Ocular Burns


Article Author:
Amanda Bates


Article Editor:
Allison Zanaboni


Editors In Chief:
Ritesh Menezes


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
2/14/2019 7:57:34 AM

Introduction

Ocular burns are true medical emergencies that can lead to devastating vision impairment. In a patient presenting with a possible ocular burn, immediate attention is required to help prevent further damage and loss of vision.[1][2][3][4]

Etiology

Ocular burns can be classified as chemical or thermal. Chemical burns occur far more commonly and can be divided into two major categories, burns secondary to alkali substances or those resulting from acid exposure. Chemical burns may occur from exposure to common household items such as drain or oven cleaner, laundry or dish detergent, bleach, and ammonia. Injuries also occur with industrial exposures to substances such as fertilizers, industrial acids, lye, lime, and cement. Exposures are primarily accidental and result from direct ocular transfer from fingers, splash or spray. Thermal ocular injuries have been reported with cooking oil, e-cigarette explosions, electric arc, and flash burns. Fireworks have the potential to cause both thermal and chemical burns.[5][6][7]

Epidemiology

Ocular burns, specifically chemical burns, are a common cause of ocular trauma. Chemical burns have been reported to cause up to 36,000 visits to emergency departments annually. While accidents leading to ocular burns befall all ages, one study found that nearly three-quarters of all chemical burns occur in individuals between the ages of 18 to 64. Men comprised slightly more than half of such injuries. The same study found that children ages 1 to 2 years had the highest rate of injury per 100,000 compared to all other ages.

Pathophysiology

As previously mentioned, chemical ocular burns can be caused by a wide variety of items found both in the home and workplace. As with burns to other body tissues, alkali burns lead to liquefactive necrosis, as opposed to coagulation necrosis characteristic of acidic burns. Liquefaction allows for alkali burns to penetrate deep into the eye. These burns can very quickly extend through the cornea and anterior chamber, resulting in cataracts, as well as damage the ciliary body and trabecular meshwork, which can lead to increased intraocular pressure and acute glaucoma. The depth of penetration from alkali burns can even destroy the limbal stem cells, therefore preventing the cornea from re-epithelializing normally. In short, alkali burns are highly destructive and carry a high risk of permanent vision loss, even with a relatively brief exposure. Acid burns are also damaging, but the resulting coagulation necrosis can prevent deeper injury to the eye. The protein denaturation of acid burns leads to eschar formation which prevents most acids from penetrating further. Hydrofluoric acid is a notable exception to this and can cause damage to the anterior chamber structures.

History and Physical

Chemical ocular burns are a medical emergency and require immediate irrigation, preferably initiated at the scene of the injury. A patient who arrives in the Emergency Department with a chemical burn should have the affected eye(s) irrigated with one to two liters of sterile saline solution before attempting any exam unless there is a strong suspicion of globe rupture. After no less than 30 minutes of irrigation, litmus paper should be used to check the pH in the conjunctival fornix. pH should be between 7.0 to 7.4. If the pH is, greater than 7.4, continue irrigating until the pH is within the acceptable range.[8][9][10]

Once the pH is within normal limits, the eye can be safely examined. After ensuring there is no globe rupture, the eye should be examined for visible foreign bodies and the lid everted to clear any debris. Fluorescein stain should be performed to assess for corneal abrasions or ulcerations, as well as slit lamp exam for injury to deeper structures in the eye. Intraocular pressure should be measured. Visual acuity testing should be performed. 

Important details of a history include the time and place of injury, determination of what substance was the cause of the burn, the length of time between the injury and start of irrigation, and both type and amount of pre-hospital irrigation. For thermal injuries, it is important to determine how the injury occurred, particularly whether there was an explosion or force that may have led to penetrating injury or foreign body in the eye. As with any traumatic injury, examining the patient closely for concomitant injury is imperative.

Evaluation

Evaluation of the eye after ocular burn should include visual inspection of the surrounding skin, lids, and lashes, as well as the exterior structures of the eye. As described previously, the evaluation should also include fluorescein staining and slit lamp exam, measurement of intraocular pressure, and visual acuity testing. Lab testing is not needed for isolated ocular burns. Maxillofacial or orbital CT may be useful, particularly with burns caused by an explosion or by projectile trauma to the face where significant injury to the globe or surrounding structures is suspected.

Treatment / Management

Immediate irrigation with copious amounts of an isotonic solution as described previously is the mainstay of treatment for chemical burns. Never use any substance to neutralize chemical exposure as the exothermic reaction can lead to secondary thermal injuries. Irrigation should continue until the pH of the eye is between 7.0 to 7.4 and remains within this range for at least 30 minutes after the irrigation has been discontinued. Severe burns may require upwards of ten liters of irrigation. Irrigation should be gentle, and care should be taken to avoid direct irrigation to the cornea to prevent further injury. Use of a commercial irrigation lens such as a Morgan lens may be helpful.[11][12]

A topical anesthetic such as tetracaine can be applied directly to the eye, or 10 mL of 1% lidocaine can be added to a liter of irrigating fluid, taking care not to reach a toxic dose if copious irrigation is required. Patients with severe blepharospasm may require forcible retraction of the upper and lower lids. Lids should be everted and a moist cotton swab used to clear the fornices.

