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Ophthalmologic Approach to Chemical Burns Clinical Presentation

  • Author: Mark Ventocilla, OD, FAAO; Chief Editor: John D Sheppard, Jr, MD, MMSc  more...
 
Updated: May 13, 2016
 

History

Most often, the patient gives a history of a liquid or a gas being splashed or sprayed into the eyes or of particles falling into the eyes. Query the patient regarding the specific nature of the chemical and the mechanism of injury (eg, simple splash vs high-velocity blast). The local poison control center can be an invaluable resource in determining the exact nature of the chemical composition, when unknown, particularly with obscure commercial products. 

Regardless of the specific mechanism of injury, the patient's complaints are frequently related to the severity of the exposure. Common complaints elicited are as follows:

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Physical

A thorough physical examination should be deferred until the affected eye is irrigated copiously, and the pH of the ocular surface is neutralized. Topical anesthetic drops may be used to aid in patient comfort and cooperation. After irrigation, a thorough eye examination is performed with special attention given to clarity and integrity of the cornea, degree of limbal ischemia, concomitant retained foreign bodies, conjunctival trauma, lid trauma, and IOP. Common physical manifestations of chemical injuries to the eye are discussed below.

Decreased visual acuity: Initial visual acuity can be decreased because of corneal epithelial defects, haze, increased lacrimation, or discomfort. In moderate-to-severe chemical burns seen soon after the injury, the corneal haze may be minimal on presentation with good vision, but it can increase significantly with time, severely reducing vision.

Increased IOP: An immediate rise in IOP may result from collagen deformation and shortening, thereby reducing the anterior chamber depth. Prolonged elevation of IOP is directly related to the degree of anterior segment inflammation.

Conjunctival inflammation: Varying degrees of conjunctival hyperemia and chemosis are possible, and even a mild chemical injury can elicit an exuberant conjunctival response. Prolonged or severe conjunctival inflammation must be aggressively treated owing to the significant risk of substantia propria cicatrization, trichiasis and entropion, symblepharon (usually more severe inferiorly), punctal stenosis, and severe dry eye due to obliteration of the lacrimal ductules and goblet cells.

Particles in the conjunctival fornices: This finding is more common with particulate injuries, such as wet plaster or concrete. If not removed, the residual particles can serve as a reservoir for continued chemical release and injury. These particles must be removed before ocular surface healing can begin.

Perilimbal ischemia: The degree of limbal ischemia (blanching) is perhaps the most significant prognostic indicator for future corneal healing because the limbal stem cells are responsible for repopulating the corneal epithelium. In general, the greater the extent of blanching, the worse the prognosis. However, the presence of intact perilimbal stem cells does not guarantee normal epithelial healing. The extent of blanching should be documented in terms of clock hours involved. Limbal ischemia also portends trabecular meshwork damage, eventual peripheral anterior synechiae, and recalcitrant glaucoma.

Corneal epithelial defect: Corneal epithelial damage can range from mild diffuse punctate epithelial keratitis (PEK) to a complete epithelial defect. A complete epithelial defect may not take up fluorescein dye as rapidly as in a routine corneal abrasion; therefore, it may be missed. If an epithelial defect is suspected but not found on the initial evaluation, the eye should be reexamined after several minutes. The size of the defect should be recorded so as to document response to treatment on subsequent visits.

Conjunctival epithelial defect: Conjunctival epithelial damage is found more commonly than corneal defects because milder burns manifest first inferiorly where chemicals aggregate with gravity and less rapid turnover from reflex blinking and squeezing. 

Stromal haze: Haze can range from a clear cornea (grade 0) to a complete opacification (grade 5) with no view into the anterior chamber.

Corneal perforation: A very rare finding at presentation, it is more likely to occur after the initial presentation (from days to weeks) in severely injured eyes that have poor healing capacity. It may also result from a simultaneous penetrating injury.

Anterior chamber inflammatory reaction: This can vary from trace cell and flare to a vigorous fibrinoid anterior chamber reaction. Generally, this finding is more common with alkaline injuries because of the greater depth of penetration. Uveitis is generally another very poor prognostic sign.

