8/28/2017 Ophthalmologic Approach to Chemical Burns Treatment & Management: Medical Care, Surgical Care, Consultations

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Ophthalmologic Approach to Chemical

Burns Treatment & Management
Updated: Apr 11, 2017
Author: Mark Ventocilla, OD, FAAO; Chief Editor: Andrew A Dahl, MD, FACS more...

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.
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Placement of a therapeutic bandage contact lens until the epithelium has regenerated can be helpful
in some patients. [10]

Amniotic membrane transplant in eyes with acute ocular burns promotes faster healing of epithelial
defects in patients with moderate grade burns. [11] 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. [11]

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.

Surgical Care
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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 [12]

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 [13, 14, 15, 16]
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 [17]

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.

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

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by an ophthalmologist. Other medical personnel may be needed as determined by the extent of the
extraocular injuries sustained.

Medication

References

1. Merle H, Gerard M, Schrage N. [Ocular burns]. J Fr Ophtalmol. 2008 Sep. 31(7):723-34.

[Medline].

2. Hodge C, Lawless M. Ocular emergencies. Aust Fam Physician. 2008 Jul. 37(7):506-9.
[Medline].

3. Spector J, Fernandez WG. Chemical, thermal, and biological ocular exposures. Emerg Med Clin
North Am. 2008 Feb. 26(1):125-36, vii. [Medline].

4. Pfister DA, Pfister RR. Acid injuries of the eye. Fundamentals of Cornea and External Disease.
Cornea. 2005. Vol 2.: 1277-84.

5. Pfister RR, Pfister DA. Alkali injuries of the eye. Fundamentals of Cornea and External Disease.
Cornea. 2005. Vol 2: 1285-93.

6. Xiang H, Stallones L, Chen G, Smith GA. Work-related eye injuries treated in hospital
emergency departments in the US. Am J Ind Med. 2005 Jul. 48(1):57-62. [Medline].

7. Morgan SJ. Chemical burns of the eye: causes and management. Br J Ophthalmol. 1987 Nov.
71(11):854-7. [Medline].

8. Klein R, Lobes LA Jr. Ocular alkali burns in a large urban area. Ann Ophthalmol. 1976 Oct.
8(10):1185-9. [Medline].

9. Wagoner MD, Kenyon KR. Chemical injuries of the eye. Clinical Practice. Albert, Jakobiec, eds.
Principles and Practice of Ophthalmology. 2000. Vol 2: 943-59.

10. Kheirkhah A, Johnson DA, Paranjpe DR, Raju VK, Casas V, Tseng SC. Temporary sutureless
amniotic membrane patch for acute alkaline burns. Arch Ophthalmol. 2008 Aug. 126(8):1059-66.
[Medline].

11. Tandon R, Gupta N, Kalaivani M, et al. Amniotic membrane transplantation as an adjunct to

medical therapy in acute ocular burns. Br J Ophthalmol. 2011 Feb. 95(2):199-204. [Medline].

12. Kheirkhah A, Johnson DA, Paranjpe DR, Raju VK, Casas V, Tseng SC. Temporary sutureless
amniotic membrane patch for acute alkaline burns. Arch Ophthalmol. 2008 Aug. 126(8):1059-66.
[Medline].

13. Jafarinasab MR, Feizi S, Javadi MA, Karimian F, Soroush MR. Lamellar keratoplasty and
keratolimbal allograft for mustard gas keratitis. Am J Ophthalmol. 2011 Dec. 152(6):925-932.e2.
[Medline].

14. Takeda K, Nakamura T, Inatomi T, Sotozono C, Watanabe A, Kinoshita S. Ocular surface

reconstruction using the combination of autologous cultivated oral mucosal epithelial
transplantation and eyelid surgery for severe ocular surface disease. Am J Ophthalmol. 2011
Aug. 152(2):195-201.e1. [Medline].

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8/28/2017 Ophthalmologic Approach to Chemical Burns Treatment & Management: Medical Care, Surgical Care, Consultations

15. Kawashima M, Kawakita T, Satake Y, Higa K, Shimazaki J. Phenotypic study after cultivated
limbal epithelial transplantation for limbal stem cell deficiency. Arch Ophthalmol. 2007 Oct.
125(10):1337-44. [Medline].

16. Clare G, Suleman H, Bunce C, Dua H. Amniotic membrane transplantation for acute ocular
burns. Cochrane Database Syst Rev. 2012 Sep 12. 9:CD009379. [Medline].

17. Tuft SJ, Shortt AJ. Surgical rehabilitation following severe ocular burns. Eye. 2009 Jan 23.
[Medline].

18. Dua HS, King AJ, Joseph A. A new classification of ocular surface burns. Br J Ophthalmol. 2001
Nov. 85(11):1379-83. [Medline].

