burns 39 (2013) 1380–1385

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journal homepage: www.elsevier.com/locate/burns

Overview of ocular complications in patients with electrical

burns: An analysis of 102 cases across a 7-year period

Eun Jin Bae, In Hwan Hong, Sung Pyo Park, Hyoung Kyun Kim,
Kyung Wha Lee, Jae Ryong Han *
Department of Ophthalmology, College of Medicine, Hallym University, Seoul, Republic of Korea

article info abstract

Article history: Background: Ocular complications from electrical burns are uncommon. Thus far, there has
Accepted 29 March 2013 been no systematic review on ocular electrical trauma with emphasis on patients’ ophthal-
mic complications and visual symptoms. Herein, we retrospectively analyzed records of
Keywords: patients with electrical injuries to summarize the ophthalmic characteristics and explore
Electrical burn their relationships with visual symptoms.
Ocular complications Methods: We collected the medical records of 102 patients who consulted from 557 electrical
Subjective outcome of visual burn patients between 2004 and 2010. Ophthalmic, systemic and demographic factors
symptoms associated with electrical burns were identified in the patient who underwent the ophthal-
mic consultations. Two sets of comparisons were used to determine the demographic and
systemic factors that were related to ophthalmic complications and the subjective outcome
of visual impairment.
Results: There were 53 eyes (29 patients) with ophthalmic complication were identified.
Corneal epithelial erosion was the most common ocular electrical injury and the primary
reason for subjective visual symptoms. Electrical burns affecting the head and neck were
significantly related to subjective symptoms of visual disturbances.
Conclusion: Present study indicates that earlier involvement of ophthalmologists in the case
of any patient who has suffered a facial burn is advisable. Appropriate management would
be helpful to prevent future complications and alleviate visual symptoms.
# 2013 Elsevier Ltd and ISBI. All rights reserved.

evaluation may not be performed until days or weeks after the

1. Introduction
While chemicals and radiation are the most common causes
of burns to the eye, a burn may also result from contact with
heat, flame, or electricity [1]. Electrical injuries induce complex
traumatic damage that in turn causes a wide variety of
complications [2]. However, ocular complications from elec-
trical burn injuries are rare, as the initial burn injury is
typically life threatening. This means that the ophthalmic
traumatic event has occurred [3,4].
Tissue damage resulting from electric shock may occur in
the form of electrical injury from the passage of electrical
currents through the tissues, electrothermal or arc burns from
the passage of electrical currents external to the body, and/or
thermal burns from the ignition of clothing or environmental
objects [5]. Numerous case series have reported that most
electrical injuries affecting the eye are accidental and typically
involve contact of the head or orbital area with electrical

* Corresponding author at: Department of Ophthalmology, Hallym University Dongtan Sacred Heart Hospital, Seokwoo-dong, Hwaseong-
si, Gyeonggi-do, Republic of Korea. Tel.: +82 31 8086 2660; fax: +82 31 8086 2774.
E-mail address: scarpel@hallym.or.kr (J.R. Han).
0305-4179/$36.00 # 2013 Elsevier Ltd and ISBI. All rights reserved.
http://dx.doi.org/10.1016/j.burns.2013.03.023
 burns 39 (2013) 1380–1385 1381

