Preventing Eye Injuries From Light and... : Journal of Cutaneous Medicine and Surgery (2025)

Patient Screening and Informed Consent

During an initial consultation with a patient seeking to undergo a light or laser-based procedure, a thorough medical history should reveal any preexisting ocular conditions or visual deficits. If present, these should be documented appropriately. It has not been routine practice to test visual acuity prior to a laser procedure because of the rarity of laser eye injuries when appropriate eye protection is worn. Though in theory laser operators may choose to document baseline visual acuity before the procedure, there are no formal guidelines that recommend this extra step.

As is standard practice before proceeding with any medical intervention, patients should be fully informed about the common and most serious potential side-effects and/or adverse events associated with light and laser-based procedures. This discussion should be specific to the device used, highlight the expected recovery (e.g., experiencing pain, swelling and erythema in the case of vascular laser) and review potential complications. Though rare, the risk of severe ocular injury including blindness must be addressed and included on the informed consent form. This risk is mitigated by using appropriate eye protection, and as such the need for the patient to keep their protective eyewear on at all times is critical and should be emphasized during the informed consent process.

Clinical Environmental Considerations

The environment in which light and laser-based procedures are performed must be tailored to safeguard against potential laser-induced ocular injuries. Ideally, the laser device will be used in a dedicated procedure room that has been thoughtfully designed to minimize and protect against direct, reflected, and/or scattered radiation exposure. Before discussing the specific safety measures that should be implemented within the treatment room, there are some important safety considerations for those outside of the treatment room that need to be addressed. Firstly, steps must be taken to ensure that no one enters the room while the laser is in use. This is accomplished using regulated entryway signage that displays the safety alert symbol, a signal word such as “warning” or “danger”, the laser safety symbol, the class of laser, as well as text specifying the risks and need for eye protection. An LED “Laser in Use” sign may also be utilized. All office staff should be notified to look for the presence of these signs and to knock/wait to be invited in before entering any treatment room that may be in use. Secondly, windows and doorframes are potential portals for the escape of laser radiation beyond the controlled treatment room. As such, window and door covers that block transmission of radiation may need to be installed based on a risk assessment of the wavelength(s) in use. ^, In such cases, care must be taken to ensure that the blocking material has a sufficiently high attenuating optical density and damage threshold for direct and scattered radiation exposure. Furthermore, the material should not be flammable and should not release toxic airborne particles upon radiation exposure.

Within the treatment room there are several factors that warrant consideration to decrease the chances of ocular injury. To begin with, the size of the treatment room needs to accommodate the presence of all necessary operating equipment and personnel. The laser operator must be able to easily move around the patient during treatment such that the laser device can be optimally directed over the desired treatment area(s). Importantly, the patient’s protective eyewear should never be removed due to an inability of the laser operator to position themselves for treatment of a particular area of skin. Similarly, the safety eyewear selected by the laser operator and the room lighting conditions must afford sufficient visual acuity such that there is no temptation/need to remove the eyewear for better treatment-field visualization. This is discussed further in the sections on selecting appropriate eye protection. Unfortunately, there are multiple reports of serious ocular injury because of inappropriate intra-procedure protective eyewear removal, underscoring the importance of this safety consideration. ^, Next, the materials comprising all the flooring, cabinetry, hardware, furniture, and equipment (e.g., Mayo stand) within the room must be nonreflective. ^- Direct viewing of a beam or its reflection can result in ocular injury, even with eye protection in place. As such, the presence of smooth, shiny, flat and/or curved surfaces that function like mirrors must be minimized. This includes any jewelry that may be worn by the patient or clinical staff, which should be removed and stored appropriately prior to the laser procedure. Furthermore, the room should be equipped with all the different types of eye protection for patient and staff that may be required based on the device in use and must be clearly identifiable. This will be discussed further below when addressing selection of protective eyewear. Another important consideration for high energy devices is the risk of fire. Particularly in the case of ablative lasers, which pose the greatest flammability risk, a fire extinguisher should be easily accessible and the proximity of alcohol-based solutions, dry drapes or dressings, and other flammable materials should be monitored. Finally, a detailed hardcopy of the standard operating procedures outlining the above safety considerations should be stored inside the treatment room. This document should be reviewed and updated at regular intervals to ensure that all staff operating within the room are familiar with the required steps to maintain safety for all.

