Ocular Burns and Chemical Injuries Treatment & Management

Many ocular burns can be adequately managed in the emergency department (ED). 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.

Transfer may be required for specialized ophthalmologic care; however, the emergency physician must evaluate the patient’s stability for transfer. In some situations, life-threatening conditions (eg, airway burns) must be stabilized prior to transfer. For patients with thermal burns, transfer to a burn center is indicated in the presence of significant facial involvement or inhalation injury. Tetanus status should be checked and updated, if necessary.

With a chemical injury, immediate initiation of copious irrigation has the greatest impact on prognosis. ^[22] Irrigation also helps to clear any residual particulate matter from the eye. Delayed treatment may result in significant morbidity. ^[11]

Ideally, 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 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, such as the Morgan lens, facilitates cooperation. A wire lid speculum can also be used to assist in eyelid retraction.

When a patient presents to the ED with an ocular burn, it is important to assess the potential for coexisting life-threatening injuries. These may have to be addressed before or simultaneously with treatment of the eye. In particular, fire victims who have sustained ocular thermal burns must first have their airway and breathing evaluated. Alkali injuries to the face also may cause tracheal or esophageal burns.

Topical antibiotics, pain relief, and tetanus immunization are required for all ocular burns. 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). ^[23]

Some authors advocate using topical steroids in selected patients (eg, those with alkali and hydrofluoric acid burns), arguing that this may limit intraocular inflammation and decrease the formation of fibroblasts on the cornea. Others argue that the risks for potential infection and ulceration outweigh the possible benefits. In general, steroid preparations should not be used unless recommended by an ophthalmologist, because they can slow healing and predispose the eye to infection. An acute rise in intraocular pressure is less of a risk with short-term use.

Radiant energy burns

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, if necessary everting the lid to remove debris; irrigation also aids in debris removal besides cooling the surface

• Treat intraocular inflammation

• Patch the eye to establish an environment conducive to reepithelialization

• If the lids are burned, apply cool saline compresses and use adequate lubrication for the globe; the burned eyelashes and eschar may have to be removed

Patients with minor thermal and ultraviolet (UV) burns can be discharged from the ED to follow-up care with an ophthalmologist within 24 hours.

Chemical burns

The most important treatment of chemical burns is extensive immediate irrigation. Sterile higher-osmotic solutions, such as amphoteric solution (Diphoterine; Prevor, Valmondois, France) or buffered solutions (eg, BSS Plus [Alcon, Fort Worth, TX] or lactated Ringer solution), are ideal. If these are 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 as a result of the cornea’s higher osmotic gradient (420 mOsm/L).

The duration and amount of irrigation are determined by the ocular pH. Continue irrigation until the pH remains at a 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, a lid speculum, or even a bent paperclip.

The end of intravenous (IV) 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.

After 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.

In the case 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 after 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.

Ascorbic acid may promote collagen production. After alkali burns, the level of ascorbic acid decreases. Some researchers have demonstrated that topical administration of 10% ascorbic acid may reduce corneal perforation. At present, however, this treatment is being used only experimentally and may be recommended by ophthalmologists. Oxygen therapy was studied and showed faster corneal epithelial defect healing and quicker vascularization of ischemic areas, although vision outcomes were not reported. ^[24]

Follow-up care

Follow-up care should occur within 24 hours after patient discharge; more severe burns may require transfer for expedited ophthalmological evaluation. Topical antibiotics and possibly cycloplegics usually are required when the patient is discharged. Patients should not be discharged with ophthalmologic topical anesthetics, because these agents can cause corneal endothelial toxicity, corneal ulceration, and scarring.

For more severe burns, particularly alkali burns, hospitalization is necessary. The patient will require topical ophthalmic antibiotics, pain medication, cycloplegics, and mydriatics. If secondary glaucoma develops, the patient will require ocular pressure–lowering medication. Inpatient treatment in a burn center is required for patients with more severe burns or alkali burns.

Active surgical intervention to remove necrotic tissue can optimize the outcome by reducing continued inflammation. In selected cases, amniotic membrane patching may be considered, ^{[25, 26, 27]}  although a 2019 randomized control trial found no significant benefit. ^[28] These decisions should be discussed with an ophthalmologist.Tissue engineering for conjunctival reconstruction is a developing field that may offer new therapies as well. ^{[29, 30, 31]} In 1 study, subconjunctival application of autologous regenerative factor-rich plasma (RFRP) was effective in treating ocular alkali burns. ^[32]