Burns 28 (2002) 276–278
Case report
Cataract formation after a major burn due to explosion: a case report a Serdar Öztürk a,∗ , Mustafa Devecı a , Fatih Zor a , Güngör Sobacı b , Mustafa Sengezer ¸ a
Gülhane Military Medical Academy, Plastic and Reconstructive Surgery and Burn Center, Ankara, Turkey b Gülhane Military Medical Academy, Ophtalmology Clinic, Ankara, Turkey Accepted 25 October 2001
Abstract Cataract is a very rare complication of burn injuries in which the eye is not directly marked. A unilateral cataract presented some 85 days after a burn injury to a 21-year-old soldier. The cataract was treated surgically with excellent return of vision. © 2002 Elsevier Science Ltd and ISBI. All rights reserved. Keywords: Burns; Cataract
1. Introduction Major thermal injury is a multisystem disorder. Cataract is a very rare complication of thermal injury which does not directly involve the eyes [1]. A case of unilateral cataract due to a major flame burn after an explosion is presented here. The clinical features and possible mechanisms involved in development of this condition are discussed and the literature is reviewed. 2. Case report A 21-year-old male was admitted to our burn center at Gülhane Military Medical Academy because of an explosion in an ammunition store. He suffered from second to third degree flame burns at his back and chest, both upper extremities, both gluteal and femoral regions comprising 52% of his total body surface area (TBSA). There were diffuse tattoos on his face with bilateral palpebral oedema and ecchimoses. Ocular examination revealed no corneal or lenticular injuries after the edema and ecchimose resolved. There was no evidence of penetrating or perforating injuries to the globes. He was neurologically intact with no evidence of skull fracture on X-ray. He had fever episodes up to 39 ◦ C on the 4th day of burn, and he was treated by use of specific antimicrobial therapy with daily wound dressings. He underwent an operation and ∗ Corresponding author. Tel.: +90-312-304-54-01; fax: +90-312-304-54-12. E-mail address:
[email protected] (S. Öztürk).
skin grafting was performed. No major metabolic or septic complications were observed during the course of treatment. The patient complained of visual disturbance beginning on the 85th day of injury. Development of cataract was observed at the right eye without any corneal pathology (Fig. 1). His left eye was normal. He underwent an operation of lens aspiration and posterior IOL (intraocular lens) implantation (Fig. 2). A week later, posterior capsulotomy was performed by use of Nd-Yag laser because of fibrosis formation. Surgical therapy resulted in excellent return of vision and the patient was discharged.
3. Discussion A cataract may be defined as any opacity in the lens or alternatively as any opacity that interferes with vision. The known etiologies of cataract include trauma, inflammation, metabolic and nutritional diseases, radiation, and aging. The effects of explosion in development of cataract formation may be two-fold: (1) direct effect, traumatic injury by the blast effect, and (2) indirect effect, systemic response due to diffuse thermal injury of the skin. Traumatic cataract may be caused by blunt or perforating injury, and is frequently unilateral, causing considerable impairment of vision of one eye while the function of the other eye is normal [2,3]. Blunt trauma to the globe or adnexa may create a “shock wave” effect resulting in sublimation or total displacement of the crystalline lens [3]. Appropriate diagnosis and proper management of traumatic cataract is necessary to restore vision and prevent sight-threatening
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Fig. 1. Cataract formation is very obvious at the right eye of the patient preoperatively.
complications in such cases [2]. The blast effect of the explosion can cause such a blunt trauma to the eye, but the initial physical examination of the present case revealed no evidence of penetrating or perforating injuries to the globe and the fundoscopic examination was normal. To our knowledge, this is the first case of cataract development after an explosion in the literature. Cataract may be seen after chemical and electrical burn injuries, but it is not a common complication of thermal injury which does not directly effect the eye [1]. The crystalline lens is a cellular tissue which loses its nerves and vessels during fetal development; it derives nutrition from the surrounding aqueous and vitreous humors. Disturbance
of these fluids may cause altered metabolic activity and result in opacification (cataract). Biochemical changes that consistently occur in cataract include change in water content, loss of potassium, increased calcium, increased oxygen consumption, decreased glutathion with associated accumulation of reduced hexoses, and decreased ascorbic acid [2,3]. The lens is a crystalline structure containing 65% water. The lens contains 35% protein by mass, the highest protein content in any body tissue. A decrease in total protein accounts for a decrease in lens protein. Oxidation of membrane components may be an initiating event in cataract formation. Osmotic disturbances in body fluids and changes in metabolic activity mostly occur in the patients with ma-
Fig. 2. Appearance of the patient after IOL operation.