If intraocular pressure is elevated, acetazolamide or a topical beta-blocker such as timolol can be used. Alpha agonists should be avoided given the concern for vasoconstriction, especially when limbal ischemia may already be present.

Ocular burns, particularly any chemical burns with corneal clouding or abrasions, should have prompt ophthalmology evaluation. Topical antibiotic ointment and possibly topical steroids may be prescribed for both chemical and thermal burns, but topical steroids should only be prescribed in consultation with an ophthalmologist.

Pearls and Other Issues

Do not delay immediate irrigation after the injury unless there is very high suspicion for globe rupture. Ocular burns are a true emergency, and prompt ophthalmology evaluation is necessary.

Enhancing Healthcare Team Outcomes

The management of ocular burns is done with a multidisciplinary team that includes an emergency department physician, ophthalmologist, nurse practitioner and the primary care provider. The immediate care is usually provded by the emergency department. All ocular burns should be referred to an ophthalmologist as soon as possible for further assessment. Patients with ocular burns need to be followed by as they may develop cataracts or glaucoma in future. The outcome of patients with ocular burns depend on the type of chemical and extent of eye injury. Those with superifical injury that does not affect vicual acuity have a good outcome, but those with corneal and lens injury, usually have a guarded prognosis. [13][14](Level V)

 

 


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Ocular Burns - Questions

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Which of the following is the most common cause of ocular chemical burns?



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When irrigating the eye after an alkaline chemical burn, what is the pH goal that needs to be reached before discontinuing irrigation?



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A patient is brought to the emergency department 20 minutes after sustaining a chemical burn to his eye from drain cleaner. The eye was irrigated with tap water for 5 minutes at the time of injury and irrigation was continued in the emergency department until the pH normalized. Exam of the affected eye reveals an intraocular pressure of 33 mm Hg. What is the first choice for treating this patient's intraocular pressure?



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A patient presents after a home glass etching workshop with severe eye pain. Which of the following is the most critical first action?



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Involvement of which of the following structures is associated with worse outcomes following ocular chemical burns?



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Ocular Burns - References

References

Slaughter RJ,Watts M,Vale JA,Grieve JR,Schep LJ, The clinical toxicology of sodium hypochlorite. Clinical toxicology (Philadelphia, Pa.). 2019 Jan 28;     [PubMed]
Gupta N,Singh A,Mathur U, Scleral Ischemia in Acute Ocular Chemical Injury: Long-Term Impact on Rehabilitation With Limbal Stem Cell Therapy. Cornea. 2019 Feb;     [PubMed]
Radhakrishnan N,Prajna NV, Commentary: Assessment of limbal ischemia in ocular burns. Indian journal of ophthalmology. 2019 Jan;     [PubMed]
Kam KW,Patel CN,Nikpoor N,Yu M,Basu S, Limbal ischemia: Reliability of clinical assessment and implications in the management of ocular burns. Indian journal of ophthalmology. 2019 Jan;     [PubMed]
Greenfield JA,Kantar RS,Rifkin WJ,Sosin M,Diaz-Siso JR,Patel P,Fleming JC,Iliff NT,Lee BW,Rodriguez ED, Ocular Considerations in Face Transplantation: Report of 2 Cases and Review of the Literature. Ophthalmic plastic and reconstructive surgery. 2018 Dec 7;     [PubMed]
Linton E,Walkden A,Steeples LR,Bhargava A,Williams C,Bailey C,Quhill FM,Kelly SP, Retinal burns from laser pointers: a risk in children with behavioural problems. Eye (London, England). 2018 Dec 13;     [PubMed]
Arnljots T,Samolov B, [Emergency management of chemical eye burns]. Lakartidningen. 2018 Oct 2;     [PubMed]
Bremond-Gignac D,Copin H,Benkhalifa M, Corneal epithelial stem cells for corneal injury. Expert opinion on biological therapy. 2018 Sep;     [PubMed]
Sharma N,Kaur M,Agarwal T,Sangwan VS,Vajpayee RB, Treatment of acute ocular chemical burns. Survey of ophthalmology. 2018 Mar - Apr;     [PubMed]
Ramponi DR, Chemical Burns of the Eye. Advanced emergency nursing journal. 2017 Jul/Sep;     [PubMed]
Baradaran-Rafii A,Eslani M,Haq Z,Shirzadeh E,Huvard MJ,Djalilian AR, Current and Upcoming Therapies for Ocular Surface Chemical Injuries. The ocular surface. 2017 Jan;     [PubMed]
Friedstat J,Brown DA,Levi B, Chemical, Electrical, and Radiation Injuries. Clinics in plastic surgery. 2017 Jul;     [PubMed]
Ghosh S,Salvador-Culla B,Kotagiri A,Pushpoth S,Tey A,Johnson ZK,Figueiredo FC, Acute Chemical Eye Injury and Limbal Stem Cell Deficiency-A Prospective Study in the United Kingdom. Cornea. 2019 Jan;     [PubMed]
Sahraravand A,Haavisto AK,Holopainen JM,Leivo T, Ocular traumas in working age adults in Finland - Helsinki Ocular Trauma Study. Acta ophthalmologica. 2017 May;     [PubMed]

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