Progress in the application of laser photocoagulation therapy in the treatment of pediatric retinal diseases

Abstract

This is a comprehensive review on the progress of laser photocoagulation therapy in the treatment of pediatric retinal diseases. The review begins by introducing the background and characteristics of pediatric retinal diseases, as well as the principles and mechanisms of retinal photocoagulation currently employed in clinical practice. Subsequently, the paper elaborates on the application of laser photocoagulation therapy in pediatric retinal diseases such as Retinopathy of Prematurity (ROP), Familial Exudative Vitreoretinopathy (FEVR), Coats' disease, Norrie disease, Incontinentia Pigmenti (IP), Morning Glory Syndrome (MGS), and Retinitis Pigmentosa (RP). Laser therapy has shown significant efficacy in slowing disease progression, improving visual function, and preventing severe complications. However, laser therapy also carries potential complications that require careful control of laser parameters during treatment. With advancements in technology and further clinical research, our understanding of the application of laser therapy in pediatric retinal diseases has deepened, but further research is needed to refine treatment protocols and enhance treatment effectiveness.

Introduction

Pediatric retinal diseases refer to a group of diseases that affect the structure and function of the retina in the pediatric population, including common retinal lesions and complex genetic and congenital developmental abnormalities. Pediatric retinal diseases often have insidious onset and diverse manifestations of lesions. Due to the special anatomical structure of the pediatric retina during growth and development, as well as differences in the pathogenesis, clinical manifestations, and outcomes of pediatric retinal diseases compared to those in adults, treatment principles for adult retinal diseases may not always be applicable to pediatric retinal diseases. In recent years, with deepening understanding of pediatric retinal diseases and updates in treatment techniques, the treatment efficacy of this category of diseases has also improved to a certain extent [1, 2]. Currently, the main treatment methods for pediatric retinal diseases include retinal cryotherapy, laser photocoagulation, intravitreal injection of anti-vascular endothelial growth factor (VEGF) drugs, vitreoretinal surgery, as well as Sub-Tenon and intravitreal steroid injections [3].

Among these, laser photocoagulation therapy, as a commonly used clinical treatment modality, has been widely studied for its application in various pediatric retinal diseases. This review aims to introduce the current progress of laser photocoagulation therapy in the treatment of pediatric retinal diseases.

Mechanism of retinal photocoagulation

Currently, there are various types of lasers used in clinical retinal photocoagulation procedures, including multi-wavelength krypton laser, 532 nm laser, argon laser, and 810 nm diode lasers. In pediatric retinal disease treatment, green (532 nm) and Infrared (810 nm) lasers are commonly employed due to their specific absorption characteristics and therapeutic advantages. The principles and effects of retinal photocoagulation therapy discovered so far include the following:

1. Retinal photocoagulation targets the ischemic regions of the retina to modulate the pathological production of VEGF, thereby preventing the progression of neovascularization and associated complications [4].

2. Retinal photocoagulation may compromise the external barrier capacity of the patient’s retinal pigment epithelium(RPE), leading to the dispersion of nutrients from the choroid to the retina, significantly altering the retinal nutritional status [5].

3. Retinal photocoagulation gradually reduces the oxygen consumption of the retina, directly damaging high-oxygen-consuming receptors, thereby transforming them into low-oxygen-consuming glial substances, providing oxygen support to residual tissues, significantly improving the patient’s blood circulation, and reducing leakage [6].

4. Retinal photocoagulation applies targeted laser energy to the retina, which can lead to alterations in the choroid and retinal barriers of the patient’s RPE cells. This process facilitates the transfer and absorption of fluid from the RPE to the choroidal capillaries, thereby modulating the microenvironment and potentially reducing fluid leakage [7].

5. Retinal photocoagulation has the effect of controlling the expansion of capillaries and microaneurysms, reducing vascular permeability, and effectively alleviating retinal edema [8–10].

nm Green laser (frequency-doubled Nd: YAG )

This wavelength is preferentially absorbed by hemoglobin and the RPE. Its high precision allows for targeted ablation of abnormal vessels while minimizing damage to the surrounding neural retina [11].

nm infrared laser

This laser penetrates deeply and is primarily absorbed by melanin in the RPE and choroid. It is suitable for treating deep-seated retinal pathologies. Its ability to traverse turbid media enables effective treatment of subretinal vascular leakage. However, the higher energy required for deep tissue ablation increases the risk of choroidal thermal injury [12].

Retinopathy of prematurity

Retinopathy of Prematurity (ROP) is an eye disease that affects premature newborns, especially those with extremely low birth weights. Its occurrence is closely linked to the degree of prematurity and the postnatal oxygen environment. Infants weighing less than 1500 g or born before 32 weeks’ gestation are most susceptible to ROP [13]. The global incidence of ROP is correlated with the rate of premature births, with variations observed due to differences in medical conditions, neonatal care, and monitoring levels among countries and regions [14, 15]. The disease typically emerges within weeks after premature birth, characterized by abnormal growth of retinal blood vessels, which can lead to retinal lesions, traction, and, in severe cases, blindness due to retinal detachment [14].

