46; However&#44; this subjective improvement contrasts with the presence of irreversible alterations in the external retina&#44; easily demonstrable with OCT&#46; The majority of patients will have a small defect in the ellipsoid zone&#46;<a class="elsevierStyleCrossRef" href="#bib0865"><span class="elsevierStyleSup">78</span></a> These sequels have been documented even 51 years after the initial exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0870"><span class="elsevierStyleSup">79</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">The appearance of long-term complications&#44; such as choroidal neovascularization&#44; seems to be low in eclipse-associated maculopathy but have been described with relative frequency after exposure to laser pointers and with significant frequency after exposure to YAG laser&#46;<a class="elsevierStyleCrossRef" href="#bib0875"><span class="elsevierStyleSup">80</span></a> As described above&#44; other complications have been described exceptionally such as the appearance of epiretinal membranes&#46;<a class="elsevierStyleCrossRef" href="#bib0740"><span class="elsevierStyleSup">53</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">It has been suggested that&#44; in addition to having a diagnostic value&#44; OCT also has a prognostic value&#46; VA is correlated with foveal thickness&#46;<a class="elsevierStyleCrossRef" href="#bib0765"><span class="elsevierStyleSup">58</span></a> Other authors have correlated VA with the tissue disruption pattern&#46; Two classifications have been proposed correlating the histological pattern with the prognostic&#46;<a class="elsevierStyleCrossRefs" href="#bib0770"><span class="elsevierStyleSup">59&#44;81</span></a> After examining 21 affected patients&#44; Gulkilik et al&#46;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">59</span></a> found that the involvement of the entire photoreceptor width is associated to poor prognosis&#46; They also found that eyes with cystic lesions in the external retina have a worse prognosis than eyes without said lesions&#46;<a class="elsevierStyleCrossRef" href="#bib0770"><span class="elsevierStyleSup">59</span></a> Jorge et al&#46;<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">81</span></a> differentiated 3 patterns and suggested that the prognostic is worse when the entire photoreceptor layer is compromised&#46;</p><p id="par0265" class="elsevierStylePara elsevierViewall">No articles have been published about the potential prognostic value of <span class="elsevierStyleItalic">in face</span> technology&#44; although it presumably has this potential because it is able to determine with great precision the area in which photoreceptors have disappeared as well as the existence of foveal compromise&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Treatment</span><p id="par0270" class="elsevierStylePara elsevierViewall">Even though the use of oral steroids have been proposed for this and other forms of photic maculopathy&#44; there is no scientific evidence that they can improve prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">25</span></a> Some authors have proposed consuming vitamin A and aspirin&#46;<a class="elsevierStyleCrossRef" href="#bib0820"><span class="elsevierStyleSup">69</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Prevention&#58; safe eclipse observation</span><p id="par0275" class="elsevierStylePara elsevierViewall">An eclipse is a highly infrequent event and nobody has sufficient experience regarding its safe observation&#46; Large amount of solar retinopathy cases have been described in patients utilizing spontaneous protection devices such as smoked glass&#44; dark plastic&#44; film negatives or compact discs&#46;<a class="elsevierStyleCrossRefs" href="#bib0640"><span class="elsevierStyleSup">33&#44;55</span></a> The truth is that it is difficult to assess the protective efficacy of a method because&#44; in order to achieve certainty the observer would have to gaze the eclipse 100&#37; of the time through the device&#44; and many patients referred using protective devices only part of the time&#46;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">19&#44;82</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall">Direct sungazing is an extreme risk for vision except during the short period of time of the total eclipse&#44; when the moon completely hides the surface of the Sun&#46; This only occurs during the short period of a total Sun eclipse&#46; The only safe way to gaze a non-eclipsed part of the Sun or a partial solar eclipse is through sunglasses specifically designed for this purpose or with handheld solar filters&#46; In any case&#44; said products should comply with the international ISO<span class="elsevierStyleHsp" style=""></span>12312-2<a class="elsevierStyleCrossRef" href="#bib0890"><span class="elsevierStyleSup">83</span></a> safety standard&#46; Home made filters or conventional eyeglasses&#44; even the dark ones&#44; are unsafe because they still allow an excessive amount of light to pass through&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> describes the instructions for safe observation utilizing solar glasses or handheld filters&#46;<a class="elsevierStyleCrossRef" href="#bib0895"><span class="elsevierStyleSup">84</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0285" class="elsevierStylePara elsevierViewall">The American Association of Astronomy &#40;AAS&#41;&#44; together