Journal of Pediatric Ophthalmology and Strabismus

Short Subjects 

Ultra-wide Field Imaging and Swept Source Optical Coherence Tomography of Ocular Electrical Injury in a Child

Brijesh Takkar, MD; Shorya Azad, MD; Kabiruddin Molla, B.Optom; Pradeep Venkatesh, MD

Abstract

History of trauma in children may be obscured and physicians often rely on signs for diagnosis. The authors discuss a case of electrical injury where ocular signs led to diagnosis of the cause of macular atrophy. A high index of suspicion must always be maintained in such atypical cases, and the setting of electrical injury to the body requires meticulous ocular examination. [J Pediatr Ophthalmol Strabismus. 2016;53:e69–e71.]

Abstract

History of trauma in children may be obscured and physicians often rely on signs for diagnosis. The authors discuss a case of electrical injury where ocular signs led to diagnosis of the cause of macular atrophy. A high index of suspicion must always be maintained in such atypical cases, and the setting of electrical injury to the body requires meticulous ocular examination. [J Pediatr Ophthalmol Strabismus. 2016;53:e69–e71.]

Introduction

Electrical injuries are potentially life-threatening and often complicated by intense morbidity and disability.1,2 Eye involvement, especially that of the posterior segment, is relatively uncommon.1 We present a case where fundus features of the fellow eye led to diagnosis of the etiology of visual loss in a case of “forgotten” ophthalmic electric injury.

Case Report

A 6-year-old boy was referred to our clinic with macular dystrophy and had vision loss in the right eye of unknown duration. The visual loss had been detected on a routine visual examination. The best corrected visual acuity was 6/36 in the right eye and 6/6 in the left eye. The eyelids, adnexa, anterior segments, and intraocular pressures were within normal limits bilaterally. Fundus examination revealed severe macular atrophy in the right eye along with pigment loss at the macula (Figure 1A). Fundus examination of the left eye revealed a normal posterior pole. However, a curvilinear streak resembling a horizontal patch of chorioretinal atrophy was detected in the periphery of the left eye, extending from the superior temporal edge of the macula to the temporal ora serrata.


(A) Fundus photograph of the right eye showing macular atrophy with pigmentary changes. Ultra-wide image of right eye (inset) showed no detectable lesion in the periphery. (B) Ultra-wide fundus image of the left eye showing a temporal peripheral curvilinear patch of chorioretinal atrophy (arrows) with surrounding pigmentary changes.

Figure 1.

(A) Fundus photograph of the right eye showing macular atrophy with pigmentary changes. Ultra-wide image of right eye (inset) showed no detectable lesion in the periphery. (B) Ultra-wide fundus image of the left eye showing a temporal peripheral curvilinear patch of chorioretinal atrophy (arrows) with surrounding pigmentary changes.

With a high degree of suspicion, leading questions were asked regarding previous trauma. Although there was no history or sign of mechanical trauma, the mother of the child described how at the age of 2 years the child accidentally touched a live wire connected to a table fan and received an electrical injury. The child had been drowsy for approximately 30 minutes and had been treated by local physicians with fluid resuscitation. On physical examination, scars suggestive of old burns at the head of the third metacarpal and along the phalanges of the third finger of the left hand (Figure 2) were noted. However, no separate exit point of the current could be detected. The patient was therefore diagnosed as having macular atrophy in the right eye secondary to electrical ocular injury.


Clinical photograph of the left hand of the child depicting the electrical burns (encircled).

Figure 2.

Clinical photograph of the left hand of the child depicting the electrical burns (encircled).

Swept source optical coherence tomography (Figure 3) of the right eye confirmed the foveal atrophy, the central retinal thickness being 80 µm. Severely disrupted outer retinal layers, absent ellipsoid zone, and vitreomacular adhesion were detected, but the choroidal vasculature appeared unaffected. The macula of the left eye was within normal limits, with a healthy central macular thickness of 250 µm. The visual prognoses and future risk of complications such as retinal detachment1 were explained to the guardians of the child and follow-up was advised.