Operator Considerations

Despite the existence of widely accepted laser safety standards to guide best practice, such as the International Electrotechnical Commission (IEC) and the American National Standards Institute (ANSI) guidelines, there is no globally accepted and enforced training or certification body that provides oversight for laser operators. ^- As such, facility medical directors are responsible for establishing a standard operating procedures manual from which their extenders and staff should be appropriately trained. All laser operators, along with any staff that will be present in the treatment room, need to be well-versed in laser safety and should be familiar with the ANSI guidelines. Completion of the required safety training should be documented and ideally should be repeated at regular intervals to ensure that staff do not forget or become complacent with laser safety measures.

As part of the above required laser safety training, there are a few salient operator considerations that must be highlighted regarding eye protection. Specifically, the laser delivery handpiece (which may emit invisible laser light) should never be looked at directly. By extension, the laser beam should never be aimed directly into a person’s eyes, even if they are equipped with protective eyewear. As a habit, the laser handpiece should be pointed towards the floor and away from all people when not in use in case it is unintentionally fired. Laser devices should also be put in stand-by mode during treatment interruptions. In addition, all staff must be aware of the laser wavelength(s) that will be in use so that they can don the appropriate protective eyewear. The specifics for selecting appropriate eye protection are discussed in the next section.

How to Choose Safety Eyewear for the Operator

Many of the laser and light-based devices used in cosmetic practice would fall under the Class 3B or Class 4 laser hazard classification scheme outlined by the American National Standards Institute (ANSI) in their ANSI Z136.1-2014 and Z136.3-2018 guidelines. ^, This means that they pose a hazard to the eyes and that eye protection is imperative for the operator of the laser, as well as any additional staff who will be present during the procedure. The specific laser hazard classification will be either listed on the device or within the operator manual and should be identified prior to using the device so that appropriate safety measures can be put in place.

To select the appropriate protective eyewear, the laser operator needs to know which wavelength(s) they intend to use and should have a basic understanding of the concept of optical density. Optical density (OD) is a measure of how much light at a specific wavelength is absorbed by the protective lenses and thus prevented from being transmitted to the eye. It is calculated using the formula , where τ is the transmittance of the specified wavelength. As an example, safety glasses with an optical density rating of 2 would have a transmittance of 0.01 or 1% for the specified wavelength(s). The optical density required for any given wavelength is determined by how much energy would need to be absorbed by the ocular structures to cause injury, i.e., the maximum permissible exposure (MPE). The optical density needs to be high enough to keep the energy of the transmitted light below this threshold. Thus, lasers that utilize higher fluences will ultimately require higher optical density lenses. The actual MPE calculations can be quite complex but are listed by wavelength and exposure duration for point, extended, UV and Far IR sources in the ANSI Z136.1-2014 guidelines.

In addition to optical density considerations, the laser operator will also need to assess how well they can see through the filtering lenses that have been selected. The more wavelengths within the visible light spectrum that are filtered out by the lenses, the poorer the visual acuity becomes, as measured by the visible luminous transmission (VLT). A VLT of 0% means that all visible light has been filtered out and the user cannot see anything. The ANSI guidelines recommend a minimum VLT of 20% to ensure that all staff can see well enough to operate within the laser treatment room safely.

Most of the commercially available healthcare laser systems already come with a set of appropriate safety eyewear and should list the minimum recommended optical density in the operator manual. Safety eyewear can also be purchased separately from suppliers who should explicitly identify that they have adhered to the safety standards outlined in the ANSI guidelines. Whether safety eyewear is already supplied, or independently purchased, several factors should be considered to ensure adequate eye safety. Firstly, the safety eyewear should be clearly marked with a label that specifies the optical density and the wavelength or range of wavelengths for which that optical density holds true. Secondly, if the laser operator plans to use multiple different wavelengths in a treatment session, care must be taken to ensure that the safety glasses are rated for all those wavelengths or are switched as needed between devices. This is especially critical when treatment rooms hold several lasers of different wavelengths that may require different sets of safety eyewear. Laser operators and any assistants/observers should inspect the eyewear label to confirm their wavelength protection prior to donning goggles. Verification of appropriate operator eye protection can be part of a pretreatment laser checklist. Thirdly, the safety glasses should be adjusted as necessary to ensure a good fit and adequate coverage over glasses such that they will not inadvertently shift during the procedure. Ideally, they should have side shields as well. Conveniently, some of the suppliers offer eyewear selection and fitment guides to assist with this. Finally, the filtering lenses should be inspected for any defects such as scratches, which may compromise the expected level of protection. If defects or poor fitment are noted, they should be replaced immediately. The user is also advised to follow the manufacturer recommended cleaning, storage, and replacement interval instructions for all protective eyewear.