with the National Science Foundation &#40;NSF&#41; of the United States&#44; include in their websites a list of companies and manufacturers of filters and sunglasses for watching eclipses which fulfill the above mentioned international safety roles&#46; Many of said companies have distributors throughout the world and are therefore easily accessible for the majority of the population&#46;<a class="elsevierStyleCrossRef" href="#bib0900"><span class="elsevierStyleSup">85</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">Probably&#44; one of the safest methods is the use of welding goggles that include specific filters&#46; Indirect observation projecting the eclipse through a &#8220;stenopeic hole&#8221; on a screen is very safe<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">25</span></a> and can be done making a small hole in a sheet of paper or using both hands&#46; Giving the back to the Sun&#44; the light that passes through the small hole is projected on the ground&#44; reproducing the shadow of the partially eclipsed Sun&#46; Another way to observe an eclipse is observing the shadow that forms when the eclipsed Sun passes through the leaves of a tree&#46; This shadow will comprise a large amount of solar crescents projected by the small spaces between leaves&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Arc welding maculopathy</span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Epidemiology</span><p id="par0295" class="elsevierStylePara elsevierViewall">The second form of described photic maculopathy is that produced by exposure to welding devices&#46; This entity was described by Terrien in 1902 who observed it in workers who were building the London underground&#46;<a class="elsevierStyleCrossRef" href="#bib0905"><span class="elsevierStyleSup">86</span></a> The most common lesion caused by exposure to welding devices is actinic keratitis&#46; Retinal compromise is very infrequent&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">Difference methods can be associated to different risks&#46; Risk is particularly high with carbon dioxide arc welding&#46;<a class="elsevierStyleCrossRef" href="#bib0910"><span class="elsevierStyleSup">87</span></a> At present&#44; this pathology is highly infrequent at least in the Western world&#46; Some articles suggested that this occupational disease was more frequent in Eastern block countries during the communist era&#44;<a class="elsevierStyleCrossRef" href="#bib0705"><span class="elsevierStyleSup">46</span></a> and that the pathology is more frequent in countries having unsophisticated labor laws&#46;<a class="elsevierStyleCrossRefs" href="#bib0915"><span class="elsevierStyleSup">88&#44;89</span></a> A study carried out in Nigeria to assess the impact of this professional activity on ocular health reported that over half of the surveyed workers admitted to never using protection and the vast majority of the remaining half used protection only occasionally&#46;<a class="elsevierStyleCrossRef" href="#bib0915"><span class="elsevierStyleSup">88</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">It is surprising that no cohort study has been published to date assessing said occupational hazard&#46; A recent study carried out in China among 86 welders reported that photic maculopathy affected 32&#37; of workers&#46; The authors found a correlation between the duration of exposure&#44; the consumption of lutein and the use of protective measures&#46;<a class="elsevierStyleCrossRef" href="#bib0920"><span class="elsevierStyleSup">89</span></a> In contrast with eclipse-induced maculopathy&#44; the subject of a significant amount of small series&#44; virtually all studies on welders maculopathy refer to individual cases&#46; Even though said entity has been regarded as a professional disease&#44; the diminished price of these devices have made them available to the general public&#44; to the point that some phototoxicity cases were reported among welding enthusiasts&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">7&#44;72</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">Acute toxicity caused by exposure to welding is very rare&#46;<a class="elsevierStyleCrossRef" href="#bib0925"><span class="elsevierStyleSup">90</span></a> However&#44; some cases have been described after exposures as short as 30<span class="elsevierStyleHsp" style=""></span>s&#46;<a class="elsevierStyleCrossRef" href="#bib0930"><span class="elsevierStyleSup">91</span></a></p><p id="par0315" class="elsevierStylePara elsevierViewall">Retinal toxicity secondary to chronic exposure is more frequent&#44; with some authors believing that this is an underestimated occupational hazard&#46;<a class="elsevierStyleCrossRef" href="#bib0935"><span class="elsevierStyleSup">92</span></a> In fact&#44; in a recent case-control study&#44; Yang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">24</span></a> demonstrated the presence of macular changes in 3 out of 80 studied eyes of professional welders in the region of Guangzhou &#40;China&#41;&#46; This high incidence of 38&#37; can be explained due to the high sensitivity of OCT for detecting subclinic damages&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">Phototoxic maculopathy is not recognized as an occupational hazard in the majority of countries&#44; probably because in most cases damages are subclinic&#46; In fact&#44; the authors of the above-mentioned series did not demonstrate