The International Committee for Classification of Retinopathy of Prematurity (ICROP) established diagnostic criteria for ROP in 1984, which have since been updated to the third edition. ROP classification is based on the zone, severity (stage), and vascular characteristics in the posterior pole (normal, pre-plus, or plus disease). Disease progression is divided into five stages, from initial demarcation lines in stage one to complete retinal detachment in stage five, as shown in Table 1 [16].

Table 1.

Stages of ROP

Stage	Clinical Features
1	Demarcation Line: A thin and flat line on the retinal plane marking the boundary between the anteriorly located avascular retina and the posterior vascularized retina.
2	Ridge: An elevation from the demarcation line which possesses height and width and extends above the plane of the retina.
3	Extraretinal Fibrovascular Proliferation: Neovascularization that extends from the ridge into the vitreous cavity or is intravitreal.
4 4 A 4B	Partial Retinal Detachment Extrafoveal detachment Foveal detachment
5	Total Retinal Detachment
5 A	Total retinal detachment is present, but the optic disc is still visible, indicating an “open-funnel” configuration.
5B	The optic disc is not visible due to the presence of retrolental fibrous tissue, indicating a “closed-funnel” configuration.
5 C	Characterized by the features of stage 5B with additional anterior segment abnormalities such as significant anterior chamber shallowing, irido-corneal-lenticular adhesions, and central corneal opacification, also suggesting a “closed-funnel” configuration.

Laser therapy, one of several management options for ROP, is primarily aimed at preventing abnormal blood vessel growth and reducing the risk of retinal detachment (Fig. 1). It is commonly performed through retinal photocoagulation when abnormal blood vessel proliferation is detected during ROP examination. This treatment targets the peripheral non-perfused areas of the retina to curb neovascularization proliferation [17, 18].

Fig. 1.

Changes in ROP following laser photocoagulation therapy

(1 A: Pre-Laser Treatment;1B: Post-Laser Treatment)

Laser photocoagulation has revolutionized the management of ROP, with multiple wavelengths offering distinct clinical advantages. The 810 nm infrared diode laser serves as the gold standard, employing typical parameters of 150–250 mW power, 100–200 ms pulse duration, 500 μm spot size, and repeat mode to deliver 2,000–3,000 near-confluent spots to the ora serrata in zone II disease, achieving 98.3% complete regression with minimal complications [19]. While its portability aids bedside use, visible wavelengths enhance burn visualization for precision. The 532 nm frequency-doubled Nd: YAG green laser excels in oxyhemoglobin absorption, using 100–300 mW power and 200 ms pulse duration with similar spot configurations. It yields 92.5% favorable outcomes across ROP subtypes, including aggressive ROP (A-ROP) and eyes with tunica vasculosa lentis (43.8% of cases), without elevated cataract or hyphema risks; comparative data show equivalent regression to diode laser but potentially fewer anterior segment complications [20, 21]. The 577 nm yellow solid-state laser aligns with oxyhemoglobin’s peak absorption while minimizing xanthophyll absorption for macular safety, employing 70–100 mW power (mean 88 mW), 100–200 ms exposure (mean 130 ms), and approximately 890 burns per eye. In subthreshold micropulse mode with 5–15% duty cycles and 50% threshold power, a pilot study of 30 eyes reported 100% regression at 3 months with no complications [22]. In contrast, the argon laser (488–528 nm blue-green) pioneered ROP treatment but was superseded due to higher complication rates, including 12% cataracts (median onset 13 weeks) and anterior segment ischemia like hyphema and iris atrophy. Despite approximately 2,500 burns per eye and ~ 73% favorable outcomes, long-term results showed 71.4% favorable visual acuity but high rates of myopia [11]. In summary, wavelength selection balances efficacy—with all modern lasers superior to argon and cryotherapy—and safety profiles: diode laser for tissue penetration, and green and yellow lasers for enhanced visualization and reduced collateral damage. The choice should be guided by disease zone, media clarity, and local availability [21].

Studies from the 1990s, including one from 1994, have shown that photocoagulation for ROP is as effective as or more effective than cryotherapy, with less associated pain and inflammation [23]. However, with the evolution of ROP classification into Type I and Type 2, the modern approach favors anti-VEGF treatments as the primary intervention, reserving laser therapy for specific cases or in combination with anti-VEGF agents. A 10-year follow-up study indicates that laser photocoagulation therapy results in better visual acuity and fewer refractive errors than cryotherapy [24], establishing it as the standard treatment for ROP. Despite its efficacy, laser therapy carries the risk of tissue damage, which can lead to permanent visual field defects and myopia [25].

