Ocular Trauma | Chemical Burn

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
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 

 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

  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/

© 2020 by tcpophthalmology.com.

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

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

Last updated September 2020