Lightning-Induced Maculopathy: Case Report of a Bilateral Case with Retinal Atrophy

Abstract

Exposure to atmospheric electrical discharges can cause permanent ocular damage, frequently involving the macula. We aim to describe a case of lightning-induced maculopathy documented with multimodal imaging and to discuss its clinical and structural presentation.

The patient underwent a comprehensive ophthalmologic evaluation, including best-corrected visual acuity (BCVA), slit-lamp biomicroscopy, tonometry, fundus examination, and ancillary imaging (color fundus photography and optical coherence tomography).

A 38-year-old, previously healthy man, presented with bilateral central scotoma and decreased vision. BCVA was 0.7 in both eyes. He reported having been hospitalized in Brazil five years earlier after being struck by lightning. The anterior segment and intraocular pressure were normal. Fundoscopy revealed, in both eyes, a well-defined, hyperpigmented macular lesion of approximately one disc diameter, centered on the fovea, compatible with bilateral macular scarring. Macular Spectral Domain Optical coherence tomography (SD-OCT) revealed foveal thinning, disorganization of the neurosensory retinal layers, subfoveal fibrosis, and bilateral perifoveal cavitations, consistent with lamellar macular holes in both eyes.

Lightning maculopathy may present with parafoveal cavitations and outer retinal/RPE alterations, reflecting preferential thermal and electrical injury to melanin-rich tissues. It may evolve, after the acute phase, with irreversible structural sequelae characterized by retinal atrophy and the formation of lamellar or full-thickness macular holes, resulting in permanent visual deficit. OCT is crucial for diagnosis, follow-up, and prognostic counseling. This case illustrates a late macular sequela following lightning injury with visual impact, highlighting the importance of a thorough clinical history in patients presenting with atypical maculopathy.