Adnexal damage/scarring: Similar to chemical injuries on other skin areas, this finding can lead to severe exposure problems if eyelid scarring prevents proper lid closure, thereby exposing an already damaged ocular surface. Lagophthalmos should be addressed early and aggressively by a surgeon experienced in oculoplastics.

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Causes

Common sources of alkali are as follows:[9]

  • Cleaning products (eg, ammonia)
  • Fertilizers (eg, ammonia)
  • Drain cleaners (eg, lye)
  • Cement, plaster, mortar (eg, lime)
  • Airbag rupture (eg, sodium hydroxide)
  • Fireworks (eg, magnesium hydroxide)
  • Potash (eg, potassium hydroxide)

Common sources of acids are as follows:[9]

  • Battery acid (eg, sulfuric acid)
  • Bleach (eg, sulfurous acid)
  • Glass polish (eg, hydrofluoric; behaves like alkali)
  • Vinegar (eg, acetic acid)
  • Chromic acid (brown discoloration of conjunctiva)
  • Nitric acid (yellow discoloration of conjunctiva)
  • Hydrochloric acid (used to clean swimming pools)
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Contributor Information and Disclosures
Author

Mark Ventocilla, OD, FAAO Adjunct Clinical Professor, Michigan College of Optometry; Editor, American Optometric Association Ocular Surface Society Newsletter; Chief Executive Officer, Elder Eye Care Group, PLC; Chief Executive Officer, Mark Ventocilla, OD, Inc; President, California Eye Wear, Oakwood Optical

Mark Ventocilla, OD, FAAO is a member of the following medical societies: American Academy of Optometry, American Optometric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology, Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery Department, Wills Eye Hospital

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Ophthalmological Society, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, International Society of Refractive Surgery, Cornea Society, Eye Bank Association of America

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cornea Society, Allergan, Bausch & Lomb, Bio-Tissue, Shire, TearScience, TearLab<br/>Serve(d) as a speaker or a member of a speakers bureau for: Allergan, Bausch & Lomb, Bio-Tissue, TearScience.

Chief Editor

John D Sheppard, Jr, MD, MMSc Professor of Ophthalmology, Microbiology and Molecular Biology, Clinical Director, Thomas R Lee Center for Ocular Pharmacology, Ophthalmology Residency Research Program Director, Eastern Virginia Medical School; President, Virginia Eye Consultants

John D Sheppard, Jr, MD, MMSc is a member of the following medical societies: American Academy of Ophthalmology, American Society for Microbiology, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, American Uveitis Society

Disclosure: Nothing to disclose.

Additional Contributors

Fernando H Murillo-Lopez, MD Senior Surgeon, Unidad Privada de Oftalmologia CEMES

Fernando H Murillo-Lopez, MD is a member of the following medical societies: American Academy of Ophthalmology

Disclosure: Nothing to disclose.

Acknowledgements

Alok S Bansal, MD Fellow, Vitreoretinal Surgery, Wills Eye Hospital

Alok S Bansal, MD is a member of the following medical societies: American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, and International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Geoffrey Broocker, MD, FACS Walthour-DeLaPerriere Professor of Ophthalmology, Department of Ophthalmology, Emory University School of Medicine; Former Chief of Service, Ophthalmology, Grady Memorial Hospital

Geoffrey Broocker, MD, FACS is a member of the following medical societies: American College of Surgeons

Disclosure: Nothing to disclose.

Evan S Loft, MD Clinical Assistant Professor, Department of Ophthalmology, Emory University

Evan S Loft is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

J Bradley Randleman, MD Associate Professor, Department of Ophthalmology, Section of Cornea, External Disease and Refractive Surgery, Emory University School of Medicine; Director of Cornea, External Disease and Refractive Surgery Fellowship, Emory University; Physician Member, Section of Ophthalmology, The Emory Clinic

J Bradley Randleman, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Cornea Society, and International Society of Refractive Surgery

Disclosure: Nothing to disclose.

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Alkali burn. Note the severe conjunctival reaction and stromal opacification blurring iris details inferiorly.
Severe chemical injury with early corneal neovascularization.
Complete cicatrization of the corneal surface following chemical injury.
 
 
 
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