Since 2007, anti-VEGF drugs have been used in the treatment of ROP. Initial studies in ROP with therapeutic indications show that combining laser photocoagulation with intravitreal anti-VEGF injections yields favorable outcomes [26], with a 90.2% efficacy rate when bevacizumab or ranibizumab is used with laser therapy [27]. However, meta-analyses comparing laser therapy with anti-VEGF therapy for Type-1 ROP have not definitively concluded the superiority of either treatment method in terms of efficacy, although laser therapy may cause more eye complications and increase the risk of myopia [28, 29]. In Zone II Stage 2 or 3 ROP with plus disease, a single intravitreal injection of ranibizumab can promote ROP regression and peripheral retinal vascularization, but a significant proportion of children experience ROP recurrence afterward [30].

In the treatment of A-ROP, some researchers advocate for the combined use of laser therapy and anti-VEGF to achieve disease control [31]. However, issues with application of anti-VEGF, such as peripheral retinal vascularization, disease reactivation, and systemic drug absorption, have been noted [32]. Consequently, other researchers prefer laser therapy as the primary treatment for A-ROP, citing its one-time treatment advantage, which avoids potential anti-VEGF side effects and the long-term presence of avascular retina [33].

Different stages and zones of ROP respond variably to retinal photocoagulation therapy and anti-VEGF agents [34]. Laser therapy sessions are typically less frequent than intravitreal anti-VEGF injections, suggesting that laser therapy provides longer-lasting inhibition of neovascularization. Different stages and zones of ROP respond variably to retinal photocoagulation therapy and anti-VEGF agents [34]. Laser therapy sessions are typically less frequent than intravitreal anti-VEGF injections, suggesting that laser therapy provides longer-lasting inhibition of neovascularization.

Familial exudative vitreoretinopathy

Familial exudative vitreoretinopathy (FEVR) is a rare hereditary eye disease with an unclear incidence rate. Its characteristics include avascular zones in the retina, neovascularization, tractional retinal detachment, and exudation. This condition typically occurs in full-term infants without a history of oxygen exposure but may also affect preterm infants, with clinical manifestations similar to ROP [35]. In addition, the two diseases share some genetic similarities, particularly in genes such as LRP5, FZD4, TSPAN12, and NDP, which are involved in the Wnt signaling pathway and play a crucial role in retinal vascular development [36]. The progression of FEVR can be divided into five clinical stages (Stage 1: Peripheral avascularity (lack of blood vessel development) without extraretinal neovascularization or exudates. Stage 2: Peripheral avascularity with extraretinal neovascularization. Stage 3: Extraretinal neovascularization with or without exudates, and without retinal detachment. Stage 4: Partial retinal detachment involving the peripheral retina but not the central macula. Stage 5: Total retinal detachment), progressing from peripheral retinal avascularity to complete retinal detachment [37]. Wide-field fluorescein angiography is crucial for early diagnosis of FEVR, aiding in timely treatment and determining the disease status of asymptomatic family members. In 2014, Kashani et al. proposed a clinical staging method for FEVR based on clinical presentations and angiography results (As shown in Table 2) [38].

Table 2.

Revised FEVR clinical staging system2014

Stage	Clinical Features
1 2 A 2B		Avascular periphery or anomalous intraretinal vascularization Without exudate or leakage With exudate or leakage
2		Avascular retinal periphery with extraretinal vascularization
2 A		Without exudate or leakage
2B		With exudate or leakage
3		Extramacular retinal detachment
3 A		Without exudate or leakage
3B		With exudate or leakage
4 4 A 4B		Macula-involving retinal detachment, subtotal Without exudate or leakage With exudate or leakage
5 5 A 5B		Total retinal detachment Open funnel Closed funnel

(2 A: Pre-Laser Treatment; 2B: Post-Laser Treatment; 2 C: 1 Week After Laser Treatment; 2D: 1 Month After Laser Treatment)