materials [4,6,7]. Furthermore, the sequelae of electrical After analyzing the patient records, we performed 2 sets of
damage can affect almost any part of the eye or orbit, comparisons to determine the demographic and systemic
including the eyelids, conjunctiva, extraocular muscles, factors that were related to ophthalmic complications and the
cornea, iris and pupil, lens, retina, choroid, and optic nerve [8]. subjective outcome of visual impairment. Therefore, patients
The first case of electrical burn to the eye was reported in were excluded if they could not articulate their symptoms or
1722 by St. Yves, who described the development of lenticular did not receive a thorough evaluation, either because they died
opacities (cataracts) in a field worker who was struck by or transferred before the examination or because they were
lightning [9]. Since this first report, many articles have not suitable for ophthalmic examination such as massive
discussed various ocular effects caused by lightning and facial dressing or vital instability. We categorized the patients
industrial electrical injuries, which have confirmed the notion according to their ophthalmic complications to identify the
that any part of the eye or visual pathway may be affected [8]. risk factors associated with specific ocular injuries. Patients
However, to the best of our knowledge, no study has been with a chief complaint of visual disturbance were enrolled in a
performed to conduct a systematic review on ocular electrical separate study designed to identify related risk factors,
trauma with an emphasis on the clinical characteristics of regardless of their best-corrected visual acuities (BCVAs).
ophthalmic problems. Both comparisons used the same patient group, with the cases
In the present study, we retrospectively reviewed the of ocular injury identified explicitly.
records of patients who presented with electrical injuries Statistical analysis was performed using a commercial
during the period from 2004 to 2010 to summarize the statistical software package (SPSS for Windows, version 18.0;
ophthalmic complications and their risk factors. Furthermore, SPSS Inc., Chicago, IL). A P-value less than 0.05 was considered
we attempted to identify the ocular electrical injuries in statistically significant. Normally distributed data are shown
patients who complained of subjective symptoms of visual as mean values  standard deviation; all other data are
impairment and explore their clinical characteristics. This presented as percentages of the total population. Using
study may help in the management of complications independent t tests, demographic and systemic factors were
associated with electrical eye injuries and improving the compared between patients who have ophthalmic complica-
quality of vision in patients who have sustained electrical tions or visual symptoms and controls without any eye-
trauma. related issues. Multivariate logistic regression analysis was
used to analyze the factors related to the incidence of ocular
complications and visual symptoms. Odds ratios (ORs) and
2. Materials and methods 95% confidence intervals (CIs) were used to describe the
influence of age, gender, location of injury, overall degree of
We retrospectively collected the medical records of 102 burns, voltage of the electricity, entry site, TBSA, and facial
patients who consulted with eye problems among total 557 involvement on the prevalence of visual symptoms and
electrical burn patients who presented at the Hallym burn ophthalmic complications. Multiple linear regression was
center from 2004 to 2010 (inclusive). The ophthalmic, used to analyze the effects of TBSA, voltage of the electricity,
demographic, and systemic factors associated with the
electrical burns were identified. Ophthalmic information
was analyzed by the identified ophthalmologist, through the Table 1 – Demographic characteristics of the study
measurement of presenting visual acuity (VA), anterior subjects.
segment examination by slit-lamp biomicroscopy, intraocu- Number Number
lar pressure measurements, direct and indirect ophthalmos- of patients of patients
copy, electroretinography (ERG), visual field test and careful
Sex TBSA
recording of ophthalmic complications over the course of the Male 101 (99.02) <10 (%) 59 (57.84)
follow-up examination. LogMAR charts were used to assess Female 1 (0.98) 10 (%) 43 (42.16)
the Initial and follow-up measurement of VA. LogMAR means Age Voltage
the logarithm of the Minimum Angle of Resolution and the 9 (years) 2 (1.96) 220 (Volts) 6 (5.88)
use of it allows analysis of visual acuity scores more 10–19 2 (1.96) 220–20,000 27 (26.47)
20 < 29 8 (7.84) 20,000 69 (67.65)
effectively and comparisons of results more precisely [10].
30 < 39 43 (42.16) Entry site
In particular, information on the patient’s chief complaint, 40 < 49 25 (24.51) Head 6 (5.88)
the type of ocular injury sustained and the management of 50 < 59 16 (15.69) Unilateral UE 35 (34.31)
ophthalmic complications was analyzed. The demographic 60 < 69 3 (2.94) Bilateral UE 8 (7.84)
information that we collected included the age of the patient Injury location Unilateral LE 1 (0.98)
at the time of the burn, gender, and location of the patient at Work 88 (86.27) Bilateral LE 1 (0.98)
Home 4 (3.92) Back 1 (0.98)
the time of trauma. The systemic information collected
Playground 10 (9.80) Unknown 50 (49.02)
included overall burn severity, total burn surface area (TBSA),
Depth of burn
location of burn, overall degree of burns, voltage of the Second degree 37 (33.70)
contact electricity and entry site. Finally, we calculated the Third degree 65 (66.30)
number of days from admission to the time of consultation
Total 102 (100)
for an ophthalmic evaluation and defined it as a consultation
Number of patients and percentage of that in parenthesis was
time. All ophthalmic examination was done within 48 h after
referred. UE: upper extremity; LE: lower extremity.
consultation.
1382 burns 39 (2013) 1380–1385

