Corneal epithelial defects can range from scattered SPK, to focal epithelial loss, to sloughing of the entire corneal epithelium. Stromal opacities or edema are possible. Focal areas of conjunctival epithelial defect, chemosis, hyperemia, and hemorrhage are possible.
This includes causes of thermal direct contact with the ocular surface (e.g., hot water, cooking oil, curling irons, flames/explosions).
Rule out an open globe injury. If there is any concern for intraocular foreign body (IOFB), send for CT (or cranial x-ray if CT is not timely or not available).
Slit-lamp examination with fluorescein staining. Evaluation also for eyelid burns, eyelid defects, and lagophthalmos. Eyelid eversion to search for foreign bodies. Evaluate and diagram conjunctival and corneal epithelial defects, ulcerations, and stromal opacities/melts. Quantify the extent of thinning as a percentage of corneal thickness. Check the IOP. In the presence of a distorted cornea, IOP may be most accurately measured with a Tono-Pen, pneumotonometer, or rebound tonometer.
Topical antibiotic drop or ointment depending on presence and size of corneal and/or conjunctival epithelial defects. See “Treatment” in 3.3, Corneal Abrasion.
Consider cycloplegic if significant photophobia, pain, or AC inflammation (e.g., cyclopentolate 1% or 2% b.i.d., atropine 0.5% or 1% daily to b.i.d.).
Frequent use of preservative-free artificial tear drops as needed.
Cautious use of topical steroids in the presence of epithelial defects or stromal melt.
Initially daily, then every few days until corneal epithelial defect is healed. Monitor for corneal epithelial breakdown, stromal thinning, and infection.
Signs (in addition to the above)
Stromal opacity/scarring, melting/perforation, and edema are all possible, especially in cases of extended contact with thermal source.
Same as for mild-to-moderate burns.
Hospital admission may be needed for close monitoring of IOP and corneal healing, or in the presence of severe facial/skin burns.
Debride necrotic tissue containing foreign matter, if present.
Topical antibiotic (e.g., trimethoprim/polymyxin B or fluoroquinolone drops q.i.d.; erythromycin or bacitracin ointment q.i.d. to q2h while awake). Caution with ciprofloxacin and large epithelial defects as it can precipitate in the cornea.
Consider cycloplegic as with mild-to-moderate burns as above.
Cautious use of topical steroids in the presence of epithelial defects or stromal melt.
Frequent (e.g., q1h while awake) use of preservative-free artificial tears or gel if not using frequent ointments.
Oral tetracyclines and vitamin C may also reduce collagenolysis and stromal melting (e.g., doxycycline 100 mg p.o. b.i.d. and vitamin C 1,000 mg p.o. daily).
Severe cases with large area of epithelial defects or concern for conjunctival adhesions may warrant the use of an amniotic membrane ring (e.g., Prokera) or suturing of a large amniotic membrane over the corneal and conjunctival epithelial defects.
For thermal burns causing problematic wound closure (such as with phacoemulsification burns), urgent surgical repair is needed for any open wounds. Suturing burned corneal tissue is challenging due to poor approximation, and multiple sutures and/or cyanoacrylate glue and/or a patch graft may be required.
For poorly healing epithelial defects or poor eyelid closure, a therapeutic soft contact lens, collagen shield, amniotic membrane graft, or temporary tarsorrhaphy may be considered.
Topical biologic fluids including autologous serum tears, platelet-rich plasma, umbilical cord serum, and amniotic membrane suspensions may be useful to promote epithelialization.
If the melting progresses (or the cornea perforates), consider cyanoacrylate tissue adhesive. An emergency patch graft or corneal transplantation may be necessary; however, the prognosis for grafts is better if performed long after initial injury (over 12 to 18 months).
These patients need to be monitored closely (daily initially). A severely dry eye may require a temporary tarsorrhaphy or a conjunctival flap. Monitor IOP closely, especially in cases requiring fluid resuscitation in the hospital, as rapid extravascular fluid shifts can occur.