DESCRIPTION 
- Inappropriate exposure of cornea to chemicals, heat, cold, electrical, or radiant energy causing damage to the cornea and often extending to adjacent structures
- Severity of injury related to duration of exposure, type of agent, anion concentration, pH level of solution
- Alkalis:
- Cause immediate rise in pH level
- Highly soluble in lipids, so rapidly penetrate the eye, causing severe corneal injury and continue to penetrate over time if no intervention undertaken
- Penetration can occur in < 1 min.
- Exception: Calcium alkalis penetrate relatively poorly secondary to soap formation; can cause corneal opacification, so may appear worse but actually have better prognosis than other alkali burns.
- Acids:
- Immediately coagulate proteins of corneal epithelium
- Cause opacification
- Coagulation produces barrier to deeper penetration
- Exception: Lipophilicity of hydrofluoric (HF) acid causes it to act similar to a base with more rapid penetration
- Thermal burns:
- Affect eyelids more than globe due to reflex blinking and Bell phenomenon (eyes roll up and outward)
- Cause direct injury to cornea
- Damage primarily depends on duration and intensity of heat
- Electrical injury:
- Occurs with current flow through head, with input at or near eye
- Radiation injury:
- Due to ultraviolet light exposure to cornea
ETIOLOGY
- Alkalis:
- Ammonia:
- Fertilizer, refrigerant, household ammonia, cleansing agents
- Potassium hydroxide:
- Magnesium hydroxide:
- Sparklers, flares, fireworks
- Lye: NaOH:
- Caustic soda, drain cleaners
- Lime: CaOH2 or MgOH2:
- Fresh lime, quicklime, calcium hydrate, slaked lime, hydrated lime, plaster, mortar, cement, whitewash
- Nonspecific alkali:
- Motor vehicle airbag on inflation releases alkali.
- Acids:
- Sulfuric acid: H2SO4:
- Car battery acid, toilet cleaner
- Sulfurous acid: H2SO3:
- Preservatives (fruit and vegetable)
- Acetic acid: CH3CO2H:
- Bleach
- Refrigerants:
- HF acid:
- Etching silicon/glass
- Cleaning brick
- Electropolishing metals
- Control of fermentation in breweries
- Commercial/household rust removal
- Thermal:
- Hot liquids, molten metal
- Flames
- Hot smoke/gases
- Flash burn
- Steam
- Cigarette burns
- Radiation:
- Sun lamps
- Tanning booths
- High-altitude sunlight
- Reflection off snow/water
- Arc welding
Pediatric Considerations
Consider child abuse or neglect.
[Outline]
SIGNS AND SYMPTOMS
- Severe ocular pain
- Photophobia
- Lacrimation
- Foreign body sensation
- Conjunctival injection
- Corneal edema
- Corneal opacification
- Impaired visual acuity
- Limbal blanching
- Lens opacification
- Vesicles clear fluid (hypothermal injury)
- Vesicles hemorrhagic fluid
- Necrosis of iris, ciliary body
History
- Type of exposure:
- Inspect any bottles accompanying the patient for active and inactive ingredients
- Vehicle of exposure:
- Aerosol: Common
- Propellant: May result in intraocular foreign body/perforation
- Duration of exposure
- Time of onset
- Time irrigation initiated
- Pre-existing visual impairment
- Protective eyewear
- Contact lens use
- Treatment before arrival
Physical Exam
Complete eye exam (after irrigation):
- Visual acuity
- Bright white light for visual inspection of cornea/conjunctivae/limbus
- Slit-lamp to evaluate anterior segment inflammation
- Fluorescein stain:
- Corneal epithelial damage:
- Punctate corneal lesions with discrete lower border from inferior lid seen in UV radiation burns
- Perforation (Seidel test)
- Check for lenticular clarity
- Fundus exam
- Measure intraocular pressure (especially in delayed presentation)
- Lid/eyelash exam
- Check pH with acid/alkali burns with litmus paper or pH indicator on urine dipstick
DIAGNOSIS TESTS & INTERPRETATION
Diagnostic Procedures/Surgery
- Fluorescein stain
- Check pH
DIFFERENTIAL DIAGNOSIS
- Infection:
- Viral keratitis
- Corneal ulcer
- Corneal erosion syndrome:
Pediatric Considerations
Handheld slit-lamp and Wood lamp helpful in exam of child's eye
[Outline]
PRE-HOSPITAL