Table 2 – Ocular complications of electrical burns in the complication were identified. The most common complication
study subjects. was multiple, punctate corneal erosions (16 cases). We
Complication Number of cases analyzed the types of ophthalmic complications in the group
of patients with subjective visual symptoms and identified 22
Total 53 cases
cases of electrical damage. Among this subgroup of patients,
Electric cataract 7 the most common complication was epithelial corneal erosion
Eyelid erythema, swelling 5
(10 cases), as was observed for the overall patient population.
Conjunctivitis 4
Seven patients with electrical cataracts were identified;
Macular edema 4
Foveal cyst 1 among these patients, only 3 patients complained of visual
RD 1 impairment. No ophthalmic complication was observed in any
Pseudohole 1 of the 22 patients who had chief complaints related to
Uveitis 2 subjective symptoms of visual impairment.
Corneal problem Comparisons of the categorical variables for patients with
PEE 16
and without complications are shown in Table 3, and the
ED 2
Filament keratitis 2
results of the multivariate logistic regression analysis are
Corneal FB 2 given in Table 4. The independent t test showed that male
Corneal stromal opacity 1 patients were significantly more likely to experience ophthal-
Exposure keratitis 2 mic complications; however, multiple logistic regression
Corneal scarring 1 analysis revealed no significant relationship between sex
RD: retinal detachment; PEE: punctate epithelial erosion; ED: and ophthalmic complications. Because nearly all of the
epithelial defect; FB: foreign body. patients in our patient population were male, our statistical
analysis might not have any significance with regard to the
association between sex and ophthalmic complications. Table
overall degree of burns, facial involvement and visual 3 presents comparisons of the categorical variables for
symptoms on consultation time. The consultation time of patients with and without visual symptoms, and the results
patient with ophthalmic complication and those without was of the multivariate logistic regression analysis are shown in
compared employing an independent t test. Table 4. The only variable related to symptoms of visual
impairment was the involvement of a facial burn (Table 2,
P = 0.013, independent t tests; Table 3, P = 0.021, multivariate
3. Results logistic regression analysis).
The average day of consultation was 44.26  55.78 days
In total, 102 consultations by patients with ocular electrical from admission in total 102 patients. Multiple linear regres-
injury were reviewed. The demographic data and injury sion analysis was used to evaluate the association between
characteristics are shown in Table 1. Apart from 1 female, several independent variables (TBSA, voltage of the electricity,
all of the patients were male. Patient age ranged from 2 to 67 overall degree of burns, facial involvement and visual
years, and 43 (42.16%) patients were between 30 and 39 years symptoms) and measured length of time to consultation
old. The injuries occurred in the workplace in 88 (86.27%) (consultation time) (Table 5). This model showed statistically
patients; majority of the patients were involved with high- significant results (R2 = 0.252, P < 0.001). TBSA showed a
voltage electrical material (n = 69; 67.65%), and 42.16% of statistically significant linear regression with the consultation
patients had major burns (TBSA  10%). time (P < 0.001). There was a positive correlation between the
These patients were analyzed and included in the consultation time and TBSA. Overall burn degrees was also
multivariate logistic regression analysis for factors associated statistically significantly correlated with consultation time
with ophthalmic complications and visual symptoms. Table 2 (P = 0.025), but there were no statistically significant associa-
shows the entire distribution of ophthalmic complications; in tions among consultation time and voltage of the electricity,
total, there were 53 eyes (29 patients) with ophthalmic facial burn and visual symptoms. Although consultation time

