Ophthalmologic Approach to Chemical Burns

Author: J Bradley Randleman, MD; Chief Editor: Hampton Roy Sr, MD more...

Updated: Feb 7, 2011

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Background
Pathophysiology
Epidemiology
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Background

Chemical injuries to the eye represent one of the true ophthalmic emergencies. While almost any chemical can cause ocular irritation, serious damage generally results from either strongly basic (alkaline) compounds or acidic compounds. Alkali injuries are more common and can be more deleterious. Bilateral chemical exposure is especially devastating, often resulting in complete visual disability. Immediate, prolonged irrigation, followed by aggressive early management and close long-term monitoring, is essential to promote ocular surface healing and to provide the best opportunity for visual rehabilitation.^{[1, 2, 3]}See the image below.

Severe chemical injury with early corneal neovascularization.

Pathophysiology

The severity of this injury is related to type, volume, concentration, duration of exposure, and degree of penetration of the chemical. The mechanism of injury differs slightly between acids and alkali.^[4]

Acid injury

Acids dissociate into hydrogen ions and anions in the cornea. The hydrogen molecule damages the ocular surface by altering the pH, while the anion causes protein denaturation, precipitation, and coagulation. Protein coagulation generally prevents deeper penetration of acids and is responsible for the ground glass appearance of the corneal stroma following acid injury. Hydrofluoric acid is an exception; it behaves like an alkaline substance because the fluoride ion has better penetrance through the stroma than most acids, leading to more extensive anterior segment disruption.^[4]

Alkali injury

Alkaline substances dissociate into a hydroxyl ion and a cation in the ocular surface. The hydroxyl ion saponifies cell membrane fatty acids, while the cation interacts with stromal collagen and glycosaminoglycans. This interaction facilitates deeper penetration into and through the cornea and into the anterior segment. Subsequent hydration of glycosaminoglycans results in stromal haze. Collagen hydration causes fibril distortion and shortening, leading to trabecular meshwork alterations that can result in increased intraocular pressure (IOP). Additionally, the inflammatory mediators released during this process stimulate the release of prostaglandins, which can further increase IOP.^[5]See the image below.

Alkali burn. Note the severe conjunctival reaction and stromal opacification blurring iris details inferiorly.

Frequency

United States

Chemical injuries are responsible for approximately 7% of work-related eye injuries treated at US hospital emergency departments.^[6]More than 60% of chemical injuries occur in workplace accidents, 30% occur at home, and 10% are the result of an assault.^[7]

Mortality/Morbidity

As many as 20% of chemical injuries result in significant visual and cosmetic disability; only 15% of patients with severe chemical injuries achieve functional visual rehabilitation.

Race

No overall racial predilection exists; however, young black males are more likely to have high-concentration, high-impact alkaline chemical injuries secondary to assault.^[8]

Sex

Males are 3 times more likely to experience chemical injuries than females.^[7]

Age

Chemical injuries can strike any population; however, most injuries occur in patients aged 16-45 years.^{[6, 7]}

Proceed to Clinical Presentation

Contributor Information and Disclosures

Author

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.

Coauthor(s)

Alok S Bansal, MD Resident Physician, Emory Eye Center

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.

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.

Geoffrey Broocker, FACS, MD Walthour-DeLaPerriere Professor of Ophthalmology, Department of Ophthalmology, Emory University School of MedicineChief of Service, Ophthalmology, Grady Memorial Hospital

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Simon K Law, MD, PharmD Associate Professor 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, American Glaucoma Society, and Association for Research in Vision and Ophthalmology

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 Institute

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

Disclosure: Allergan Honoraria Speaking and teaching; Allergan Consulting fee Consulting; Alcon Honoraria Speaking and teaching; Inspire Honoraria Speaking and teaching; RPS Ownership interest Other; Vistakon Honoraria Speaking and teaching; EyeGate Pharma Consulting; Inspire Consulting fee Consulting; Bausch & Lomb Honoraria Speaking and teaching; Bausch & Lomb Consulting fee Consulting

Lance L Brown, OD, MD Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri

Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences

Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology

Disclosure: Nothing to disclose.

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