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jor thermal burns. So, we proposed that any of the systemic changes due to major skin burns may be involved in cataract formation. Cataract formation is one of the devastating and long-term complication of electrical injury [4–9]. Electrical burns can be divided into flash or typical thermal injury and high-tension injury. Cataracts can often be delayed for several years, although the onset of blurred vision usually begins about 6 months after electric injury [10]. Because this complication can occur in as many as 30% of persons receiving an electrical bum with contact above the clavicles, physicians must check for this complication in all patients and make patients aware of its possibility [11]. The current pathway, as well as its points of entry does not show any relation with the presence of renal failure, cataracts and cardiac arrhymia [7]. Major thermal injury often accompanies the electrical burns. Although the electrical injury is the most common type of burn in terms of cataract formation, the exact mechanism is not known, because no direct relation was shown between the current pathway and formation of cataract. Systemic response of the thermal injury is generally neglected, although large areas of skin burn accompany the electrical injury. If there could be any relation between large burn areas and cataract formation, this mechanism might be responsible in the present case with a 52% TBSA. Many drugs and chemicals have been shown to induce cataracts. Among the commonly used medications associated with cataract are corticosteroids, which cause opacification of the posterior subcapsular region after long-term systemic or topical use. No medication which could cause lenticular opacification was used during treatment. Cataract formation may be seen after chemical injuries [12,13]. In the present case, initial examinations of the eyes revealed no findings of corneal injury such as chemical keratitis. Moreover, no known chemicals which could be responsible for cataract formation were included in the composition of the explosion powder.
Cataract in adults usually occur after age of 30–40 years and are usually progressive. The present case is a very young person without any systemic illness and the onset is very sudden. In conclusion, cataract formation can be seen after major flame injury due to explosion. The exact mechanism of cataract formation after major bum injuries remains to be unknown. Systemic inflammatory response after such injuries affects many organs, and so the lens may be one of the target organs. The primary care of the physician plays an important role in evaluating patients sustained to explosion with major flame burn. References [1] Resch CS, Sullivan WG. Unexplained blindness after a major burn. Burns 1988;14:225–7. [2] Jones WL. Traumatic injury to the lens. Optom Clin 1991;1:125–42. [3] Ajamian PC. Traumatic cataract. Optom Clin 1993;3:49–56. [4] Saffle JR, Crandall A, Warden GD. Cataracts: a long-term complication of electrical injury. J Trauma 1985;25:17–21. [5] Van Johnson E, Kline LB, Shalka HW. Electrical cataracts: a case report and review of the literature. Ophthalmic Surg 1987;18:283–5. [6] Al Rabiah SM, Archer DB, Millar R, Collins AD, Shepherd WF. Electrical injury of the eye. Int Ophthalmol 1987;11:31–40. [7] Ferreiro I, Melendez J, Regalado J, Bejar FJ, Gabilondo FJ. Factors influencing the sequelae of high tension electrical injuries. Burns 1998;24:649–53. [8] Reddy SC. Electric cataract: a case report and review of the literature. Eur J Ophthalmol 1999;9:134–8. [9] Luce EA. Electrical burns. Clin Plast Surg 2000;27:133–43. [10] Monafo WW, Freedman BM, Electrical and lightning injury, In: Boswick J.A., (Ed.). The art and science of burn care. Rockville: Aspen Publishers Inc., 1987: 241–54. [11] Robson MC, Smith DJ. Care of thermally injured victim. In: Jurkiewicz MJ, Krizek TJ, Mathes SJ, Ariyan S (Eds.), Plastic Surgery: Principles and practice. St. Louis: CV Mosby Company, 1990: 1355–410. [12] Awan KJ. Delayed cataract formation after alkali burn. Can J Ophthalmol 1975;10:423–6. [13] Schmitt-Bernard CF, Arnaud B. Ocular trauma and caustic burns by air bags. CH-1. J Fr Ophthalmol 1998;21:220–2.