Currently, the treatment of FEVR mainly includes laser photocoagulation therapy and vitreoretinal surgery. Laser therapy is primarily used in the early stages of neovascularization in avascular areas to reduce further disease progression and prevent retinal detachment (Fig. 2). The selection of laser modalities and parameters depends on the disease stage and anatomical involvement: For early-stage lesions confined to the peripheral retina, the 532 nm green laser is preferred due to its selective absorption by hemoglobin and RPE, enabling precise photocoagulation of superficial abnormal vessels with typical energy settings of 100–300 mW, exposure times of 0.1–0.2 s, and spot sizes of 200–500 μm. In contrast, advanced cases with deep retinal or choroidal involvement, or those complicated by vitreous hemorrhage, require the 810 nm infrared diode laser, which penetrates turbid media and targets melanin-rich deeper layers to ablate subretinal pathologies. For these cases, energy settings of 200–400 mW, exposure times of 0.2–0.4 s, and spot sizes of 200–500 μm are typically employed, with careful titration to achieve a gray-white endpoint indicating appropriate RPE and choroidal response. Near the macula, smaller spot sizes (100–200 μm) may be used cautiously to minimize collateral damage [39]. By selectively targeting and modifying abnormal neovascularization within the lesion area, laser therapy reduces exudation and mitigates secondary retinal traction, thereby preserving central vision [40, 41]. Furthermore, laser therapy can be synergistically integrated with anti-VEGF therapy to enhance suppression of pathologic angiogenesis and reduce post-procedural hemorrhage risks [42].

Fig. 2.

Changes in FEVR following laser photocoagulation therapy

However, laser therapy is not suitable for all FEVR patients, and its indications depend on the extent, location, and severity of the lesions in individual patients [40]. In the management of familial diseases, prophylactic retinal photocoagulation in some FEVR patients can maintain stable vision [41]. Kashani et al. suggest that laser therapy should be conducted early at sites exhibiting leakage or within areas of the retina that are not fully vascularized because FEVR may progress linearly or skip certain stages. However, even with treatment, lesions at the vitreoretinal interface can still evolve into tractional retinal detachment, which can result in vitreous hemorrhage or retinal detachment [38]. The advantage of laser therapy lies in its non-invasiveness and precision, but it may not be effective enough for patients with existing retinal detachment or extensive exudation. Therefore, laser therapy, as an important tool in the treatment of FEVR, requires personalized treatment based on the patient’s progression.

Coats’ disease

Coats’ disease is a primary retinal vascular disorder characterized by retinal telangiectasia, exudation, and exudative retinal detachment. In 1908, George Coats first described a series of patients presenting with retinal telangiectasia accompanied by extensive intraretinal and subretinal exudation. Despite the continuous progress in the diagnosis and treatment of Coats’ disease over the past century, its exact underlying etiology remains unknown [43]. Coats’ disease is generally considered non-familial and usually unrelated to systemic diseases. Due to its frequent occurrence in infancy, it is believed to be a congenital condition and is common in young males. Shields et al. conducted a consecutive clinical observation of 150 cases of Coats’ disease in 2001 and proposed a staging system for Coats’ disease, which is widely used today, as shown in Table 3 [44].

Table 3.

Coats shields’ classification

Stage	Clinical Features
1	Retinal telangiectasia only
2	Telangiectasia and exudation
2 A	Extrafoveal exudation
2B	Foveal exudation
3	Exudative retinal detachment
3 A	Subtotal detachment (1) Extrafoveal (2) Foveal
3B	Total retinal detachment
4	Total retinal detachment and glaucoma
5	Advanced end-stage disease

(3 A: Pre-Laser Treatment; 3B: Post-Laser Treatment)

Vascular leakage is the main cause of vision loss in Coats’ disease, so the primary goal of treatment for this condition is to destroy abnormal vessels and aneurysmal dilatations. The first successful treatment of Coats’ disease was achieved through transscleral diathermy, followed by retinal laser photocoagulation becoming the mainstay of treatment in clinical practice [43].

Laser photocoagulation therapy is suitable for Coats’ disease, whether it is in the early stages with exudation but without retinal detachment or shallow retinal detachment, or in the advanced stages [44] (Fig. 3). Studies have shown that green laser (532 nm) can effectively treat both early and advanced Coats’ disease, including cases with significant retinal detachment [45]. For cases where retinal photocoagulation is ineffective due to dense exudates, cryotherapy may be considered [46]. Due to the slow resolution of exudation, multiple laser treatments are often needed, with a recommended interval of at least 3 months between two laser sessions [44].

Fig. 3.

Changes in coats’ disease following laser photocoagulation therapy

Laser photocoagulation serves as the cornerstone treatment for Coats disease, with distinct laser types offering unique characteristics. Argon laser emits 514.5–532 nm green light, primarily absorbed by RPE melanin and hemoglobin, with treatment parameters including power ranging from 150 to 200 mJ to 400-800mW, spot sizes of 100–500 μm, and exposure times of 0.1–0.2 s [47, 48], demonstrating efficacy in early-stage Coats disease, though limited by thermal damage diffusion to adjacent healthy tissue and energy blockage by subretinal fluid [49]. Diode laser (810 nm near-infrared) offers superior penetration through blood and macular pigment, primarily absorbed by RPE and choroidal melanin, utilizing parameters of 1000mW power, 300msec pulse duration, and 75–125 μm spots in diabetic studies [50], but lacking dedicated clinical research and optimal parameter validation for Coats disease. The 577 nm yellow laser coincides with oxyhemoglobin absorption peak while being efficiently absorbed by melanin but minimally by xanthophyll, providing a wider therapeutic window than 532 nm green laser with higher operational tolerance, minimizing neural epithelial damage when treating near-macular lesions, with clinical applications averaging approximately 400 photocoagulation spots per session [51], though large-scale prospective studies remain insufficient. Subthreshold micropulse laser (SML) employs 5%-15% duty cycles to fragment continuous laser beams into microsecond pulses, achieving therapeutic effects through biostimulation rather than destructive coagulation while avoiding permanent structural damage, with case reports demonstrating safety and efficacy for macular-involved Coats disease [52], however current evidence remains low-grade, lacking randomized controlled trials to validate optimal treatment protocols and long-term outcomes.