- Irrigate at scene 15–30 min unless other coexisting life-threatening conditions require immediate transfer
- Bring bottle of substance to hospital
- Continuous irrigation en route to hospital with NS or water
INITIAL STABILIZATION/THERAPY
- Chemical exposure:
- Suspect acid or alkali in all exposures to unknown substances
- Irrigate with any available diluting substance but preferably water or NS
- Thermal exposure:
- Cool-moist dressing with overlying ice packs
ED TREATMENT/PROCEDURES
- Chemical exposure: Alkalis/acids/mace:
- Continuous irrigation to achieve pH 7.3–7.5 (1–2 L via a Morgan lens > 30–60 min):
- Measure pH every 30 min
- Dip pH paper in inferior conjunctival fornix
- Topical anesthetic (proparacaine) may be necessary during irrigation
- pH should be evaluated at 5 and 30 min after irrigation to ensure normalization of pH
- Evaluate fornices in detail and eye in full range of motion to ensure removal of all particulate chemical substance
- Antibiotic prophylaxis for Staphylococcus/Pseudomonas until epithelialization is complete:
- Cycloplegics to minimize posterior synechiae formation:
- Oral analgesics
- If increased intraocular pressure:
- Immediate ophthalmologic consultation
- Administer acetazolamide 125 mg PO QID and timolol 0.5% drops BID
- Topical steroids to control anterior uveitis (consult ophthalmology)
- Eye patch (consult ophthalmology)
- May require surgical intervention if frank corneal penetration
- Ophthalmologic consultation by phone in mild injuries
- Immediate ophthalmologic consultation in all moderate to severe injuries; if unavailable at your hospital, arrange transfer to closest eye center
- HF acid:
- Treat as above, + 1% calcium gluconate eyedrops
- Systemic analgesia for 24 hr
- Thermal exposure:
- Frequent moist dressing changes
- Antibiotics drop QID
- Generous lubricant application
- Moisture chamber when extensive injury to eyelid
- Steroids (consult ophthalmologist; do not use for > 1 wk)
- Ophthalmology consultation for any 2nd- or 3rd-degree burn to eyelids
- Cigarette ash and hot liquid splashes usually result in corneal epithelial injury:
- Treat as corneal abrasion
- Electrical injury:
- Irrigation
- Wound care
- Antibiotic ointment
- Cycloplegic (if anterior uveitis)
- Analgesia
- Radiation injury:
- Topical anesthetic
- Short-acting cycloplegic
- Antibiotic ointment
- Consider oral opioids for pan control
Pediatric Considerations
- Patching poorly tolerated
- May require systemic analgesia for complete exam
MEDICATION
- Artificial tears
- Atropine: 0.5%, 1%, 2% drops (cycloplegia 5–10 days, mydriasis 7–14 days) 1 drop TID
- Bacitracin ointment: QID
- Ciprofloxacin: 0.35% 1 drop QID
- Cyclopentolate: 0.5%, 1%, 2% drops (cycloplegia 1–2 days, mydriasis 1–2 days) 1 drop TID
- Erythromycin: 0.5% ointment QID
- Gentamicin: 0.3% ointment QID
- Gentamicin: 0.3% drops 1 drop q6h
- Homatropine: 5% drops 1–2 drop BID–TID
- Proparacaine: 0.5% drops 1 drop
- Sulfacetamide: 10% ointment QID
- Sulfacetamide: 10% drops QID
- Tetracaine: 0.5% drops 1–2 drops
- Tobramycin: 0.3% ointment q6h
- Tobramycin: 0.3% drops q6h
- Tropicamide: 0.5%, 1% drops (cycloplegia none; mydriasis 6 hr) 1 drop
[Outline]
DISPOSITION
Admission Criteria
- Intractable pain
- Increased intraocular pressure
- Corneal penetration requiring immediate surgical intervention
- HF acid burn; admit for 24 hr of systemic analgesia
- Suspected child abuse
Discharge Criteria
All mild corneal burns
FOLLOW-UP RECOMMENDATIONS
Mandatory follow-up with ophthalmologist in 12–24 hr; arrange before patient discharge
[Outline]
- Dargin JM, Lowenstein RA. The painful eye. Emerg Med Clin North Am. 2008;26(1):199–216.
- Khaw PT, Shah P, Elkington AR. Injury to the eye. Br Med J. 2004;328:36–38.
- Marx J, Hockberger R, Walls R, eds. Rosen's Emergency Medicine. 7th ed. Elsevier, 2009.
- Naradzay J, Barish RA. Approach to ophthalmologic emergencies. Med Clin N America. 2006;90:305–328.
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