How to Choose Safety Eyewear for the Patient

Most of the considerations outlined above for selecting protective eyewear for operators also apply to the selection of protective eyewear for the patient. However, there are several additional important factors to consider to ensure optimal safety conditions within the treatment room. Typically, patients are supplied with a pair of well-fitting, reusable, periorbital goggles that are placed over the closed eyelids. To decrease patient discomfort from exposure to bright light during facial procedures, these are often blackout goggles. The term “blackout” refers to the fact that this type of eyewear has a VLT of 0%. From a safety perspective, the main benefit to the use of periorbital goggles is the fact that the optical density of the materials used is independent of the incident angle of light exposure. This is very important as the patient will be exposed to various incident angles of reflected and scattered light from the laser device. In comparison, particularly if dielectric-coated, the wrap-around glasses worn by the operator may have an optical density that is exposure angle dependent, thus requiring the wearer to be looking directly at the treatment field for optimal protection. An important corollary of this is that it is generally not appropriate for patients to wear wrap-around glasses, especially when procedures occur on or near the face, as they will not be fully protected. Likewise, the periorbital goggle edges need to be fully in contact with the patient’s skin such that the eyes are not inadvertently exposed to light through gaps. To this end, silicone rims can help ensure a tight fit or disposable external eye shields that stick to the patient’s skin may be appropriate. The use of gauze underneath the periorbital goggles is not recommended due to the flammability risk with many lasers and possible decrease in overall goggle fitment. ^, For light and laser-based procedures that are not occurring on or near the face (e.g., laser tattoo removal on the arm), the patient may wish to wear safety glasses that permit them to see what is going on in the treatment room to decrease their anxiety. In this situation, the patient should be encouraged to look in the direction of the treatment to avoid incident laser light at the periphery of the goggle.

The material substance comprizing the periorbital goggles also warrants consideration. The light energy which is incident upon the protective eyewear will be transmitted, absorbed, reflected, and scattered to various degrees. Light energy that is absorbed can cause the material to heat up, which could result in thermal injury to the periorbital skin and damage to the protective eyewear. Now a rare occurrence, this was demonstrated prior to the implementation of more rigorous manufacturing standards, but should still be kept in mind when performing multiple pulses close to the protective eyewear. Today, the dyes used in some materials are still susceptible to saturable absorption, or photobleaching, after which optical density begins to decrease with an associated loss of protection. This decrease may be transient or permanent and seems to occur with some Q-switched and ultrashort pulses. The ANSI guidelines recommend evaluating the potential for saturable absorption for any laser eye protection that utilizes absorbing dyes prior to purchase. In addition to these absorption-related considerations, the risk of exposure to reflected light energy, particularly specular (mirror-like) reflections as described in the environmental considerations section, remains a concern. To decrease the risk of injury from harmful reflections originating from the patient’s goggles, the stainless steel from which they are generally constructed should not be shiny or smooth. Either an anodized brushed finish should be sought, or laser-safe stickers that also act to diffuse the incident beam should be applied as needed.

When to Use a Corneal Eye Shield

A corneal eye shield is a form of eye protection, shaped like a contact lens, that sits directly atop of the corneal surface. ^, Some models come with an attached handle for easier placement and removal from the ocular surface, while others come with a separate suction cup that can be attached when required. ^, They are generally comprised of nonreflective stainless steel to prevent specular reflections and to better withstand damage and temperature increases during laser and intense pulsed light procedures. ^,,, Even so, care must be taken to never aim the beam directly at the metal surface to avoid corneal burns. Likewise, plastic Plastic shields are also available and should be used for procedures that rely on radiofrequency (or any electrical current) as metal shields will conduct the electrical current and heat up considerably. ^, Plastic shields should not, however, be used for any laser treatments given their propensity to melt or combust upon exposure to laser energy, as demonstrated with the CO₂ and 1064 nm Nd:YAG lasers. ^, Before use, the anterior surface of the corneal shield should be examined for scratches that may compromise the nonreflective coating while the posterior surface and edges should be examined to ensure there are no defects that may result in corneal abrasions. ^,

There are no formal guidelines specifying at what treatment distance from the eye a corneal eye shield should be used instead of external “blackout” eye goggles. In practice, corneal eye shields are generally used when any laser or light-based treatments are occurring “near” the eyes, for instance when treating the upper eyelid or the lower eyelid where no underlying bony structures can be palpated. ^,, Laser operators must also consider the bulk of the device handpiece that is being used. Some case reports of laser eye injury highlighted that eye protection was sometimes removed or “pushed out of the way” to accommodate the laser handpiece. The safety compromise of this scenario is unacceptable, and this clearly represents a situation where a corneal eye shield should be placed.

