eMedicine Specialties > Emergency Medicine > Ophthalmology
Burns, Ocular: Treatment & Medication
Updated: Aug 12, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
- Irrigation
- With chemical injury, immediate initiation of copious irrigation has the greatest impact on prognosis.8 Irrigation also helps to clear any residual particulate matter from the eye.
- In ideal situations, the affected eye should be irrigated as soon as possible in an eyewash or shower station with sterile saline solution. Sterile physiologically balanced solutions reduce the chances of further damage to the eye. If sterile saline is not available, cold tap water allows for dilution of the agent.
- The patient must try to open the eyelids as wide as possible to obtain the best irrigation. Topical anesthetic prior to irrigation or insertion of a lid speculum facilitates cooperation. A wire lid speculum can also be used to assist in eyelid retraction.
Emergency Department Care
When a patient presents to the ED with an ocular burn, assessing the potential for coexisting life-threatening injuries is important. These may need to be addressed prior to or simultaneously with treatment of the eye. In particular, a fire victim sustaining ocular thermal burns must first have the airway and breathing evaluated. Alkali injuries to the face also may cause tracheal or esophageal burns.
- All ocular burns require topical antibiotics, pain relief, and tetanus immunization.
- Thermal burns: The treatment of isolated thermal corneal burns usually can be considered virtually identical to the treatment of corneal abrasions. In addition to a discussion of appropriate follow-up care, ED treatment includes the following:
- Remove the offending agents, which may require lid eversion to remove debris. Irrigation also aids in debris removal as well as to cool the surface.
- Treat intraocular inflammation.
- Patch the eye to establish a conducive environment for reepithelialization.
- When the lids are burned, cool saline compresses are needed, and adequate lubrications for the globe are important. The burned eyelashes and eschar may need to be removed.
- Chemical burns
- The most important treatment of chemical burns is extensive immediate irrigation. Sterile higher osmotic solutions such as amphoteric solution (Diphoterine) or buffered solutions (BSS or lactated Ringer) are ideal. If not available, sterile isotonic saline is an appropriate irrigant. Hypotonic solutions, such as water, result in deeper penetration of corrosive material into the corneal structures due to the cornea's higher osmotic gradient (420 mOs/L).
- The duration and amount of irrigation is determined by the eye pH. Continue irrigation until the pH remains at normal level for 30 minutes. Use of a Morgan lens or other eye irrigation system can minimize interference from blepharospasm, which can often be severe. If these are unavailable, the lid can be retracted manually with a Desmarres retractor, lid speculum, or bent paperclip. The end of intravenous tubing can direct the stream of sterile fluid across the eye. In addition, use a cotton swab to remove any particulate matter that may be retained in the fornices. Soak the swab in ethylenediaminetetraacetic acid (EDTA) 1% if the causative agent contained calcium oxide.
- Following irrigation, a thorough ophthalmologic examination is mandatory. If the injury is minor, the patient may be discharged with topical ophthalmic antibiotics, oral analgesics, and an eye patch. Follow-up evaluation should occur within 24 hours.
- More severe burns, particularly alkali burns, require hospitalization. The patient requires topical ophthalmic antibiotics, pain medication, cycloplegics, and mydriatics. If secondary glaucoma develops, the patient requires ocular pressure–lowering medication.
Consultations
- Patients with minor thermal and UV burns can be discharged from the ED to follow-up care with an ophthalmologist within 24 hours.
- The emergency physician should consider at least a telephone consultation with an ophthalmologist for any patient with significant chemical eye exposure.
- Any serious thermal burn, any alkali chemical globe exposure, or any vision-threatening injury most likely warrants emergent ophthalmologic consultation.
Medication
The goal of therapy is to reduce inflammation, pain, and risk of infection. If secondary glaucoma develops, administer ocular pressure–lowering medications.
In addition to the medications described below, ascorbic acid may promote collagen production. Following alkali burns, the level of ascorbic acid decreases. Some researchers have demonstrated that the topical administration of 10% ascorbic acid may reduce corneal perforation. However, this treatment is being used only experimentally.
In the treatment of hydrofluoric acid burns, optimum care has not been established. Some studies have used 1% calcium gluconate as an irrigant or as eyedrops to treat these burns. Magnesium compounds also have been used anecdotally for hydrofluoric acid burns; however, little research supports their effectiveness. Irrigation with magnesium chloride has been found to be nontoxic to the eye. Benefits of this treatment have been reported anecdotally even 24 hours from injury when other treatments had been unsuccessful. Some authors recommend drops every 2-3 hours because irrigation may be irritating and may lead to corneal ulceration. Do not undertake subconjunctival injection.