(A) Swept source optical coherence tomography (SS-OCT) image of the right eye showing foveal atrophy, disrupted ellipsoid zone, and outer retinal layers. The choroidal vasculature is preserved. (B) SS-OCT image of the left eye showing normal retinal and choroidal vasculature.

Figure 3.

(A) Swept source optical coherence tomography (SS-OCT) image of the right eye showing foveal atrophy, disrupted ellipsoid zone, and outer retinal layers. The choroidal vasculature is preserved. (B) SS-OCT image of the left eye showing normal retinal and choroidal vasculature.

Discussion

Electrical burns, also known as Joules burns, can be caused by direct contact with an energy source or indirectly, as with flash burns. The effect of electricity on human tissue depends on the amount of current, duration of contact, type of contact, and pathway of current inside the body.1 The damage incurred can be due to the electrical current itself or the thermal injury dissipated to the surrounding tissues during its passage. The thermal injury is directly proportional to the resistance offered by the tissue to the passage of current, the resistance being the lowest in the neuronal and vascular tissue.2

The brunt of such injuries is commonly borne by the anterior segment,3 resulting in manifestations such as cataract in both eyes, keratitis, hyphema, and uveitis.1,3 Such trauma is believed to be thermal in nature, whereas posterior injuries are electrical in nature.3 This may be because the estimated energy level at the retina, especially in the setting of a usual domestic injury, is not sufficient to result in significant thermal tissue burns.4 Hence, common posterior findings include disrupted outer retinal layers, abnormal electroretinograms, macular cysts, lamellar or full-thickness macular holes, papillopathy, edema, and retinal tears.1,3,5–8 However, as with our case, sometimes the visual loss is dense or irreversible due to severe macular atrophy attributed to local increase of electrical resistance by melanocytic granules.1

Although the left hand of the child was definitely the entry route of the electricity (suggested by history and characteristic burn pattern), we could not decipher the exit route taken by the current to effect a flow circuit. Reasons for more damage to the contralateral eye could be multifactorial, including proximity of the right eye to the exit route of the current. Free passage of the electrical current first through the optic nerve of the right eye and then through the outer retinal layers of the macula explain the macular atrophy and swept source optical coherence tomography features due to the mechanisms discussed above.2 The curvilinear tract of chorioretinal atrophy visualized in the periphery of the retina represents the ocular passage of the current along the long ciliary neurovascular bundle of the left eye of the child. Because the visual loss of the child was detected incidentally after a gap of 2 years, the findings of the left eye provide the strongest evidence linking ophthalmic pathology to the electrical injury.

Ocular electrical injury can result in irreversible vision loss. The presence of a curvilinear tract of chorioretinal atrophy should alert the physician to previous ocular passage of electrical current. In the setting of electrical injury, meticulous ocular examination should always be conducted.

References

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  7. Lin CJ, Yang CH, Yang CM, Chang KP. Abnormal electroretinogram and abnormal electrooculogram after lightning-induced ocular injury. Am J Ophthalmol. 2002;133:578–579. doi:10.1016/S0002-9394(01)01400-3 [CrossRef]
  8. Korn BS, Kikkawa DO. Images in clinical medicine: ocular manifestation of electrical burn. N Engl J Med. 2014;370. doi:10.1056/NEJMicm1213581 [CrossRef]
Authors

From Vitreo Retina Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All-India Institute of Medical Sciences, New Delhi, India.

The authors have no financial or proprietary interest in the materials presented herein.

Correspondence: Pradeep Venkatesh, MD, Vitreo Retina Services, Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All-India Institute of Medical Sciences, New Delhi 110029, India. E-mail: venkyprao@yahoo.com

Received: June 08, 2016
Accepted: September 28, 2016
Posted Online: December 08, 2016

10.3928/01913913-20161102-02

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