significant VA differences between welders and controls&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">24</span></a></p><p id="par0325" class="elsevierStylePara elsevierViewall">Radiations emitted by said devices expand through a broad spectrum&#44; from infrared to beyond ultraviolet&#46; Exposure to ultraviolet is regarded as responsible for actinic keratitis&#44; whereas exposure to longer wavelengths produces photochemical damages in the retina&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Clinic</span><p id="par0330" class="elsevierStylePara elsevierViewall">Acute toxicity due to exposure to welding is very rare&#46;<a class="elsevierStyleCrossRef" href="#bib0925"><span class="elsevierStyleSup">90</span></a> Most articles report cases produced by chronic exposure&#46; Even though retinal changes are not infrequent&#44; they usually course with hardly any repercussion on the visual function&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">24</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Diagnostic</span><p id="par0335" class="elsevierStylePara elsevierViewall">Diagnostic considerations are not significantly different in comparison to other forms of photic retinopathy&#46;<a class="elsevierStyleCrossRefs" href="#bib0825"><span class="elsevierStyleSup">70&#44;86&#44;92</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Prognosis</span><p id="par0340" class="elsevierStylePara elsevierViewall">Prognosis is good&#46; Many of the described cases had subclinic expression although severe cases have been described evolving into the formation of lamellar macular holes&#46;<a class="elsevierStyleCrossRef" href="#bib0925"><span class="elsevierStyleSup">90</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Treatment</span><p id="par0345" class="elsevierStylePara elsevierViewall">As in other forms of photic maculopathy&#44; some authors administer systemic corticoids although the usefulness thereof is not demonstrated&#46;<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">7&#44;90</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Prevention</span><p id="par0350" class="elsevierStylePara elsevierViewall">Observation of labor laws is crucial&#46; As discussed above&#44; in less developed countries many workers admit to not using protection&#46;<a class="elsevierStyleCrossRef" href="#bib0915"><span class="elsevierStyleSup">88</span></a> However&#44; even in Western countries with highly developed labor legislations&#44; the implementation of these prevention measures is difficult&#46; Even though workers are advised to wear protection all the time&#44; the fact is that total protection is not possible because in some cases they must weld in areas with very little lighting<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">72</span></a> and in uncomfortable positions in which protection is difficult&#44; in addition to being inevitably exposed to the &#8220;friendly fire&#8221; of other workers&#46;<a class="elsevierStyleCrossRefs" href="#bib0595"><span class="elsevierStyleSup">24&#44;93</span></a></p><p id="par0355" class="elsevierStylePara elsevierViewall">It has been speculated that the use of vitamin A and aspirin could have protective effects&#46;<a class="elsevierStyleCrossRef" href="#bib0905"><span class="elsevierStyleSup">86</span></a> Similarly&#44; the use of medicaments such as fluphenazine should be avoided as they exhibit a potential effect that increases sensitivity to light&#46;<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">46&#44;94&#44;95</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Legal considerations</span><p id="par0360" class="elsevierStylePara elsevierViewall">Due to the sensitivity of OCT to identify photic damage&#44; it would probably be recommendable to carry out a macular OCT before individuals and start working as welders&#46;</p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusion</span><p id="par0365" class="elsevierStylePara elsevierViewall">Solar maculopathy is the oldest form of photic maculopathy&#46; In some cases it expresses as small epidemics related to the observation of solar eclipses although it can also be related to the consumption of drugs and religious ceremonies&#46; It was initially proposed that the lesion occurred due to thermal mechanisms&#44; but nowadays it is clear that photochemical mechanisms are probably the main culprits&#46; Some histological studies have been carried out in animals and also in humans scheduled for enucleation due to intraocular tumors&#46; It is believed that if the nucleus is not damaged&#44; photoreceptors have a degree of regenerative capacity&#46; This explains that some degree of recovery frequently occurs&#46; For a long time&#44; the gold standard in the diagnostic of this pathology was FA&#44; but now it has been clearly replaced by OCT&#46; The visual prognosis of solar maculopathy is good&#44; as the majority of patients recover most of the lost VA&#46; Some authors have utilized corticoids for treating this entity&#44; without scientific evidence supporting this treatment&#46;</p><p id="par0370" class="elsevierStylePara elsevierViewall">Maculopathy associated to the use of welding devices is an infrequent entity&#44; at least in more developed countries&#46; On many occasions&#44; OCT reveals morphological changes in welders but these do not usually compromise VA&#46; From the diagnostic viewpoint&#44; welders maculopathy is not different to solar maculopathy&#46; There is no treatment but it is recommendable to advise these patients to avoid the use of medicaments that have the potential of increasing sensitivity to light&#46;</p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Funding</span><p id="par0375" class="elsevierStylePara elsevierViewall">The research for this review has not received any specific ground from agencies of the public&#44; commercial or nonprofit sectors&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conflicts of interest</span><p id="par0380" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Solar retinopathy&#58; photic maculopathy secondary to exposure to sunlight"
