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Designed by Soumaya Bouhout, Amina Yasmine Acher, Dr. Andre Ali-Ridha.

New Content and Updates by Ali Salimi and Dr. Andre Ali-Ridha

Last updated September 2019

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Background

Soumaya Bouhout, Dr. Ali-ridha, Dr. Discepola
Corneal opacification, six months post-alkali burn
Picture from eyerounds.org

  • Can cause severe corneal opacification and irreversible damage.

  • Chemical burns varies in intensity depending on :

    • The amount of product

    • Area of exposure      

    • Duration of exposure

    • Type of chemical

    • Related thermal effect

  • The majority are accidental but a few of them are assaults.

  • Two third of them occur at work and one third at home.

  • Alkali burns are twice more frequent than Acid burns

  • Alkalis burns are more severe than Acids

    • Alkalis penetrates more deeply the tissues than acids and can progress over weeks

    • Acids coagulate the tissue and cause a protecting barrier

    • Ammonia and sodium hydroxide (both alkali) tend to cause more damage because of rapid penetration

Management | Time is vision !

1. Copious irrigation urgently! Start IMMEDIATELY

  • Does not need an ophthalmology referral prior to irrigation
    • Speed of irrigation is the most important prognostic factor 

  • Topical anesthetic should be given prior to irrigation 

  • Can use a lid speculum 

  • If available; use a special lens that directly attached to the an IV and irrigate the entire surface (e.g. Morgan Lens-see picture bellow)

  • Irrigate with NS or Ringer lactate for 15-30 minute (tap water can be use if no sterile fluid is available)

  • Wait 5 minutes after irrigation is stopped and measure the pH in the fornices 

  • You should sweep the conjunctival fornices with Q-tip to remove any residue of chemical, especially with persistent abnormal pH

  • Measure the pH with pH paper. You should irrigated until the measured pH is neutral ( pH =7.0 to 7.4)

    • The volume needed to neutralize the pH may vary but you may need over 8 to 10L !

Morgan Len | Available in most E.R. department and directly connects to the IV set. Picture from themorganlens.com
Ph reference table for common products

 2. Key questions on history

  • The type of chemical
  • The mechanism and timing of injury

  • Loss of vision? Ocular pain ?

  • Any chance it affected the other eye?

 

 3. Ocular exam

  • Vital signs of the eye : Vision, Pupils, Intra-ocular pressure (IOP)

  • Slit-lamp exam | May vary from superficial keratitis to severe conjunctival and corneal damage

    • Any eyelid involvement?

    • Comment on the clarity of the cornea, conjunctival erythema​

    • Fluorescein should be used to examine the status of the cornea and conjunctiva

 4. Medication 

  • Cycloplegic drops ( e.g. Cyclogyl 1% 1 drop t.i.d.) to decrease iris spasm and pain

  • If IOP is significantly high , consider prescribing a pressure lowering drops

    • e.g. Timolol 0.5% b.i.d. if no contraindication, do not prescribe Alpha-agonist drops as it can cause vasoconstriction and lead fo more limbal ischemia

  • Topical steroids should only be prescribed by an ophthalmologist

 5. Ophthalmology referral

  • This is an ophthalmology true emergency, needs to be seen as soon as possible once the pH is neutralized.

  • Key information the ophthalmologists needs to know when contacted :

Type of injury (acid or alkali)

Timing of injury

Is the pH now neutralized ?

Vitals signs of the eye : Vision, Pupils, Intra-ocular pressure

Alkali Burn
Picture from eyerounds.org
Superficial keratitis
Can be seen in very mild chemical exposure. Seen in the inter-palpebral area. 
Picture from eyerounds.org

References 

  1. Bagheri, Nika, and Brynn N. Wajda. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease. , 2017. Internet resource.

  2. “How to irrigate the eye” Community eye health vol. 29,95 (2016): 56.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5340106/