Table 3 – Comparisons of the categorical variables for patients with and without visual symptoms.
A (n = 29) B (n = 73) P valuey C (n = 36) D (n = 66) P valuey
Sex (M:F) 28:1 72:1 0.025 35:1 65:1 0.664
Age (yrs,Mean  SD) 42.66  6.02 39.81  5.62 0.261 38.97  5.32 41.51  5.95 0.288
TBSA (%,Mean  SD) 11.41  7.10 10.93  4.75 0.843 11.86  5.81 10.63  5.34 0.592
Voltage (Mean  SD) 16,853.79  19,856.71  0.428 23,302.22  16,701.82  0.055
4266.59 9429.84 12,447.62 4436.01
Facial burn 15 63 0.372 34 44 0.013
Depth of burn (28:38, mean  SD) 9:20 28:45 0.145 8:29 29:37 0.120
TBSA: total burn surface area; SD: standard deviation; A: the group of patients who had ocular complication; B: The remaining patients not
included in group A; C: the group of patients who had subjective visual disturbances; D: the remaining patients not included in group C.
y
Based on independent t test. P < 0.05 was considered statistically significant.
 burns 39 (2013) 1380–1385 1383

Table 4 – The relationship between various factors and visual disturbances or complications.
A B

OR 95% CI P valuez OR 95% CI P valuez

Sex 1.392 0.000 0.999 2.578 0.097–68.480 0.571
Age 1.029 0.973–1.090 0.312 0.978 0.934–1.025 0.353
Voltage 1.536 0.188–12.550 0.689 2.006 0.227–17.750 0.532
TBSA 1.037 0.985–1.090 0.165 0.990 0.948–1.030 0.650
Facial burn 0.469 0.143–1.541 0.212 3.249 1.192–8.860 0.021
Depth of burn 0.988 0.972–1.003 0.124 0.997 0.988–1.005 0.410
Injury location 0.226 0.903
Home 0.085 0.005–1.397 0.084 0.674 0.050–9.080 0.766
Playground 0.000 0.000 0.999 0.427 0.011–17.240 0.652
Entry site 0.055 0.302
Extremities 2.153 0.209–22.150 0.519 7.296 0.583–91.270 0.123
Unknown 0.276 0.086–0.890 0.031 1.112 0.429–2.890 0.827
OR: odds ratio; TBSA: total burn surface area; CI: confidence interval. A: the statistical significance of ocular complications. B: The statistical
significance of subjective visual disturbances.
z
Based on Logistic regression test. P < 0.05 was considered statistically significant by multiple logistic regression analysis.

