This document discusses chemical injuries of the eye, specifically alkali and acid burns. It describes the epidemiology, physical exam findings, classification systems, management, and treatment approaches for different grades of injuries. For mild injuries (Grade I), topical steroids, antibiotics and artificial tears are used. More severe injuries (Grade II-III) involving the cornea and conjunctiva may also require oral vitamins, debridement, amniotic membrane grafts, and surgery. The most severe injuries (Grade IV) often necessitate early surgical intervention like Tenonplasty to reestablish limbal vascularity and prevent further necrosis. Proper irrigation, classification, and multimodal medical and surgical management can help improve outcomes for
chemical injury to eye by alkali, acids and irritants.
pathophysiology and management.
recent advances in management.
ITS A TRUE EMERGENCY IN OPHTHALMOLOGY
Ocular Chemical Burns - Pathophysiology and Evidence-Based TreatmentSteven M. Christiansen
This case-based presentation describes the pathophysiology of ocular chemical burns (alkali and acid), as well as the evidence behind currently recommended medical and surgical treatment options.
Ophthalmologic approach to chemical burns Chimozi Tembo
Chemical burns are one of the true ophthalmologic emergencies. The ophthalmologist and general practitioner thus needs to be aware of the management of this type of eye injury.
Chemical (alkali and acid) injury of the conjunctiva and cornea is a true ocular emergency and requires immediate intervention.
Epidemiology:>-Chemical injuries to the eye represent between 11.5%-22.1% of ocular traumas.
etiology:-Chemical injuries occur as a result of acid, alkali, or neutral agents.Alkalis being responsible for 60%.
pathophysiology:-Alkali agents are lipophilic and therefore penetrate tissues more rapidly than acids.the damaged tissues then secrete proteolytic enzymes, which lead to further damage.Acids are generally less harmful than alkali .
coagulated proteins act as a barrier to prevent further penetration .
Symptoms & signs:-Pain,Lacrimation,Photophobia,Blepharospasm
Grading of severity:=1) Roper-Hall (modified Hughes) classification
2) Dua classification
MANAGEMENT:-Emergency treatment
Medical treatment
Surgical treatment
chemical injury to eye by alkali, acids and irritants.
pathophysiology and management.
recent advances in management.
ITS A TRUE EMERGENCY IN OPHTHALMOLOGY
Ocular Chemical Burns - Pathophysiology and Evidence-Based TreatmentSteven M. Christiansen
This case-based presentation describes the pathophysiology of ocular chemical burns (alkali and acid), as well as the evidence behind currently recommended medical and surgical treatment options.
Ophthalmologic approach to chemical burns Chimozi Tembo
Chemical burns are one of the true ophthalmologic emergencies. The ophthalmologist and general practitioner thus needs to be aware of the management of this type of eye injury.
Chemical (alkali and acid) injury of the conjunctiva and cornea is a true ocular emergency and requires immediate intervention.
Epidemiology:>-Chemical injuries to the eye represent between 11.5%-22.1% of ocular traumas.
etiology:-Chemical injuries occur as a result of acid, alkali, or neutral agents.Alkalis being responsible for 60%.
pathophysiology:-Alkali agents are lipophilic and therefore penetrate tissues more rapidly than acids.the damaged tissues then secrete proteolytic enzymes, which lead to further damage.Acids are generally less harmful than alkali .
coagulated proteins act as a barrier to prevent further penetration .
Symptoms & signs:-Pain,Lacrimation,Photophobia,Blepharospasm
Grading of severity:=1) Roper-Hall (modified Hughes) classification
2) Dua classification
MANAGEMENT:-Emergency treatment
Medical treatment
Surgical treatment
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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.
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.
8.
9.
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
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.
25. Diffuse epithelial disruption of the inferior two-thirds of the cornea after an
acute alkali burn to the eye from cement.
Editor's Notes
1-Clare, G., et al., Amniotic membrane transplantation for acute ocular burns. Cochrane database of systematic reviews, 2012. 9: p. CD009379.
2- Wagoner, M.D., Chemical injuries of the eye: current concepts in pathophysiology and therapy. Survey of ophthalmology, 1997. 41(4): p. 275-313.
Note: The intraocular pressure should also be documented, as alkali injuries have been found to both acutely and chronically cause an elevation of IOP.
1- Colby, K., Chemical injuries of the Cornea. Focal Points in American Academy of Ophthalmology.2010. 28(1): p. 1-14.
They should be considered if there is significant corneal melting and can be administered both topically (tetracycline ointment four times daily) and systemically(doxycycline 100 mg twice daily tapering to once daily
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Representative clinical photographs of eyes with varying grades of ocular chemical injury. (Top row) Grade II chemical injury, showing good recovery and favorable prognosis. (Top row left) Eye with grade II chemical injury at presentation. Note the epithelial defect and ciliary congestion. (Top row middle) Six-month follow-up. (Top row right) One-year follow-up. Note the nearly clear cornea with no significant sequelae. (Second row) Grade III chemical injury showing good recovery and favorable prognosis. (Second row left) Eye with grade III chemical injury at presentation. Note the epithelial defect and limbal involvement (Second row middle) Six-month follow-up. (Second row right) One-year follow-up. Note the corneal opacity at the site of limbal involvement. (Third row) Grade IV chemical injury showing poor recovery and unfavorable prognosis. (Third row left) Eye with grade IV chemical injury at presentation. Note the epithelial, stromal, limbal, and conjunctival involvement. (Third row middle) Six-month follow-up. (Third row right) One-year follow-up. Note the leukomatous corneal opacity with pannus formation. (Bottom row) Grade VI chemical injury showing dismal recovery and unfavorable prognosis. (Bottom row left) Eye with grade VI chemical injury at presentation. Note the involvement of the entire ocular surface and corneal stroma. (Bottom row middle) Six-month follow-up. Note the persistence of inflammation. (Bottom row right) One-year follow-up. Note the large vascularized corneal opacity with 360-degree pannus formation.
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I would favor the use of prednisolone acetate 1% drops every 2 hours in both eyes. Along with this, I would cover with a broad-spectrum antibiotic drop such as a fourth-generation fluoroquinolone 4 times daily, and I would add a cycloplegic agent such as scopolamine 0.25% 4 times daily or atropine 1% twice daily (not phenylephrine because of its vasoconstrictive properties). Furthermore, I would consider either oral vitamin C 1 g 4 times daily (don’t forget to remind the patient to drink a lot of water) or oral doxycycline 100 mg twice daily (or both) to prevent stromal melting.3Sodium citrate 10% drops can also be used for this purpose, but it is difficult to obtain and, in this case, is probably not necessary. If the intraocular pressure is elevated, oral acetazolamide 250 mg 4 times daily or 500 mg twice daily can be used, or a topical beta-blocker should be given. Frequent use of preservative-free artificial tears should be encouraged on an hourly basis and, if necessary, an oral analgesic can be prescribed.