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Ophthalmologic Approach to Chemical Burns Medication

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

Medication Summary

Medical therapy following irrigation in chemical injuries is geared toward promoting epithelial healing, preventing infection, eliminating inflammation, preventing glaucomatous damage from increased IOP, and controlling pain.

Epithelial healing is promoted through aggressive lubrication, ascorbate replenishment, and judicious use of topical corticosteroids. Artificial tears and ointments are especially important with severely scarred and exposed eyes, best recommended in a preservative-free form in anticipation of frequent prolonged use. Ascorbate, both oral and topical, aids in the synthesis of collagen fibrils. Topical steroids decrease ocular surface inflammation, facilitating new epithelial cell growth and ocular surface regeneration. The presence of epithelial defects and corneal exposure necessitates the use of prophylactic topical antibiotics to prevent infection in the already compromised eye.

Antibiotic ointments can serve the dual purpose of providing lubrication and preventing infection. Broad-spectrum antibiotic coverage is required to most effectively minimize infection risk.

Moderate and severe injuries often stimulate an increase in IOP due to anterior chamber inflammation and collagen fibril shortening. This condition is treated most effectively with aqueous suppressants, especially oral carbonic anhydrase inhibitors and topical beta-adrenergic blockers.

Inflamed eyes often experience ciliary spasm, which can be painful. This spasm is blocked by relatively long-acting mydriatic cycloplegics. In severe chemical injuries, oral pain medication may be required to comfort the patient. 

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Topical antibiotics

Class Summary

Prevent ocular surface infection and effectively lubricate the eye.

Erythromycin ophthalmic

 

Macrolide broad-spectrum antibiotic.

Ciprofloxacin HCl (Ciloxan)

 

Fluoroquinolone broad-spectrum bacteriocidal antibiotic.

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Carbonic anhydrase inhibitors

Class Summary

Carbonic anhydrase inhibitors reduce aqueous humor production, thereby reducing IOP.

Methazolamide (Neptazane)

 

Reduces aqueous humor formation by inhibiting the enzyme carbonic anhydrase, which results in decreased IOP.

Acetazolamide (Diamox)

 

Decreases secretion of aqueous humor through the same mechanism as methazolamide, lowering IOP.

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Cycloplegic mydriatics

Class Summary

Cycloplegic mydriatics reduce pain by blocking ciliary spasm, and they reduce intraocular inflammation by stabilizing the blood-aqueous barrier. Drugs from this category are chosen based on their duration of action. Intermediate-acting compounds, such as homatropine or scopolamine, are preferred to short-acting compounds, such as tropicamide, or extremely long-acting compounds, such as atropine sulfate. Recently, the availability of standard generic and proprietary topical cycloplegics has been plagued by shortages.

Homatropine (Isopto Homatropine)

 

Blocks responses of sphincter muscle of iris and muscle of ciliary body to cholinergic stimulation, producing pupillary dilation (mydriasis) and paralysis of accommodation (cycloplegia).

Induces mydriasis in 10-30 min and cycloplegia in 30-90 min. These effects last up to 48 h.

Scopolamine ophthalmic (Isopto Hyoscine)

 

Anticholinergic agent that blocks constriction of sphincter muscle of iris and ciliary body muscle, which, in turn, results in mydriasis (dilation) and cycloplegia (paralysis of accommodation). These effects last up to 5 days.

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Ascorbate

Class Summary

Critical cofactor necessary for collagen fibril synthesis. Released from the damaged cornea and the anterior chamber, and it must be replenished to promote corneal wound healing.

Ascorbic acid (Ce-vi-sol, Cecon, Cevi-Bid)

 

Water-soluble vitamin that serves as a cofactor regulating collagen synthesis.

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Beta-adrenergic blockers

Class Summary

Topical beta-blockers reduce aqueous humor production, which then reduces IOP.

Timolol maleate 0.25%, 0.5% (Betimol, Istalol, Timoptic, Timoptic XE)

 

May reduce elevated and normal IOP, with or without glaucoma, by reducing production of aqueous humor or by outflow facilitation.

Levobunolol hydrochloride 0.25%, 0.5% (Betagan)

 

Nonselective beta-adrenergic blocking agent that lowers IOP by reducing aqueous humor production and possibly increasing outflow of aqueous humor.

Betaxolol ophthalmic (Betoptic S)

 

Selectively blocks beta 1-adrenergic receptors with little or no effect on beta 2-receptors. Reduces IOP by reducing production of aqueous humor.

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Topical corticosteroids

Class Summary

Steroids decrease ocular surface inflammatory response, facilitating earlier epithelial healing and regeneration. These medications should be tapered after 7-10 days because of the risk of corneal melting with prolonged use. Should inflammation persist, systemic anti-inflammatory agents, including oral steroids (prednisone), should be considered.

Prednisolone acetate 1% (Pred Forte, Econopred)

 

Decreases corneal inflammation and neovascularization, uveitis, and anterior segment inflammation.

Fluorometholone acetate 0.1% (FML, FML Forte, Flarex)

 

Decreases corneal inflammation and neovascularization, uveitis, and anterior segment inflammation.

Rimexolone 1% (Vexol)

 

Decreases corneal inflammation and neovascularization, uveitis, and anterior segment inflammation.

Loteprednol etabonate 0.5% (Lotemax)

 

Decreases corneal inflammation and neovascularization, uveitis, and anterior segment inflammation. Reduces risk of steroid-induced IOP elevation.

Difluprednate 0.05% (Durezol)

 

Decreases corneal inflammation and neovascularization, uveitis, and anterior segment inflammation. Considered the strongest topical steroid, contains less toxic preservative sorbitol, and more likely to induce significant IOP elevations than other topical steroids.

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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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