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            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Epidemiology"
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              "titulo" => "Animal models"
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              "identificador" => "sec0030"
              "titulo" => "Pathological anatomy"
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              "titulo" => "Clinic"
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              "titulo" => "Prevention&#58; safe eclipse observation"
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          "titulo" => "Arc welding maculopathy"
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          "titulo" => "Conclusion"
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    "fechaRecibido" => "2018-04-21"
    "fechaAceptado" => "2018-06-30"
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            0 => "Photic maculopathy"
            1 => "Solar maculopathy"
            2 => "Eclipse maculopathy"
            3 => "Arc welding maculopathy"
            4 => "Handheld laser maculopathy"
            5 => "Macular dystrophy"
          ]
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          "palabras" => array:6 [
            0 => "Maculopat&#237;a f&#243;tica"
            1 => "Maculopat&#237;a solar"
            2 => "Maculopat&#237;a por eclipse"
            3 => "Maculopat&#237;a por dispositivos de soldar"
            4 => "Maculopat&#237;a por puntero l&#225;ser"
            5 => "Distrofia macular"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The human retina&#44; as transducer of light energy&#44; is especially exposed to light toxicity&#46; Solar maculopathy has been the only form of photic maculopathy for millennia&#44; often secondary to the observation of an eclipse&#46; During the last century&#44; technological advances have led to the appearance of new forms of photic maculopathy&#44; related to the exposure to new forms of artificial light&#44; such as welding devices and lasers&#46; In recent years&#44; the general use of laser pointers has led to an upturn in interest in this pathology&#46; The aim of this review is to offer an integrated view of the different types of photic maculopathy&#46; Due to the extension of this topic&#44; the review is presented divided into two parts&#46; In this first part solar maculopathy and welding arc maculopathy are presented&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La retina humana&#44; como tejido transductor de la energ&#237;a lum&#237;nica&#44; est&#225; especialmente expuesta a la toxicidad inducida por la exposici&#243;n a la luz&#46; La maculopat&#237;a solar ha sido durante milenios la &#250;nica forma de maculopat&#237;a f&#243;tica&#44; muchas veces en relaci&#243;n con la observaci&#243;n de un eclipse&#46; Durante el &#250;ltimo siglo los avances tecnol&#243;gicos han conducido a la aparici&#243;n de nuevas formas de retinopat&#237;a f&#243;tica&#44; en relaci&#243;n con la exposici&#243;n a nuevas formas de luz artificial como los dispositivos de soldar o emisores de l&#225;ser&#46; En los &#250;ltimos a&#241;os la generalizaci&#243;n del uso de punteros l&#225;ser ha hecho que repunte el inter&#233;s por esta patolog&#237;a&#46; El objetivo de esta revisi&#243;n es ofrecer una visi&#243;n integrada de los diversos tipos de maculopat&#237;a f&#243;tica&#46; La revisi&#243;n se presenta dividida en dos partes&#44; debido a la extensi&#243;n del tema tratado&#46; En esta primera parte se trata la maculopat&#237;a solar y la maculopat&#237;a producida por exposici&#243;n a los dispositivos de soldar&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Gonz&#225;lez Mart&#237;n-Moro J&#44; Hern&#225;ndez Verdejo JL&#44; Zarallo Gallardo J&#46; Maculopat&#237;a f&#243;tica&#58; revisi&#243;n de la literatura &#40;I&#41;&#46; Arch Soc Esp Oftalmol&#46; 2018&#59;93&#58;530&#8211;541&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Vitelliform lesion that appeared several days after exposure&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Lesion reproducing the shape of the Sun that is not hidden by the moon&#46; Image shown with the authorization of Sutter et al&#46;<a class="elsevierStyleCrossRef" href="#bib0755"><span class="elsevierStyleSup">56</span></a></p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">FA&#46; During the chronic phase the presence of window defects translating the atrophy of the retinal pigment epithelium is typical&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Changes in OCT during the chronic photic maculopathy phase&#44; showing the way in which the interruption of the retinal strata affects the retinal pigment epithelium&#44; the