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Ophthalmologic Approach to Chemical Burns Follow-up

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

Further Outpatient Care

Close follow-up care is mandatory in the first weeks following a severe chemical injury to assess epithelial regeneration and corneal melting, to change medications, to control inflammation and IOP, and to prevent secondary infection. Patients should be under the care of an ophthalmologist during this critical period.

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Further Inpatient Care

In patients with severe chemical injuries, short hospitalization may be warranted to closely monitor IOP, corneal integrity, medication use, and pain control.

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Inpatient & Outpatient Medications

See the list below:

  • Prednisolone acetate 1%, loteprednol etabonate, or difluprednate (1 gtt qid)
  • Erythromycin or bacitracin ophthalmic ointment (4-8 times/d)
  • Homatropine 5% or scopolamine 0.25% (1 gtt tid)
  • Ascorbate (500 mg PO qid)
  • Levobunolol hydrochloride 0.5% (1 gtt bid) or acetazolamide (500 mg PO bid) - Pressure-lowering agents, such as levobunolol and acetazolamide, are indicated only if IOP is increased (>30 mm Hg). 
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Transfer

After completing initial irrigation and treatment, patients should be transferred to facilities that have ophthalmologists available to assume their care. 

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Deterrence/Prevention

Education and training regarding the prevention of chemical exposures in the workplace can help prevent chemical injuries to the eye.

Persons who may be exposed to chemicals in the workplace are advised to wear safety goggles.

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Complications

Primary complications include the following:

  • Conjunctival inflammation
  • Corneal haze and edema
  • Acute rise in IOP
  • Corneal melting and perforations

Secondary complications include the following:

  • Secondary glaucoma
  • Secondary cataract
  • Bulbar conjunctival scarring
  • Lid scarring, trichiasis, and entropion
  • Corneal thinning and perforation
  • Complete ocular surface disruption with corneal scarring and vascularization
  • Corneal ulceration (sterile or infectious)
  • Complete globe atrophy (phthisis bulbi): See the image below.
    Complete cicatrization of the corneal surface foll Complete cicatrization of the corneal surface following chemical injury.
  • Secondary severe dry eye (long-term) due to loss of conjunctival goblet cells and lacrimal ductules
  • Tarsal conjunctival scarring, leading to symblepharon formation, trichiasis, and cicatricial ectropion or ectropion
  • Complete ocular surface disruption with corneal scarring, keratinization, and vascularization due to loss of limbal stem cells
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Prognosis

In general, the prognosis of ocular chemical injuries is directly correlated with the severity of insult to the eye and adnexal structures.

Many classification systems and revisions thereof have been aimed at classifying ocular burns in relation to their prognosis, including the following systems: Thoft, Hughes, Roper-Hall, and Pfister.[9] In essence, all systems aim to quantify the degree of corneal epithelial involvement, the degree of limbal stem cell loss, and the degree of conjunctival involvement.[18]  

Injuries can be graded from 0-5, as follows:

  • Grade 0 - Minimal epithelial defect, clear corneal stroma, no limbal ischemia
  • Grade 1 - Partial-complete epithelial defect, clear corneal stroma, no limbal ischemia, corneal epithelial involvement only
  • Grade 2 - Partial-complete epithelial defect, mild stromal haze, none or only mild limbal ischemia
  • Grade 3 - Complete epithelial defect, moderate stromal haze, less than one third of the limbus is ischemic
  • Grade 4 - Complete epithelial defect, stromal haze blurring iris details, one third to two thirds of the limbus is ischemic
  • Grade 5 - Complete epithelial defect, stromal opacification, greater than two thirds of the limbus is ischemic

Grades 0-2 can be expected to heal well with proper care and follow-up examinations.

The course for grades 3-5 is more tenuous and may require surgical intervention, in the form of either limbal stem cell transplantation to regenerate the ocular surface or penetrating keratoplasty to replace the corneal stroma and endothelium. These cases have a much poorer prognosis. 

Higher-grade injuries are more susceptible to secondary complications.

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Patient Education

If the injury resulted from a preventable accident, proper safety instruction should be provided.

If a patient is left functionally monocular from an injury, the patient should be instructed in the use of safety eyewear (eg, polycarbonate lenses).

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center and Eye and Vision Center. Also, see eMedicineHealth's patient education articles Chemical Burns, Chemical Eye Burns, and Eye Injuries.

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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.

References
  1. Merle H, Gerard M, Schrage N. [Ocular burns]. J Fr Ophtalmol. 2008 Sep. 31(7):723-34. [Medline].