19. Brodovsky SC, McCarty CA, Snibson G, et al. Management of alkali burns : an 11-year
retrospective review. Ophthalmology. 2000 Oct. 107(10):1829-35. [Medline].

20. Dohlman CH, Cade F, Pfister R. Chemical burns to the eye: paradigm shifts in treatment.
Cornea. 2011 Jun. 30(6):613-4. [Medline].

21. Hemmati H, Colby K. Treating Acute Chemical Injuries of the Cornea. EyeNet. October 2012.
[Full Text].

22. Stern G, Goins K, Pelton R. Focal points, Chemical Injuries of the Cornea. March 2010. 1-14.

23. Suri K, Kosker M, Raber IM, Hammersmith KM, Nagra PK, Ayres BD, et al. Sutureless amniotic
membrane ProKera for ocular surface disorders: short-term results. Eye Contact Lens. 2013
Sep. 39(5):341-7. [Medline].

Media Gallery

Alkali burn. Note the severe conjunctival reaction and stromal opacification blurring iris details
inferiorly.
Severe chemical injury with early corneal neovascularization.
Complete cicatrization of the corneal surface following chemical injury.

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Contributor Information and Disclosures

Author

Mark Ventocilla, OD, FAAO Adjunct Clinical Professor, Michigan College of Optometry; Editor,
American Optometric Association Ocular Surface Society Newsletter; Chief Executive Officer, Elder
Eye Care Group, PLC; Chief Executive Officer, Mark Ventocilla, OD, Inc; President, California Eye
Wear, Oakwood Optical

Mark Ventocilla, OD, FAAO is a member of the following medical societies: American Academy of
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Optometry, American Optometric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology,
Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of
Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of

Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery
Department, Wills Eye Hospital

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of

Ophthalmology, American Ophthalmological Society, American Society of Cataract and Refractive
Surgery, Cornea Society, Contact Lens Association of Ophthalmologists, Eye Bank Association of
America, International Society of Refractive Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cornea
Society, AAO, OMIC, Aerie, Bausch & Lomb, Bio-Tissue, Shire, TearLab<br/>Serve(d) as a speaker or
a member of a speakers bureau for: Allergan, Bausch & Lomb, Bio-Tissue.

Chief Editor

Andrew A Dahl, MD, FACS Assistant Professor of Surgery (Ophthalmology), New York College of
Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health
and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center

Andrew A Dahl, MD, FACS is a member of the following medical societies: American Academy of
Ophthalmology, American College of Surgeons, American Intraocular Lens Society, American Medical
Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of
Ophthalmologists, Medical Society of the State of New York, New York State Ophthalmological
Society, Outpatient Ophthalmic Surgery Society

Disclosure: Nothing to disclose.

Additional Contributors

Fernando H Murillo-Lopez, MD Senior Surgeon, Unidad Privada de Oftalmologia CEMES

Fernando H Murillo-Lopez, MD is a member of the following medical societies: American Academy of

Ophthalmology

Disclosure: Nothing to disclose.

Acknowledgements

Alok S Bansal, MD Fellow, Vitreoretinal Surgery, Wills Eye Hospital

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8/28/2017 Ophthalmologic Approach to Chemical Burns Treatment & Management: Medical Care, Surgical Care, Consultations

Alok S Bansal, MD is a member of the following medical societies: American Academy of

Ophthalmology, American Society of Cataract and Refractive Surgery, Association for Research in
Vision and Ophthalmology, and International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Geoffrey Broocker, MD, FACS Walthour-DeLaPerriere Professor of Ophthalmology, Department of

Ophthalmology, Emory University School of Medicine; Former Chief of Service, Ophthalmology, Grady
Memorial Hospital

Geoffrey Broocker, MD, FACS is a member of the following medical societies: American College of
Surgeons

Disclosure: Nothing to disclose.

Evan S Loft, MD Clinical Assistant Professor, Department of Ophthalmology, Emory University

Evan S Loft is a member of the following medical societies: American Academy of Ophthalmology,
American Medical Association, American Society of Cataract and Refractive Surgery, Association for
Research in Vision and Ophthalmology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

J Bradley Randleman, MD Associate Professor, Department of Ophthalmology, Section of Cornea,

External Disease and Refractive Surgery, Emory University School of Medicine; Director of Cornea,
External Disease and Refractive Surgery Fellowship, Emory University; Physician Member, Section of
Ophthalmology, The Emory Clinic

J Bradley Randleman, MD is a member of the following medical societies: Alpha Omega Alpha,
American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Cornea
Society, and International Society of Refractive Surgery

Disclosure: Nothing to disclose.

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