When combined with other medications during retinal photocoagulation: intravitreal injection of triamcinolone acetonide can be used as adjunctive therapy, leading to reduced central retinal thickness, resolution of exudates, and possible improvement in vision. However, the use of steroids can lead to complications such as cataracts and glaucoma [53]. Limited case reports and clinical studies have shown that adjunctive anti-VEGF therapy helps with the regression of abnormal vessels, resolution of macular edema, and stabilization or improvement of exudates [43]. However, since VEGF is not a key factor in the pathogenesis of Coats’ disease, anti-VEGF therapy can only assist in treatment and cannot treat Coats’ disease itself [54].

Studies have shown that the visual prognosis of patients with Coats’ disease has improved in recent years, possibly due to early detection and aggressive treatment [55]. Improvements in techniques such as retinal laser photocoagulation, retinal repositioning surgery, and intraocular injections have contributed to the treatment and management of Coats’ disease.

Norrie disease

Norrie disease is a rare genetic disorder that primarily affects the retina and typically leads to blindness. Ocular manifestations include leukocoria, posterior lens fibrous tissue proliferation, severe retinal dysplasia, and retinal detachment. Norrie disease patients often experience blindness (no light perception) due to bilateral retinal detachment shortly after birth or within the first few months of life, with additional systemic symptoms such as hearing impairment, neurological disorders, and peripheral vascular diseases being possible. Due to its X-linked recessive inheritance, this disease almost exclusively affects male infants, although there have been a few reports suggesting that female patients may exhibit milder disease features [56–58].

Currently, there is no established standard treatment protocol for Norrie disease. Reports have indicated that retinal laser photocoagulation surgery and vitrectomy are effective in some cases. Because Norrie disease patients have incomplete development of deep retinal capillaries and large areas of avascular retina, leading to continuous neovascularization, laser photocoagulation in the early stages of Norrie disease fibrosis may help slow disease progression [59].

In treatment reports of diagnosed Norrie disease patients, Chow et al. reported the first case of laser photocoagulation of the avascular retina in a newborn delivered at 37 weeks of gestation in 2010. The patient was diagnosed with Norrie disease on the first day of life and subsequently underwent laser photocoagulation of both eyes’ avascular retina. One month after treatment, the fibrous vascular proliferation outside the retina completely regressed, and there was no retinal detachment at the 24-month follow-up [60]. In 2014, Sisk et al. reported the first case of medically induced preterm birth after identifying a pathogenic NDP gene mutation via amniocentesis. The patient underwent retinal photocoagulation treatment postnatally, leading to regression of neovascularization and absorption of hemorrhage [61]. These two cases suggest that laser ablation of the avascular retina in Norrie disease eyes before correcting for gestational age at 40 weeks may be beneficial for the visual prognosis of affected infants.

It is worth mentioning that in studies investigating the efficacy of intravitreal anti-VEGF injection combined with retinal photocoagulation, research suggests that combination therapy does not have significant clinical benefits in preventing tractional retinal detachment and inhibiting neovascularization [59].

Given the rapid progression of ocular manifestations in Norrie disease, planned preterm delivery after prenatal genetic testing identifies an NDP mutation and prompt retinal photocoagulation of the ischemic retina during the vascular active phase after Norrie disease diagnosis appears to be a reasonable management approach. Timely retinal photocoagulation may aid in neovascular regression and prevention of tractional retinal detachment (TRD), although the optimal laser dosage and the need for repeat and supplemental laser therapy remain undetermined. However, the long-term outcomes of early retinal photocoagulation treatment for Norrie disease are still unknown, and the mechanisms underlying adverse complications such as high myopia, high astigmatism, and posterior staphyloma during follow-up remain unclear [61]. Therefore, until pioneering treatment modalities emerge, retinal laser photocoagulation remains the primary treatment modality for Norrie disease.

