Case Report: A rare case of lightning strike causing corneal burn injury

Introduction

Lightning causes catastrophic injury and death worldwide. Electrical injuries cause extensive traumatic damage that can lead to a wide range of consequences.¹ Aystolic cardiac arrest and ventricular fibrillation are the most prevalent causes of death are asystolic cardiac arrest and ventricular fibrillation.² In 1722, St. Yves recorded the first case of electrical burn in the eye. He documented the development of cataracts in a field worker who was affected by lightning.³ Various injuries related to lightning strikes have been documented, including keratitis, cataracts, anterior segment uveitis, retinal detachments, papillitis, and macular hole formation.⁴ Studies have shown that lightning injuries often affect the cornea, resulting in epithelial erosions, and the lens, with a potential for up to 6-7% formation of anterior and posterior subcapsular cataracts⁵; however, with the development of optical coherence tomography (OCT) in the last decade, a greater number of posterior segment diseases caused by lightning have been identified. Thermal papillitis, optic neuropathy, loss of pupillary light sensitivity, anisocoria, Horner syndrome, and multiple facial nerve palsies are all potential neurological problems involving the eye.⁶

Inflammatory changes in the iris and ciliary body are common after trauma, and acute and transient iritis may occur within one–eight weeks after the incident. The melanin-rich retinal pigment epithelium makes the macular region resistant to electrical currents, making it vulnerable to heat damage. Consequently, various macular injuries can occur.⁷

Various mechanisms have been suggested for the ocular damage caused by lightning. Initially, the electric current passes through the ocular tissues, leading to the rupture of cell membranes. Second, the heat generated by electrical current may be harmful. Finally, tissue ischemia can occur as a result of vasoconstriction and damage can occur as a result of localized inflammation or reperfusion injury.⁸

Case report

A 45-year-old woman presented to the emergency department with sudden pain, redness, and decreased vision in both eyes. This occurred four hours after being struck by lightning in the face while standing near a window. The symptoms worsened suddenly and rapidly, accompanied by blepharospasm and watering of the eyes.

During eye examination, first-degree burns were observed on the face, affecting the eyebrows, lashes, and eyelids. The eyelid was also swollen (Figure 1), and visual acuity was reduced to the perception of light. Upon further examination of the right eye using a slit lamp, conjunctival congestion, chemosis, and corneal stromal edema were observed. Descemet membrane folds were also present along with corneal melting at the 3-4 and 6 o’clock positions. The anterior chamber was shallow, and there was an inferior blood clot (as shown in Figure 2). Iridodialysis was identified in both eyes, and the iris was irregular in shape with a sluggish reaction to light an ultrasonography (USG) of the eye was performed and the results indicated that everything appeared normal. The eye was examined with fluorescent stain under blue light filter shows stain positive (as shown in Figure 3).

Figure 1. Shows right sided facial burn lesions.

Figure 2. Slit lamp examination of right eye showing corneal melting, descemet membrane folds, corneal edema and shallow anterior chamber.

Figure 3. Slit lamp image of the right eye with a fluorescent stain.

During examination of the left eye, visual acuity was found to be counting fingers at a distance of two meters. No improvement was observed with the pinholes. Eyelid edema and stinging of eyelashes were present, as well as conjunctival congestion and chemosis (as shown in Figure 4) The cornea was also oedematous., Descemet membrane folds were seen. Corneal melting was observed inferiorly at the 5 clock position. The depth of the anterior chamber was normal. (as shown in Figure 5) pupils were semi-dilated and were reacting sluggishly to light.

Figure 4. Shows left sided facial burn marks with conjunctival chemosis.

Figure 5. Slit lamp image of the left eye on admission.

Upon admission, the patient was treated with oral and topical antibiotics, cycloplegics, and lubrication. Multiple corneal foreign bodies were observed under the microscope. After a week of treatment, the patient underwent re-evaluation, and a reduction in corneal haze and conjunctival chemosis was observed (as shown in Figure 6). Multiple macular opacities were observed in the cornea. The patient’s anterior chamber showed no abnormalities; however, they was diagnosed with cataracts in both eyes. The patient’s representatives were informed that the recommended course of action was lens aspiration with intraocular lens implantation and keratoplasty.

Figure 6. Slit lamp image after one week of treatment.

Showing reduction in corneal haze and conjunctival chemosis.

Discussion

Lightning that can cause injuries to the eyes is rare; however, when it occurs, it can cause damage to different parts of the eye, including the structures in the front and back. Electrical energy from lightning can cause cell destruction and swelling, leading to various eye problems. This is due to changes in the cell membrane and electrical potential, and is called electroporation.⁹ When lightning strikes, electrical current can cause significant harm to tissues and organs throughout the body. This damage can manifest in various ways, including anatomical, histological, and biochemical changes. In particular, people commonly experience superficial corneal lesions after being struck by lightning. These lesions can typically be treated with symptomatic care, although they may sometimes heal independently.¹⁰ Lens opacity can develop after being struck by light. Several theories have attempted to explain why this happens, such as reduced permeability of the lens capsule, coagulation of proteins caused by the electrical current, disruption of lens feeding due to iritis, and mechanical damage to the lens fibers.¹¹ Cataract formation typically begins in the eye and is closest to the site of injury. It can take anywhere from 1 to 10 months before a cataract is detected in another eye. Our patient had post-traumatic punctate corneal epitheliopathy, and the production of heat energy can also cause burns, as in our case. The patient suffered from burns on the face, bilateral corneal edema, and cataractous lens. Patients need to undergo regular check-ups at eye clinics to monitor for any potential issues that may arise. These can include early-, mid-, and late-stage diseases related to lightning injuries.

Conclusion

These types of injuries are commonly caused by lightning strikes, and our case study emphasizes the different ocular symptoms that can result from lightning strike injuries. Lightning injury can cause severe damage to the eyes and corneal edema, corneal melting, hyphema, and iridocyclitis; in the latter stages, exudative retinal detachment is likely to occur. The patient was thoroughly examined, and early treatment yielded favorable results. Patients should be allowed to flow for a long duration for early diagnosis and treatment of late complications of lightning electric burn injuries. Patients suffering from these injuries can have a positive outcome if they are detected early and treated properly.

Consent

Written informed consent was obtained from the patient, which included permission to publish the case details including the images.