Additionally, subconjunctival injections of calcium gluconate and calcium chloride have not been found to be beneficial.
Some chemical and thermal burns may require nonpreserved lubricants. Adequate lubrication helps to prevent the formation of symblepharon (ie, adhesions of the eyelid to the eyeball). Some authors recommend the use of topical steroids in some patients, particularly those with alkali and hydrofluoric acid burns. The advocates believe steroids may limit intraocular inflammation and decrease the formation of fibroblasts on the cornea. Others argue the risks of potential infection and ulceration outweigh the possible benefits.
Consider each patient on an individual basis with a consulting ophthalmologist.
Cycloplegic mydriatics
Aid in the prevention of ciliary spasm. Additionally, these agents are believed to stabilize the permeability of blood vessels, thus reducing inflammation. Homatropine 5% often is recommended because of its medium duration of 12-24 h, a time within which the patient should have a follow-up examination by an ophthalmologist. Longer acting cycloplegics, such as scopolamine and atropine, are used less commonly.
Homatropine (Isopto-homatropine)
Blocks responses of sphincter muscle, 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.
Adult
Solution (2%): 1-2 gtt; repeat q15-20min prn
Solution (5%): 1 gtt; repeat q15-20min prn
For prolonged cycloplegia: 1-2 gtt at intervals of up to q3-4h
Pediatric
Administer as in adults, but only use 2% solution
None reported
Documented hypersensitivity; narrow-angle glaucoma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in elderly patients in whom increased intraocular pressure may be present; toxic anticholinergic systemic adverse effects can occur but are rare when used sparingly; adverse effects are more common in children, especially infants; compressing lacrimal sac by digital pressure for 1-3 min following instillation minimizes systemic absorption
Atropine (Isopto-atropine)
Acts at parasympathetic sites in smooth muscle to block response of sphincter muscle of iris and muscle of ciliary body to acetylcholine; effects produce mydriasis and cycloplegia.
Adult
Solution (1%): 1-2 gtt qid; compress lacrimal sac by digital pressure for 1-3 min after instillation
Ointment: Apply 0.5-inch ribbon in conjunctival sac tid; compress lacrimal sac by digital pressure for 1-3 min after instillation
Pediatric
Solution (0.5%): 1-2 gtt into eye(s) bid/tid
Ointment: Not established
Coadministration with other anticholinergics has additive effects
Documented hypersensitivity; thyrotoxicosis; narrow-angle glaucoma; tachycardia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid use in Down syndrome and in children with brain damage (patients may demonstrate hyperreactive response to topical atropine)
Scopolamine (Isopto-hyoscine)
Blocks action of acetylcholine at parasympathetic sites in smooth muscle, producing pupillary dilation (mydriasis) and paralysis of accommodation (cycloplegia).
Adult
1-2 gtt qid
Pediatric
Not established
None reported
Documented hypersensitivity; primary glaucoma or initial stages of disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid excessive systemic absorption by compressing lacrimal sac, using digital pressure for 1-3 min after instillation; may produce drowsiness, blurred vision, or sensitivity to light (due to dilated pupils); observe caution while driving or performing other tasks requiring alertness, coordination, or physical dexterity
Antibiotics (ophthalmic)
Patients with burns to the cornea, conjunctiva, and sclera usually are administered prophylactic, broad-spectrum, topical ophthalmic antibiotic drops or ointment (eg, tobramycin, gentamicin, ciprofloxacin, norfloxacin, bacitracin). Neomycin and sulfa drugs are used less frequently because of a high incidence of sensitivity. Patients with burns to the skin (eg, eyelids) rarely are administered prophylactic antibiotics.
Tobramycin (Tobrex, AKTob)
Interferes with bacterial protein synthesis by binding to 30S and 50S ribosomal subunits, resulting in defective bacterial cell membrane.
Available as solution and as ointment.
Adult
Solution: 1-2 gtt q4h during waking hours; less frequently at night
Severe infections: 2 gtt q30-60min initially; followed by less frequent intervals of administration
Ointment: Apply 0.5-inch ribbon in conjunctival sac bid/tid
Severe infections: Apply q3-4h
Pediatric
<2 years: Not established
>2 years: Administer as in adults
Effects are decreased when used concurrently with gentamicin
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use in deep-seated ocular infections or in those that may become systemic; prolonged use of antibiotics may result in bacterial or fungal overgrowth of nonsusceptible organisms
Gentamicin (Genoptic)
Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used in combination with an agent against gram-positive organisms.