Incontinentia pigmenti

Incontinentia pigmenti (IP), also known as Bloch-Sulzberger syndrome, is a rare X-linked dominant genetic syndrome that manifests at birth or during infancy. The main clinical feature of this disease is the appearance of characteristic progressive skin lesions, initially presenting as vesicular lesions, which then progress to swirling pigmentary lesions in the fourth stage. IP has an incidence rate of 0.0025%, predominantly affecting females. 36.5% of IP patients exhibit detectable ocular pathological changes, among which 60%-90% have retinal issues. Peripheral retinal avascularity and macular occlusive diseases are more common [62, 63]. Retinal lesions stem from vascular occlusion, including neovascularization, hemorrhage, absence of the central fovea, optic nerve atrophy, congestion, and tractional retinal detachment. Pathological changes in the central nervous system, teeth, and hair are also common in IP. The diagnosis of this disease is mainly based on the child’s symptoms, ophthalmic examination, and genetic testing. Currently, there is no cure for IP, and treatment is limited to symptom control [64].

The treatment of ischemic retinal lesions in IP is similar to that of ROP. Studies suggest performing retinal laser photocoagulation or cryotherapy in the avascular peripheral retina [65] (Fig. 4). In a long-term follow-up study of 14 IP patients who underwent prophylactic ablation, one case of retinal detachment occurred. Due to the lack of high-quality controlled clinical trials for evaluation, the indications and success rates of prophylactic ablation remain uncertain [66]. Therefore, IP patients should undergo frequent ophthalmic examinations in infancy and early childhood to initiate treatment promptly when the disease progresses.

Fig. 4.

Changes in ip following laser photocoagulation therapy

(4 A: Pre-Laser Treatment; 4B: Post-Laser Treatment; 4 C: 1 Month After Laser Treatment)

Morning glory syndrome

Morning glory syndrome (MGS) is a rare congenital anomaly of the optic disc, typically unilateral, severely affecting the visual acuity of affected children. The hallmark feature of MGS is an enlarged funnel-shaped optic disc with peripapillary choroidal retinal pigment disturbances, radial retinal vessels, and central glial tuft resembling the appearance of a morning glory flower [67]. The incidence rate of MGS is approximately 2.6 per 100,000 individuals, often associated with peripapillary or macular edema, brain developmental abnormalities, and/or cutaneous vascular malformations [68]. The exact etiology of MGS remains unclear. Previous studies have suggested associations between MGS and developmental anomalies of the posterior sclera and lamina cribrosa during embryogenesis [69], craniofacial abnormalities [70], multiple sclerosis [71], chronic myeloid leukemia-Philadelphia chromosome [72], and other diseases.

Additionally, MGS often presents with other severe ocular conditions, including cataracts, secondary glaucoma, corneal leukoma, strabismus, nystagmus, and retinal detachment (RD) [73]. Approximately one-third of MGS patients may develop RD, primarily due to migration of cerebrospinal or vitreous fluid into the subretinal space and traction on the preretinal glial tissue [74–76]. Surgical treatment for late-stage MGS complicated by RD is challenging and associated with poor visual prognosis, with no definitive effective treatment regimen established [77–80].

In recent years, juxtapapillary laser photocoagulation (JLP) has emerged as a standard treatment for Cavitary Optic Disc [81] (Fig. 5). The mechanism of JLP involves creating adhesions between the RPE, neuroepithelium, and choroid through thermal effects, forming a barrier that prevents fluid migration into the retina, thus reducing the incidence of RD [76]. However, JLP treatment remains controversial due to the risk of macular bundle (PMB) damage induced by laser, which may lead to vision loss. Recent studies have indicated that laser in the PMB region does not result in loss of visual function [82]. Nieraj Jain and Mark W Johnson advocate for vitrectomy and gas tamponade after JLP to create a permanent intra- and subretinal fluid barrier, ensuring safety [76]. A retrospective study on Cavitary Optic Disc revealed that JLP combined with vitrectomy and gas tamponade safely prevents fluid migration caused by cavitary optic disc anomalies, promoting resolution of macular edema and long-term prevention of recurrent macular lesions [81]. However, a multicenter retrospective study by the King Khaled Eye Specialist Hospital (KKESH) International Retina Collaborative Research Group found no significant functional and anatomical benefits from combining pars plana vitrectomy (PPV) with JLP in treating MGS macular lesions compared to PPV alone [83].

Fig. 5.

Changes in MGS following laser photocoagulation therapy

(5 A: Pre-Laser Treatment; 5B: Post-Laser Treatment; 5 C: 1 Week After Laser Treatment; 5D: 1 Month After Laser Treatment)

A single-center retrospective study from China proposed that early prophylactic juxtapapillary laser photocoagulation (Prophylactic JLP) may improve anatomical structure and visual prognosis in MGS. The study retrospectively analyzed 22 MGS patients aged 0–15 years who underwent prophylactic JLP, observing no significant RD in the short-term follow-up, with over 50% of patients experiencing improved visual acuity. However, the prophylactic use of JLP requires further long-term clinical observation to confirm its efficacy and safety [84].

