Ophthalmologic Approach to Chemical Burns Treatment & Management

Updated: Sep 18, 2018
  • Author: Mark Ventocilla, OD, FAAO; Chief Editor: Andrew A Dahl, MD, FACS  more...
  • Print
Treatment

Medical Care

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) eliminating 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 over 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, to a range of 7.0-7.2, usually requiring 1-2 liters of fluid. Monitor the pH at 15- to 20-minute intervals after stabilization to ensure that no further particles are present to continue changing the pH. Once irrigation is finished, a complete thorough eye examination should be performed. Care should be taken to examine the fornices and under the upper lids via tarsal eversion for residual particles.

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. Topical antibiotic ointment should be applied frequently to help the surface heal and to prevent secondary infection. Topical steroids are also needed to control inflammation, which facilitates epithelial healing.

Ascorbate plays a fundamental role in collagen remodeling, leading to an improvement in corneal healing. It may also prevent or delay corneal ulceration. It is available in topical and oral forms. Oral tetracycline class antibiotics (tetracycline, minocycline, doxycycline) may also decrease the risk of corneal melting through inhibition of matrix metalloproteinases.

Placement of a therapeutic bandage contact lens until the epithelium has regenerated can be helpful in some patients. [11]

Amniotic membrane transplant in eyes with acute ocular burns promotes faster healing of epithelial defects in patients with moderate grade burns. [12] Amniotic membranes have anti-inflammatory, antimicrobial, anticollagenolytic, and growth factor properties that can enhance epithelial rejuvenation. The Prokera (Bio-Tissue) brand device is a sutureless office-based amniotic membrane that has been proven to be extremely useful in acute moderate chemical injuries.

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 vascularization in a controlled clinical setting. [12]

Eliminate inflammation

Inflammatory mediators released from the ocular surface at the time of injury cause tissue necrosis, neovascularization, and scarring 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. Prednisolone acetate 1% should be used 4 times daily for 1 week in a mild chemical burn. Difluprednate and loteprednol etabonate are also extremely useful topical steroid preparations for chemical ocular-surface disease. The steroid dose should be increased to hourly dosing in more severe burns. Steroids should be discontinued or tapered rapidly by 10-14 days to avoid corneal melting.

Acetylcysteine (10% or 20% Mucomyst prepared in a certified compounding pharmacy) 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 much more susceptible to infection.

Prophylactic topical antibiotics are warranted during the initial treatment stages. Ointment preparations such as bacitracin may be soothing to the patient but difficult to administer and somewhat blurring. Topical moxifloxacin (Vigamox) is preservative-free and offers broad-spectrum coverage. Polymyxin B trimethoprim (PolyTrim) and besifloxacin (Besivance) are also well-tolerated and broad-spectrum.

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 topical cycloplegic agents; however, oral pain medication may be necessary initially to control pain.

Next:

Surgical Care

Surgical intervention may be required if the above medical treatments do not result in epithelial healing within a few weeks.

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 or cement) is responsible for the injury.

Promote ocular surface healing

See the list below:

  • Debridement of necrotic conjunctival/corneal tissue

  • Temporary amniotic membrane patching [13]

Limbal stem cell transplant, either autologous from a fellow healthy eye or allograft from a living relative or cadaver

See the list below:

  • Cultivated corneal epithelial stem cell sheet transplantation [14, 15, 16, 17]

  • 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 or descemetoceles threatening perforation.

Visual rehabilitation

See the list below:

  • Penetrating keratoplasty with or without cataract extraction [18]

  • Keratoprosthesis

Control IOP

Glaucoma filtering surgery or aqueous tube shunt placement may be used for cases of increased IOP refractory to medical management. Both require intact conjunctiva, which is more likely to be found superiorly after chemical exposure.

Previous
Next:

Consultations

In most instances, patients present to non-ophthalmologists 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 appropriately by an ophthalmologist. Other medical personnel may be needed as determined by the extent of the extraocular injuries sustained.

Previous
Next:

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.

Previous
Next:

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.

Previous
Next:

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.

Previous
Next:

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).
Previous
Next:

Transfer

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

Previous