Even with appropriate selection and placement of a corneal eye shield, care must be taken to minimize the risk of laser-induced ocular injury. This is especially relevant for the more deeply penetrating lasers functioning within the 755 nm to 1064 nm range, which account for the majority of reported ocular injuries. Of note, the 1064 nm Nd:YAG laser bears special consideration because of its deep optical penetration, affinity for both melanin and hemoglobin, as well as its invisible nature. This laser is best avoided within the orbit, even with an intraocular eye shield in place. In practice, if a lesion requiring the use of the 1064 nm Nd:YAG laser sits at the edge of the orbit, a stainless steel corneal shield should be placed and the periorbital skin should be stretched such that the lesion sits over bone before delivering a pulse of Nd:YAG laser. Importantly, the handpiece/laser-beam must always be directed away from the eye during pulse delivery. Alternative treatment options must also be carefully considered, as they may avoid the use of laser energy altogether.

How to Place a Corneal Eye Shield

Once the decision to use a corneal eye shield has been made, the next step is to determine the appropriate shield size for the patient. The commercially available corneal shields come in a variety of sizes, ranging from extra-small to large. A bedside assessment of the patient’s eye size and periorbital tissue laxity is required to judge which size is most appropriate. Ideal fitment would cover a large proportion of the globe without causing excessive stretching of the eyelid and therefore discomfort for the patient. Appropriate sizing and thorough inspection for defects will serve to minimize the risk of corneal abrasions.

It is important to recognize that patients may be considerably anxious about the process of corneal eye shield insertion. As such, it is helpful to walk the patient through the process so that they know what to expect. Specifically, topical anesthetic drops will first be applied. ^,,, These may sting and cause the eyes to tear temporarily. Next, a lubricant ointment will be applied to the inner surface of the corneal shield to help ensure a smooth insertion. ^, At this point, the patient should be instructed to look upwards. The lower lid is then held while the corneal shield is placed in the lower fornix. Patients can assist this maneuver by opening the mouth in an “O” shape, which stretches the lower eyelid skin. A slight rotation of the shield can then be performed to slide it underneath the upper eyelid at either canthi. Care must be taken not to apply too much pressure to the shield (and therefore the globe) during these steps. Once insertion is complete, make sure that the patient is comfortable. Well-placed corneal shields are comfortable and painless. Keeping patients at ease is important during corneal shield placement: successful and comfortable placement can be compromised if patients actively close the eye during the procedure.

Removal of the corneal eye shields occurs in a near-reverse fashion to that described above. Of note, the shield first needs to be tilted laterally to break the vacuum seal rather than trying to pull straight up, otherwise the removal process will be more difficult and uncomfortable. The shield may then be tilted upward to free the inferior aspect from underneath the lower lid before complete removal. It is generally more comfortable to hold the lower lid down to open the eye aperture for corneal shield removal. Finally, as the shields are reusable, it is important to follow the manufacturer’s instructions for cleaning and sterilization. As a note of caution here, the use of chlorhexidine solution on the shields should be strictly avoided due to its cytotoxic effects and risk of corneal injury. There is at least one reported incidence of bilateral corneal ulcers that occurred because an inadequately trained staff member rinsed the corneal shields in chlorhexidine solution immediately before placement. If rinsing of the corneal shields is required, the use of sterile saline or sterile water is recommended.

What to Do if You Suspect an Eye Injury

Despite best efforts to prevent ocular injury with appropriate eye protection use, there is still a small risk that accidental injury may occur. It is important for the treating clinician to have an approach to the management of this situation, should it arise. Ocular or periocular injury may be noticed by the patient during the procedure, but symptoms may only develop several hours or even days later. If at any point during the procedure the patient starts to complain of eye discomfort or pain, the treatment should be terminated immediately, and the patient should be examined to determine the cause. In general, patients should be instructed to contact the physician’s office if they develop worsening vision, ocular pain, or other worrisome periocular symptoms after leaving the clinic. In all cases of suspected laser-induced injury, the patient will need urgent assessment by an ophthalmologist to guide treatment depending on the type of injury they have sustained. Treatment may include topical antibiotics, topical steroids, eye patching, ongoing monitoring, or even surgical intervention. Physicians performing and supervising laser treatments should consider having an established contact to expedite the consultation process.

If a laser-induced ocular or periocular injury does occur in a patient or the laser operator/clinical staff, a thorough audit of the potential contributing factors should be undertaken once the situation has been acutely managed. Indeed, quality improvement assessments are imperative for refining clinical practice and preventing similar future occurrences. Where possible, case reports detailing the ocular injury that occurred, along with suggestions for improved practice, should be published to raise awareness amongst those using lasers in their own cosmetic practices.