In conclusion, JLP is an effective means to prevent subretinal fluid migration in MGS, but further high-quality clinical research evidence is needed to comprehensively understand the effects of JLP on ocular anatomy and visual prognosis in children with MGS. Future research directions may include improving laser treatment techniques, reducing potential complications, and exploring optimal practices for monotherapy and combination therapy.

Retinitis pigmentosa

Retinitis pigmentosa (RP) is a hereditary disease characterized by a series of genetic mutations leading to gradual loss of photoreceptors, clinically manifested by night blindness, narrowed visual field, central visual impairment, retinal pigment deposition, and photopsia [85]. It typically begins in childhood, but the exact onset time and rate of deterioration vary among individuals. The prevalence of this disease is approximately 1 in 4000 individuals [86]. RP is caused by mutations in many genes, making the pathogenesis difficult to elucidate [87].

Retinal photocoagulation aids in reducing the migration of RPE cells and retinal remnants, as well as improving electroretinography (ERG) findings in RP. In the past clinical treatment of RP, continuous-wave laser photocoagulation has been the classical treatment modality, but it has drawbacks such as choroidal retinal scarring and loss of photoreceptors [88].

With technological advancements, different laser modes can now be applied in RP treatment. Compared to traditional laser modes, subthreshold diode micropulse laser therapy (SDM) selectively modulates the function of RPE cells by targeting the melanosomes, effectively addressing pathological changes within the RPE cells while minimizing the risk of thermal damage to the adjacent retina [89]. Studies have shown that early RP treatment with SDM may slow disease progression and reduce long-term visual loss [90]. However, existing clinical studies mainly focus on adult populations after disease development, and there is a lack of research on the preventive effects of retinal photocoagulation in children with RP.

Other pediatric retinal diseases

In real-world clinical practice, laser therapy has shown efficacy in pathological changes of retinal vasculature caused by genetic diseases, such as retinal vascular tumors in Blue rubber bleb nevus syndrome (BRBNS) [91], retinal detachment in Stickler syndrome [92], retinal vascular tumors in von Hippel-Lindau syndrome [93], retinal capillary dilation in facioscapulohumeral muscular dystrophy (FSHD) [94], exudative vascular lesions in Leber congenital amaurosis [95], and neovascularization in Alström syndrome patients [96].

In the application of laser therapy for retinoblastoma (RB) (Fig. 6), different laser intensities should be used to treat tumors of different sizes, supplemented by other therapies [97].

Fig. 6.

Changes in RB Following Laser Photocoagulation Therapy

(6 A: Pre-Laser Treatment; 6B: Post-Laser Treatment; 6 C: 1 Month After Laser Treatment)

Discussion

Although laser therapy is an established treatment for ROP, its application for other pediatric retinal diseases requires further research and clarification. Internationally, despite extensive clinical research on ROP, there is no unified global guideline for the indications and treatment protocols of laser therapy in pediatric retinal diseases. While the aforementioned guidelines discuss the indications for laser treatment of ROP [16], they do not cover all possible pediatric retinal conditions. To address this gap, the selection of laser modalities and parameters must be tailored to the specific pathophysiology of each disease. For example, the 532 nm green laser (e.g., frequency-doubled Nd: YAG ) targets hemoglobin and retinal pigment epithelium (RPE), making it ideal for superficial vascular pathologies such as ROP and retinal hemangiomas, with typical settings of 100–300 mW energy and 0.1-0.2-second pulses. In contrast, the 810 nm infrared diode laser penetrates deeper into melanin-rich choroidal layers, enabling closure of subretinal leakage in Coats disease at higher energies (400–600 mW), albeit requiring staged treatment to avoid retinal detachment. Laser parameter optimization must also account for anatomical vulnerabilities: macular lesions demand smaller spot sizes (100–200 μm) and reduced energy (50–150 mW) to preserve central vision, while emerging techniques like 577 nm micropulse laser (300–600 mW/cm², 200 µs pulses) offer subthreshold therapy to minimize scar formation in early-stage diseases.

To systematically compare the therapeutic effects and parameter characteristics of different laser modalities across various pediatric retinal diseases, we present a comprehensive comparison table below. This table synthesizes current evidence while highlighting critical knowledge gaps that require future investigation (Table 4).

Table 4.