Adult
Ointment: Apply 0.5-inch (0.04-cm) ribbon in conjunctival sac bid/tid
Solution: 1-2 gtt q2-4h
Severe infections: 2 gtt qh
Pediatric
Apply as in adults
None reported
Documented hypersensitivity; mycobacterial, viral, and fungal infections of eye; avoid using with steroid combinations after uncomplicated removal of foreign body from cornea
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat ocular infections that may become systemic; prolonged or repeated antibiotic therapy may result in bacterial or fungal overgrowth of nonsusceptible organisms and may lead to secondary infections
Ciprofloxacin (Ciloxan)
Bactericidal antibiotic that inhibits bacterial DNA synthesis and consequently growth by inhibiting DNA-gyrase in susceptible organisms.
Indicated for pseudomonal infections and those due to multidrug-resistant gram-negative organisms.
Adult
1-2 gtt q2h while awake for 2 d; followed by 1-2 gtt q4h while awake for another 5 d
Pediatric
Not established
None reported
Documented hypersensitivity; viral, mycobacterial, and fungal eye infections; avoid coadministration with steroid combinations after uncomplicated removal of a foreign body from cornea
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
A white crystalline precipitate located in superficial portion of corneal defect may occur (onset starts in 1-7 d); precipitate usually is cleared within 2 wk and does not adversely affect clinical course or outcome; do not use in ocular infections that may become systemic; superinfections may occur with prolonged or repeated antibiotic therapy
Analgesics
Some ophthalmologists are advocating application of diclofenac drops. This therapy may prove to be an effective alternative to patching in patients with insults to the cornea, permitting the patient to maintain binocular vision during treatment.
Diclofenac (Voltaren)
Has analgesic properties. Inhibits prostaglandin synthesis by decreasing activity of enzyme cyclooxygenase, which in turn results in decreased formation of prostaglandin precursors.
Also facilitates outflow of aqueous humor and decreases vascular permeability.
Adult
1 gtt qid for up to 2 wk
Pediatric
<12 years: Not established
>12 years: Administer as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Corneal thinning may occur
Toxoids
Used to induce active immunity.
Tetanus toxoid
Used to induce active immunity against tetanus in selected patients. Immunizing agents of choice for most adults and children >7 y are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life.
Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product.
In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is mid thigh laterally.
Adult
Primary immunization: 0.5 mL IM; administer 2 injections 4-8 wk apart and a third dose 6-12 mo after second injection
Booster dose: 0.5 mL q10y
Pediatric
Administer as in adults
Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of medication with systemic chloramphenicol since it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude concurrent use)
Documented hypersensitivity; history of any type of neurologic symptoms or signs following administration; FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat actual tetanus infections or for immediate prophylaxis of nonimmunized individuals (use instead tetanus antitoxin, preferably human tetanus immune globulin); diminished antibody response to active immunization may be observed in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons is recommended
More on Burns, Ocular |
| Overview: Burns, Ocular |
| Differential Diagnoses & Workup: Burns, Ocular |
 Treatment & Medication: Burns, Ocular |
| Follow-up: Burns, Ocular |
| References |
| Further Reading |
| « Previous Page | Next Page » |
References
Tuft SJ, Shortt AJ. Surgical rehabilitation following severe ocular burns. Eye. Jan 23 2009;[Medline].
Merle H, Gerard M, Schrage N. [Ocular burns]. J Fr Ophtalmol. Sep 2008;31(7):723-34. [Medline].
Xiang H, Stallones L, Chen G, Smith GA. Work-related eye injuries treated in hospital emergency departments in the US. Am J Ind Med. Jul 2005;48(1):57-62. [Medline].
Stern JD, Goldfarb IW, Slater H. Ophthalmological complications as a manifestation of burn injury. Burns. Mar 1996;22(2):135-6. [Medline].
Kuckelkorn R, Schrage N, Keller G, Redbrake C. Emergency treatment of chemical and thermal eye burns. Acta Ophthalmol Scand. Feb 2002;80(1):4-10. [Medline].
Das S, Chohan A, Snibson GR, Taylor HR. Capsicum spray injury of the eye. Int Ophthalmol. Aug-Oct 2005;26(4-5):171-3. [Medline].
Javadi MA, Yazdani S, Sajjadi H, et al. Chronic and delayed-onset mustard gas keratitis: report of 48 patients and review of literature. Ophthalmology. Apr 2005;112(4):617-25. [Medline].
