eye chemical injuries . epidemiology , examination and management

1. Chemical injuries of the eye
Presented by:
Dr. Dana Sultan

2. the outcome
• Epidemiology
• Physical examination
• International Classification
• Management “medical”

3. Types of chemical injuries
• Alkali burns
most dangerous , rapid penetrating.
• Acid burns
lesser sever , do not penetrate except hydrofluoric acid.
• Irritants
pepper , pain rarely causes any damage to the eye.

4. Common causes of alkali and acid injuries

5. Epidemiology
• 11.5%-22.1% of ocular traumas1
• two thirds of these injuries occur in young men.
• Alkali materials are found more commonly in building materials and
cleaning agents and occur more frequently than acid injuries. 2

6. Physical examination
• pH of both eyes if not in normal range (between 7 and 7.2) ( irrigate )
• Assess the extent and depth of injury (the degree
of corneal, conjunctival and limbal involvement ).
• The palpebral fissures should be checked and the fornices should be swept
during the initial exam
• The intraocular pressure IOP should also be documented.
NOTE

7. Two major classification schemes
• The Roper-Hall classification
-Based on the degree of corneal involvement and limbal ischemia.
• The Dua classification
-based on an estimate of limbal involvement (in clock hours) and the
percentage of conjunctival involvement.

10. Grade I chemical injury: hydrochloric acid (HCl). Burn of the cornea only.
Coagulated corneal epithelium with ‘ground glass’ appereance. Partial
removal of the epithelium, clear corenal stroma.

11. Grade III chemical injury: sodium hydroxide (NaOH). Complete corneal and
proximal conjunctival epithelial defect with loss of corneal stromal clarity.
Limbal ischemia in theinferior quadrants.

12. Grade IV chemical injury:sodium hydroxide (NaOH). Loss of corneal
transparency, ectropion uveae and cataract formation, circular loss of
conjunctival and episcleral tissue down to the fornices.The sclera is ischemic

13. Management
• Irrigation
• Debridement of necrotic areas of corneal epithelium
• Medical treatment
• SurgicalTreatments

14. Irrigation
• TypeTopical anaesthetic
• Irrigate the eye for 15–30 minutes or until the measured pH is neutral..

15. Cement particles lodged in the upper fornix of a gentleman who suffered an
alkali burn to the eye with cement. Failure to identify and remove these
particles will result in a reservoir for continued alkali release onto the ocular
surface. (Photo courtesy of Richard L. Abbott, MD.).

16. Debridement of necrotic areas of corneal
epithelium
• should be performed as early as possible because necrotic tissue serves as a
source of inflammation and can inhibit epithelialization.1

17. Medical treatment
1. Antibiotics- A topical antibiotic ointment like erythromycin ointment four
times daily.
2. Cycloplegic agents such as atropine or cyclopentolate can help with
comfort.
3. Artificial tears- preferably preservative free, should be used generously for
comfort.

18. 4. Steroid drops- In the first week following injury,
reduce inflammation and neutrophil infiltration, and
address anterior uveitis. However, they also impair stromal
healing by reducing collagen synthesis and inhibiting
fibroblast migration.
-topical prednisolone(Predforte) can be employed four
times daily. In more severe injuries, every hour.
the steroids should be tapered after 7–10 days when sterile
corneal ulceration is most likely to occur.

19. 5. Ascorbic acid improves wound healing, promoting the synthesis of mature
collagen by corneal fibroblasts.
Topical sodium ascorbate 10% can be given 2-hourly in
addition to a systemic dose of 1–2 g vitamin C (L-ascorbic
acid) four times daily .
6. Tetracyclines are effective collagenase inhibitors and also inhibit
neutrophil activity and reduce ulceration.
They should be considered if there is significant corneal
melting and can be administered both topically and
systemically
7. Citric acid is a powerful inhibitor of neutrophil activity and reduces the
intensity of the inflammatory response.

20. Grade I
• Topical antibiotic ointment (erythromycin ointment or similar) four times a
day
• Prednisolone acetate 1% four times a day
• Preservative free artificial tears as needed
• If there is pain, consider a short acting cycloplegic like cyclopentolate three
times a day

21. Grade II
• Topical antibiotic drop like fluoroquinolone four times daily
• Prednisolone acetate 1% hourly while awake for the first 7-10 days. Consider
tapering the steroid if the epithelium has not healed by day 10-14. If an epithelial
defect persists after day 10, consider progestational steroids (1%
medroxyprogesterone four times daily)
• Long acting cycloplegic like atropine
• Oral Vitamin C, 2 grams four times a day
• Doxycycline, 100 mg twice a day (avoid in children)
• Preservative free artificial tears as needed
• Debridement of necrotic epithelium and application of tissue adhesive as needed
• Sodium ascorbate drops (10%) hourly while awake

22. Grade III
• As for Grade II
• Consider amniotic membrane transplant/Prokera placement.This should
ideally be performed in the first week of injury. Experienced surgeons have
emphasized placement of the amniotic membrane to cover the palpebral
conjunctiva by suturing to the lids in the operating room, not just covering
the cornea and bulbar conjunctiva.

23. Grade IV
• As for Grade II/III
• Early surgery is usually necessary. For significant necrosis, a Tenonplasty
can help reestablish limbal vascularity. An amniotic membrane transplant
is often necessary due to the severity of the ocular surface damage.

24. Grade II
Grade III
Grade IV
Grade IV

25. Diffuse epithelial disruption of the inferior two-thirds of the cornea after an
acute alkali burn to the eye from cement.