Ophthalmologic Approach to Chemical Burns Treatment & Management

Treatment of chemical injuries to the eye requires medical and surgical intervention, both acutely and in the long term, for maximal visual rehabilitation.

Regardless of the underlying chemical involved, common goals of management include the following: (1) removing the offending agent, (2) promoting ocular surface healing, (3) controlling inflammation, (4) preventing infection, and (5) controlling IOP.

Remove inciting chemical (irrigation)

Immediate copious irrigation remains the single most important therapy for treating chemical injuries. If available, the eye should be anesthetized prior to irrigation.

Ideally, the eye should be irrigated with a sterile balanced buffered solution, such as normal saline solution or Ringer's lactate solution. However, immediate irrigation with even plain tap water is preferred without waiting for the ideal fluid.

The irrigation solution must contact the ocular surface. This is best achieved with a special irrigating tubing (eg, Morgan lens) or a lid speculum. Irrigation should be continued until the pH of the ocular surface is neutralized, usually requiring 1-2 liters of fluid.

Promote ocular surface (epithelial) healing

Once the inciting chemical has been completely removed, epithelial healing can begin. Chemically injured eyes have a tendency to poorly produce adequate tears; therefore, artificial tear supplements play an important role in healing.

Ascorbate plays a fundamental role in collagen remodeling, leading to an improvement in corneal healing.

Placement of a therapeutic bandage contact lens until the epithelium has regenerated can be helpful in some patients.^[10]

Amniotic membrane transplant in eyes with acute ocular burns promotes faster healing of epithelial defect in patients with moderate grade burns.^[11] No long-term advantage of amniotic membrane transplant is evident when compared with medical and mechanical release of adhesions in terms of final visual outcome appearance of symblepharon and corneal vascularis in a controlled clinical setting.

Control inflammation

Inflammatory mediators released from the ocular surface at the time of injury cause tissue necrosis and attract further inflammatory reactants.

This robust inflammatory response not only inhibits reepithelialization but also increases the risk of corneal ulceration and perforation.

Controlling inflammation with topical steroids can help break this inflammatory cycle.

Citrate both promotes corneal wound healing and inhibits PMNs via calcium chelation. One study showed better visual outcomes using both ascorbate and citrate compared to controls in chemically injured eyes.^[12]

Acetylcysteine (10% or 20%) can inhibit collagenase to reduce corneal ulceration, yet its clinical use is currently controversial.

Prevent infection

When the corneal epithelium is absent, the eye is susceptible to infection.

Prophylactic topical antibiotics are warranted during the initial treatment stages.

Control IOP

The use of aqueous suppressants is advocated to reduce IOP secondary to chemical injuries, both as an initial therapy and during the later recovery phase, if IOP is high (>30 mm Hg).

Control pain

Severe chemical burns can be extremely painful.

Ciliary spasm can be managed with the use of cycloplegic agents; however, oral pain medication may be necessary initially to control pain.

• Remove inciting chemical

  • After instilling topical anesthesia, sweep the fornices with a moist sterile cotton swab to remove any retained foreign material.
  • This technique is especially important when particulate matter (eg, plaster) is responsible for the injury.
• Promote ocular surface healing

  • Debride necrotic conjunctival/corneal tissue
  • Temporary amniotic membrane patching^[13]
  • Limbal stem cell transplant
  • Cultivated corneal epithelial stem cell sheet transplantation^[14]
  • Lysis of conjunctival symblepharon. Adhesions are a later finding, and they can be managed with repeated lysis using a glass rod or a sterile cotton swab.
• Prevent infection: Cyanoacrylate tissue adhesive may be applied for the treatment of small corneal perforations.
• Visual rehabilitation^[15]

  • Penetrating keratoplasty with or without cataract extraction
  • Keratoprosthesis
• Control IOP: Glaucoma filtering surgery or aqueous tube shunt placement may be used for cases of increased IOP refractory to medical management.

In most instances, patients present to nonophthalmologists for their immediate care. At a minimum, patients with mild chemical injuries should have follow-up care arranged with an ophthalmologist. Any patient with a moderate-to-serious injury should be immediately evaluated and followed accordingly by an ophthalmologist. Other medical personnel may be needed as determined by the extent of the extraocular injuries sustained.