Ikeda N, Hayasaka S, Hayasaka Y, Watanabe K. Alkali burns of the eye: effect of immediate copious irrigation with tap water on their severity. Ophthalmologica. 2006;220(4):225-8. [Medline].
Prabhasawat P, Tesavibul N, Prakairungthong N, Booranapong W. Efficacy of amniotic membrane patching for acute chemical and thermal ocular burns. J Med Assoc Thai. Feb 2007;90(2):319-26. [Medline].
Tejwani S, Kolari RS, Sangwan VS, Rao GN. Role of amniotic membrane graft for ocular chemical and thermal injuries. Cornea. Jan 2007;26(1):21-6. [Medline].
Peate WF. Work-related eye injuries and illnesses. Am Fam Physician. Apr 1 2007;75(7):1017-22. [Medline].
Bentur Y, Tannenbaum S, Yaffe Y, Halpert M. The role of calcium gluconate in the treatment of hydrofluoric acid eye burn. Ann Emerg Med. Sep 1993;22(9):1488-90. [Medline].
Blais BR. Treating chemical eye injuries. Occup Health Saf. Sep 1996;65(9):23-6. [Medline].
Bouchard CS, Morno K, Perkins J, McDonnell JF, Dicken R. Ocular complications of thermal injury: a 3-year retrospective. J Trauma. Jan 2001;50(1):79-82. [Medline].
Corazza M, Trincone S, Virgili A. Effects of airbag deployment: lesions, epidemiology, and management. Am J Clin Dermatol. 2004;5(5):295-300. [Medline].
Gangadhar DV, Kenyon KR, Wagoner MD. The surgical management of chemical ocular injuries: present and future strategies. Int Ophthalmol Clin. Winter 1995;35(1):63-9. [Medline].
Guy PR, Taggart I, Adeniran A, Burd DA. Corneal burns with eyelid sparing and their treatment. Burns. Dec 1994;20(6):561-3. [Medline].
Gérard M, Merle H, Ayeboua L, Richer R. [Prospective study of eye burns at the Fort de France University Hospital]. J Fr Ophtalmol. Oct 1999;22(8):834-47. [Medline].
Hammerton ME. Management of ocular burns. Aust Fam Physician. Jun 1995;24(6):1006-10. [Medline].
Khaw PT, Shah P, Elkington AR. Injury to the eye. BMJ. Jan 3 2004;328(7430):36-8. [Medline].
Kirkpatrick JJ, Enion DS, Burd DA. Hydrofluoric acid burns: a review. Burns. Nov 1995;21(7):483-93. [Medline].
Lubeck D, Greene JS. Corneal injuries. Emerg Med Clin North Am. Feb 1988;6(1):73-94. [Medline].
Onofrey BE. Management of corneal burns. Optom Clin. 1995;4(3):31-40. [Medline].
Ryan CM, Schoenfeld DA, Thorpe WP, Sheridan RL, Cassem EH, Tompkins RG. Objective estimates of the probability of death from burn injuries. N Engl J Med. Feb 5 1998;338(6):362-6. [Medline].
Saini JS, Sharma A. Ocular chemical burns--clinical and demographic profile. Burns. Feb 1993;19(1):67-9. [Medline].
Shukla PC. Ocular burn from microwaved egg. Pediatr Emerg Care. Aug 1994;10(4):229-31. [Medline].
Still JM Jr, Law EJ, Belcher KE, Moses KC, Gleitsmann KY. Experience with burns of the eyes and lids in a regional burn unit. J Burn Care Rehabil. May-Jun 1995;16(3 Pt 1):248-52. [Medline].
White JE, McClafferty K, Orton RB, Tokarewicz AC, Nowak ES. Ocular alkali burn associated with automobile air-bag activation. CMAJ. Oct 1 1995;153(7):933-4. [Medline].
Further Reading
Related eMedicine topics
Burns, Chemical (from Ophthalmology)
Burns, Chemical (from Emergency Medicine)
Facial Burns (from Otolaryngology and Facial Plastic Surgery)
Burns, Chemical (from Dermatology)
Hydrofluoric Acid Burns (from Emergency Medicine)
Guidelines
Management of Burns and Scalds in Primary Care
Eye
Clinical studies
The Role of Amniotic Membrane Transplantation in Ocular Chemical Burns
Keywords
eye burns, ocular burns, sclera burns, conjunctiva burns, cornea burns, eyelid burns, conjunctival burns, scleral burns, corneal burns, chemical burns to the eye, ocular injury