  2. Hodge C, Lawless M. Ocular emergencies. Aust Fam Physician. 2008 Jul. 37(7):506-9. [Medline].

  3. Spector J, Fernandez WG. Chemical, thermal, and biological ocular exposures. Emerg Med Clin North Am. 2008 Feb. 26(1):125-36, vii. [Medline].

  4. Pfister DA, Pfister RR. Acid injuries of the eye. Fundamentals of Cornea and External Disease. Cornea. 2005. Vol 2.: 1277-84.

  5. Pfister RR, Pfister DA. Alkali injuries of the eye. Fundamentals of Cornea and External Disease. Cornea. 2005. Vol 2: 1285-93.

  6. Xiang H, Stallones L, Chen G, Smith GA. Work-related eye injuries treated in hospital emergency departments in the US. Am J Ind Med. 2005 Jul. 48(1):57-62. [Medline].

  7. Morgan SJ. Chemical burns of the eye: causes and management. Br J Ophthalmol. 1987 Nov. 71(11):854-7. [Medline].

  8. Klein R, Lobes LA Jr. Ocular alkali burns in a large urban area. Ann Ophthalmol. 1976 Oct. 8(10):1185-9. [Medline].

  9. Wagoner MD, Kenyon KR. Chemical injuries of the eye. Clinical Practice. Albert, Jakobiec, eds. Principles and Practice of Ophthalmology. 2000. Vol 2: 943-59.

  10. Kheirkhah A, Johnson DA, Paranjpe DR, Raju VK, Casas V, Tseng SC. Temporary sutureless amniotic membrane patch for acute alkaline burns. Arch Ophthalmol. 2008 Aug. 126(8):1059-66. [Medline].

  11. Tandon R, Gupta N, Kalaivani M, et al. Amniotic membrane transplantation as an adjunct to medical therapy in acute ocular burns. Br J Ophthalmol. 2011 Feb. 95(2):199-204. [Medline].

  12. Kheirkhah A, Johnson DA, Paranjpe DR, Raju VK, Casas V, Tseng SC. Temporary sutureless amniotic membrane patch for acute alkaline burns. Arch Ophthalmol. 2008 Aug. 126(8):1059-66. [Medline].

  13. Jafarinasab MR, Feizi S, Javadi MA, Karimian F, Soroush MR. Lamellar keratoplasty and keratolimbal allograft for mustard gas keratitis. Am J Ophthalmol. 2011 Dec. 152(6):925-932.e2. [Medline].

  14. Takeda K, Nakamura T, Inatomi T, Sotozono C, Watanabe A, Kinoshita S. Ocular surface reconstruction using the combination of autologous cultivated oral mucosal epithelial transplantation and eyelid surgery for severe ocular surface disease. Am J Ophthalmol. 2011 Aug. 152(2):195-201.e1. [Medline].

  15. Kawashima M, Kawakita T, Satake Y, Higa K, Shimazaki J. Phenotypic study after cultivated limbal epithelial transplantation for limbal stem cell deficiency. Arch Ophthalmol. 2007 Oct. 125(10):1337-44. [Medline].

  16. Clare G, Suleman H, Bunce C, Dua H. Amniotic membrane transplantation for acute ocular burns. Cochrane Database Syst Rev. 2012 Sep 12. 9:CD009379. [Medline].

  17. Tuft SJ, Shortt AJ. Surgical rehabilitation following severe ocular burns. Eye. 2009 Jan 23. [Medline].

  18. Dua HS, King AJ, Joseph A. A new classification of ocular surface burns. Br J Ophthalmol. 2001 Nov. 85(11):1379-83. [Medline].

  19. Brodovsky SC, McCarty CA, Snibson G, et al. Management of alkali burns : an 11-year retrospective review. Ophthalmology. 2000 Oct. 107(10):1829-35. [Medline].

  20. Dohlman CH, Cade F, Pfister R. Chemical burns to the eye: paradigm shifts in treatment. Cornea. 2011 Jun. 30(6):613-4. [Medline].

  21. Hemmati H, Colby K. Treating Acute Chemical Injuries of the Cornea. EyeNet. October 2012. [Full Text].

  22. Stern G, Goins K, Pelton R. Focal points, Chemical Injuries of the Cornea. March 2010. 1-14.

  23. Suri K, Kosker M, Raber IM, Hammersmith KM, Nagra PK, Ayres BD, et al. Sutureless amniotic membrane ProKera for ocular surface disorders: short-term results. Eye Contact Lens. 2013 Sep. 39(5):341-7. [Medline].

 
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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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