of patients identified their ocular complications by examina-

tion (27.21  34.61 days) was shorter than those without
complications (48.17  59.04 days), there was no significant
relationship between them (P = 0.088).
We measured the BCVA in 74 of 102 patients at the time
of the initial examination. The overall average logMAR
visual acuity was 0.11  0.56 (SD). The average logMAR
visual acuity for the subjects with ophthalmic complications
was 0.24  0.54 (SD) (in the affected eye). There was no
record of BCVA for 4 of the affected eyes. The average
logMAR visual acuity for the subjects with subjective visual
symptoms was 0.12  0.57 (SD); 8 patients had logMAR
visual acuity better than 0.0 in both eyes. 6 patients had a
result of visual field test; 2 patients were normal, 3 results
were not reliable and valid, and a visual field defect was
identified in a patient who was diagnosed with glaucoma,
which had not been progressed since last examination.
There was no medical record for ERG. The maximal follow-
up period was 570 days, and the average was 49.5  27.82
days. During this period, 5 eyes underwent invasive
procedures, including phacoemulsification with intraocular
lens (IOL) insertion and subtenon triamcinolone injection.
Electrical cataract was diagnosed in 7 eyes; 3 eyes under-
went phacoemulsification and IOL insertion. Two eyes from
4 patients with macular edema received subtenon triam-
cinolone injections. Thus, with the exception of 5 patients,
all patients were managed conservatively.
Table 5 – Multiple regression analysis for potential
factors associated with time to consultation.
b  SE
TBSA 2.077  0.529
Voltage 0.000  0.000
Burn degree 19.462  8.568
Facial burn 7.219  11.176
Visual symptom 0.401  10.813
SE: standard errors; TBSA: total burn surface area.
z
Based on multiple regression test. P < 0.05 was considered
statistically significant.
4. Discussion
The present study describes the clinical and demographic
information related to electrical ocular injuries. Although
the incidence estimates differ from country to country,
electrical burns account for only a small proportion of all
presentations to burn centers [11]. According to the current
literature, the majority of these injuries is work related and
occurs in young men [11,12]. The same trends were
observed in our study population. The majorities of these
were work-related injuries (88%) that occurred in male
patients (99%), aged 30–49 years old (43 patients, 42.16%).
The demographic details of our patients showed that
electrical injuries that affected the eye primarily occurred
in an occupational setting.
From 2004 to 2010, 557 patients were admitted for electrical
burns to our hospital. The present study indicated that among
the 102 patients seen at our department during this 7-year
period, there were 29 patients with ophthalmic complications
and we found 53 cases of ocular injury. Although we only
reviewed the medical records of patients who underwent an
ophthalmic consultation, the incidence of electrical eye
damage was 5.2%.
Through careful ophthalmic examination, we were able to
characterize the ophthalmic complications of these patients.
The most common complication was punctate epithelial
erosions of the cornea. Interestingly, cataract formation is
widely accepted as the most common sequelae of electrical
burns [3,13,14]. However, most previous studies examined
injuries caused specifically by the flow of electrical current. In
a previous review of electrical burns that occurred during the
P valuez period from 2000 to 2008, the authors only studied patients
0.000 who were damaged by flash burns [12]. All patients with facial
0.368 burns in that study received an ophthalmic examination; the
0.025 most common ophthalmic complication was corneal damage.
0.520 The present study included all possible mechanisms of
0.971
electrical burns including high- and low-voltage electrical
injury, electrothermal or arc burns and thermal injury from
electronic objects. We thus documented the distribution of
complications in a large number of patients for the first time
1384 burns 39 (2013) 1380–1385
and showed that the cornea was the most common site of
electrical injury.
Our statistical analysis using the independent t test and
multivariate logistic regression analysis showed no relation-
ship between ophthalmic complications and any other
variable examined, including the voltage of the electrical
source. In general, high-voltage electrical burns were more
strongly associated with systemic complications than low-
voltage burns; thus high-voltage injuries were identified as the
most potentially debilitating type of injury [15–17]. In a
retrospective analysis conducted from 1994 to 2004, high-
voltage injuries were significantly associated with a higher
TBSA, an increased need for operative treatment, and a longer
hospitalization period [18]. However, from an ophthalmology
viewpoint, Han and Park demonstrated that ocular complica-
tions were not significantly related with high-voltage electrical
injuries or TBSA; the only variable related to complications
was the entry site [14]. Although our study population
included more patients with high-voltage as compared to
low-voltage burns (69 patients, 67.65%), ocular complications
were not significantly related to either high voltage or entry
site in our study. In contrast to the previous study, we included
not only electrical injuries from the passage of electrical
currents, but also arc and thermal injuries. Furthermore, the
initial burn injury was usually life threatening, which meant
that detailed history-taking and evaluations might not be
performed until days or weeks after admission. The entry site
was typically not reported or missing, even in patients with
true electrical injuries. Many entry sites of our patients were
unknown either due to the data not being recorded or since
data were missing from patient charts.
In the patients whose main reason for consulting the
ophthalmology department was complaints of visual distur-
bance, other variables such as TBSA, entry site, and voltage
were not significantly related to visual disturbances. Head and
neck involvement were correlated with visual disturbances;
however, the vision of these patients was generally not