Verhoeff line &#40;interdigitation of the retina pigment epithelium and photoreceptors&#41; and the photoreceptor integrity line &#40;joining of the external and internal photoreceptor segments&#41;&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Even though Gass initially proposed that the image was pathognomic&#44; numerous dystrophies could simulate this pattern&#46; The image shows idiopathic macular telangiectasia exhibiting a similar image&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author&#44; publication date&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Date of eclipse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46; of eyes&#47;no&#46; of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Conclusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kabra&#44; 1982&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16-02-1980&#46; Hyderabad&#44; India&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">84 eyes&#59; 42 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Only one solar retinopathy case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Penner&#44; 1966&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4-02-1962&#44; Hawaii&#44; USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">52 eyes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Only in 3 eyes the visual prognostic was worse than 20&#47;50&#46; The dominant eye is more compromised&#46; Many homemade devices do not provide sufficient protection for observing eclipses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Jain&#44; 2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Does not match a specific eclipse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21 eyes&#59; 11 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OCT is more sensitive than retinography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">K&#228;llmark&#44; 2005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11-08-1999&#46; Stockholm&#44; Sweden&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15 eyes&#59; 15 patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Significant improvement in 14 out of 15 cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Main solar retinopathy series&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Class&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Wavelength and pigment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Mechanism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Situations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 1<br>Thermal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The entire spectrum&#46;<br>Melanin<br>Almost immediate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Heat is generated faster than it can be dissipated&#46;<br>Protein denaturation and coagulation&#46;<br>In extreme cases&#44; tissue vacuolization due to formation of water steam&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Laser Argon and Krypton&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 2<br>Photochemical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Blue light<br>Rhodopsine<br>Hours of delay&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No heating&#46; Damage occurs at the molecular level due to oxidation &#40;proteins and nucleic acids&#41;&#46;<br>Mechanism equivalents to that of Sun damages on skin&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Very important mechanism in various forms of photic maculopathy&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Class 3<br>Photodisruption&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mechanical&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fast absorption preventing dissipation of energy&#46; Tissue is disintegrated in ions and electrons &#40;plasma&#41;&#46; The formation of water steam contributes to cavitation&#46;<br>Not dependent on pigmentation&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Laser YAG&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Inspect the sun filder before use&#46; If folds&#44; scrapes or other damages are found&#44; do not use&#46; In addition&#44; read and follow the printed instructions on the filter packaging&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Always supervise children while they use the filters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; If using ammetropia corrective spectacles do not remove them&#44; placing the filters over them or maintaining the hand filter in front of the spectacles&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Never gaze at the uneclipsed part of the Sun&#44; or a partial eclipse through an unfiltered photo camera&#44; telescope or binoculars&#46; Also&#44; do not gaze at the Sun through said devices with filters in place because the concentration of energy amplified by optical devices could damage the eyes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; When the eclipse is total&#44; it is possible to gaze without the filters&#44; but when the Sun begins to emerge place the filters in front of the eyes to watch the partial eclipse phases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; If the &#8220;eclipse goggles&#8221; or filters are not damaged they can be reutilized many times as they do not &#8220;wear out&#8221;&#46; In fact&#44; reuse is included in the update of the ISO 12312-2 standard adapted in 2015&nbsp;\t\t\t\t\t\t\n
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