Comparison of laser types and applications in photocoagulation

Laser Type	Wavelength(nm)	Power (W)	Application	Advantages	Limitations
Argon Laser	488/514	100–800	ROP, FEVR, Coats Disease	High penetration, widely used in ophthalmology	Risk of inner retinal damage, limited in macular diseases
Krypton Laser	568/647.1	100–1500	Coats Disease, subretinal hemorrhage	Better penetration through hemorrhage	Less commonly used, complex equipment
532 nm Nd: YAG	532	100–750	ROP, FEVR, Coats Disease	High safety for macula, clear coagulation	Limited in severe media opacity
810 nm Diode Laser	810	200–1200	ROP, especially in infants with media opacity	Strong penetration, portable, bedside use	Delayed coagulation, higher pain perception
577 nm Micropulse Laser	577	100–1500	DME, CSC (adults)	Sub-threshold, tissue-preserving	Limited evidence in pediatric retinal diseases, no clear endpoint
Argon Laser	488/514	100–800	ROP, FEVR, Coats Disease	High penetration, widely used in ophthalmology	Risk of inner retinal damage, limited in macular diseases

Due to its effective disease control, retinal laser photocoagulation is considered a long-term treatment option for various pediatric retinal diseases. Even in the era of anti-VEGF intravitreal drugs, factors such as treatment burden, economic benefits, and low long-term follow-up rates for pediatric patients have established the role of retinal laser photocoagulation in pediatric retinal vascular diseases. This individualized approach not only enhances vascular closure rates but also reduces complications like retinal scarring and choroidal ischemia, thereby balancing disease control with functional preservation. Future efforts should prioritize standardized parameter guidelines and explore synergies with anti-VEGF agents or AI-driven protocols to address challenges such as limited long-term data.

As a key technology for the treatment of pediatric retinal diseases, retinal laser photocoagulation requires extensive training to master. Especially when treating newborns and children, it should be performed under conditions of general anesthesia and fully dilated pupils due to their difficulty in cooperation. During the treatment, attention should be paid to whether there are any missed lesion areas, and the laser energy should be adjusted in a timely manner based on retinal response to prevent delays in treatment due to insufficient therapy.

However, complications from retinal laser photocoagulation have always been a challenging issue in clinical practice. The long-term effects of laser scars generated by laser thermal effects on infant retinal development are not yet clear. In subsequent research, the efficacy and safety of different laser settings should be a focal point. This will allow for a better understanding of how to mitigate potential complications while maximizing treatment benefits. For instance, while the 532 nm laser reduces macular damage compared to argon lasers, its energy must be carefully calibrated (100–300 mW) to prevent peripheral visual field loss. Similarly, the 810 nm laser’s deep penetration risks choroidal injury if exceeding 400 mW in prolonged exposures (> 0.4 s). Clinical doctors can only prevent retinal structural damage caused by excessive retinal photocoagulation treatment by precisely controlling the laser treatment intensity during the development of different diseases.

However, it is crucial to acknowledge that for many pediatric retinal conditions, there remains insufficient high-quality evidence to establish definitive laser treatment protocols. Diseases such as Norrie disease, Incontinentia Pigmenti, and Morning Glory syndrome lack comprehensive studies delineating optimal laser parameters, specific disease characteristics, comparative advantages, and potential limitations. This knowledge gap significantly hampers clinical decision-making and underscores the urgent need for systematic research in these areas.

Since there are fewer clinical studies on laser treatment of pediatric retinal diseases compared to adult retinal diseases, the long-term effects of retinal laser photocoagulation on the growth and development of pediatric retinas are not yet clear. Therefore, in subsequent clinical studies, attention should be paid to changes in retinal structure and physiology after laser treatment to better understand the development and outcomes of pediatric retinal diseases, which can contribute to the management of pediatric retinal diseases. Multicenter registries tracking parameters (e.g., wavelength, energy, spot size) and outcomes (e.g., visual acuity, scar progression) are urgently needed to establish evidence-based protocols, particularly for those understudied conditions where current clinical practice relies largely on expert opinion rather than robust scientific evidence.

Conclusion

In conclusion, laser photocoagulation, as an important tool for the treatment of pediatric retinal diseases, demonstrates good disease control effects. However, careful selection of appropriate laser parameters is necessary to ensure maximal therapeutic efficacy while minimizing potential complications. This comprehensive review provides an overview of the application of laser photocoagulation in the treatment of pediatric retinal diseases and discusses treatment strategies for different diseases in detail, providing valuable insights for clinical practice.

Author Contribution

QZ, XC & DG: Conceptualization, writing - original draft. YY, GZ: Investigation, writing - review and editing.GM: Supervision, project administration.

Funding

This work was funded by the Introduction Plan of High-Level Foreign Experts (G2022026027L), Major Program of Medical Science Challenging Plan of Henan province(SBGJ202102190) and Hainan Provincial Natural Science Foundation of China (826QN0870).

Data Availability

Data availability is not applicable to this article as no new data were created or analyzed in this study.

Declarations

Competing interests

The authors declare no competing interests.