impaired, and ocular complications were relatively mild.
Aggarwal et al. noted 6 patients who had facial burns due to
electrical flash burns; the most serious complication reported
was post-traumatic stress (PTSD) [12]. The symptoms reported
included depression, sleep disorders, nightmares, flashbacks,
difficulty concentrating, and a diminished ability to have
healthy relationships with family members. The authors also
found that many patients had an intense phobic response to
the site where the injury was incurred. In a review of electrical
injuries, Grossman et al. reported identical symptoms of PTSD
in from patients whose injuries were not related with the
passage of electrical current [18]. On the basis of the results
presented here and those documented in the literature, we
can assert that symptoms of visual disturbance in patients
with electrical eye injuries represent a variant of PTSD.
As our studies, many ophthalmologists generally examine
the patient with burn injuries after consultation of ophthalmic
examination being made by burn providers. Thus, we
calculated the number of days from admission to consultation
and analyzed the possible variables influencing the timing of
consultation. Our results showed that TBSA and overall degree
of burns significantly affected the consultation time with a
positive correlation, which means that as electrical damages
of burns become more severe, ophthalmic consultation is
delayed and the burn providers consult the patients for
ophthalmic evaluations after the patients become stable.
There was no statistically significant correlation between
facial involvement of electrical burn and consultation time,
but our result showed that facial burn was the only significant
risk factor of the patients complaining visual disturbances.
Thus, there should be a low threshold for obtaining ophthal-
mic complication, especially when there is any facial
involvement of burn.
Several limitations of the present study should be
mentioned. Because of the retrospective nature of our study,
some medical information regarding patient examination and
management during follow up period was lacking. Because
several patients were lost to follow-up and several charts were
incomplete, the data set was not complete for each patient.
This lack of information related to sequential examination
and management of patients prevented us from predicting the
prognosis following a severe ocular electrical injury. Another
limitation of the current study is that the exact etiology of the
subjective visual disturbances was difficult to confirm. The
coexistence of several diseases unrelated to electrical burns
(e.g., dry eye syndrome, unspecified cataract, diabetic reti-
nopathy, and age-related macular degeneration) may contrib-
ute to visual symptoms and the lack of results from functional
tests (e.g., visual field test, ERG, visual evoked potential (VEP)
test, and microperimetry) may also be the reason for that.
Therefore, it is difficult to discriminate the exact cause of
visual symptoms, and careful ophthalmic examination is
required. Even among patients who were likely to receive eye
examinations, the unknown etiology of ocular complications
and subjective reports of visual impairment detracted from
the strength of any conclusions drawn. For each type of
electrical damage, clinicians must be able to diagnose and
anticipate the potential complications. The use of techniques
such as visual field test, ERG and the visual evoked potential
(VEP) test may solve this limitation.
Information regarding the prevalence and causes of visual
disturbance is important to increase our understanding of the
pathogenesis of electrical trauma. Therefore, it is critical to
investigate the visual acuity in each patient for a better
understanding of how ocular electrical injury is related to
visual outcome. Unfortunately, the evaluation of visual acuity
was not fully possible in the 102 patients included in this
study. We did not obtain BCVA in 28 participants. Severe facial
burns, failure to correct refractory errors, a lack of medical
records, and the need for certain patients to remain confined
in bed were the major reasons for the lack of BCVA
measurements in these patients. Furthermore, previous
ocular history records were not available for the majority of
patients, which hampered the clinician’s ability to diagnose
the underlying cause of visual impairment. The limited
information on BCVA and the lack of previous ophthalmic
histories prevented us from examining the relationship
between BCVA and electrical ocular injury.
Notably, previous studies have widely recognized the
importance of incorporating the patient’s perspective on the
outcomes of medical and surgical interventions [19]. This is
one reason we chose to focus on patients with subjective
symptoms of visual disturbance and to explore the associated
 burns 39 (2013) 1380–1385
risk factors. The knowledge gained through this retrospective
study should contribute to efforts to improve visual quality or
function in patients with ocular electrical injuries. In conclu-
sion, this is the first study to focus on visual symptoms in
patients with electrical burns. The most common ocular injury
associated with electrical burns is multiple, punctate corneal
erosions, which is also the most common ophthalmic
complication associated with visual symptoms. The results
show that a facial burn was significantly related to subjective
visual symptoms. We therefore recommend the earlier
involvement of ophthalmologists in the treatment of any
patient who has suffered a facial burn. Even if patients are
unable to cooperate with careful ophthalmic examinations
during the early stage of injury, conservative management
including the use of eye lubricants or topical antibiotics would
be helpful to prevent future complications and alleviate visual
symptoms.
Conflict of interest statement
There are none of any financial and personal relationships
with people or organizations that could inappropriately
influence our work.
Acknowledgements
There was no conflict of interest statement, and no financial
support.
The contents are solely the responsibility of the authors.
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