dr. Kartika Lilisantosa, Sp.

M
• Riwayat Pendidikan
• S1 Fakultas Kedokteran Universitas Hasanuddin, Makassar tahun 2003-2006
• Profesi Kedokteran Universitas Hasanuddin, Makassar tahun 2007-2009
• Kursus Tagalog English Language di Emilio Aguinaldo College, Philippines, July
2013
• Residency Training Program of Ophthalmology in Rizal Medical Center,
Philippines, tahun 2013-2017
• Program adaptasi Ilmu Kesehatan Mata Fakultas Kedokteran Universitas
Hasanuddin, Makassar, tahun 2019
• Karya Ilmiah
• Association Between Hyperglycemia and Retinopathy of Prematurity (ROP)
among Premature Infants Admitted in Neonatal Intensive Care Unit (NICU) at
the Rizal Medical Center (RMC). Free paper Presenter di 3rd Asean
Ophthalmology Society Congress 2017, Jakarta, 20 July 2017.
• True ocular emergency requiring immediate
assessment and initiation of treatment.
• Produce extensive damage to the ocular surface
epithelium, cornea, anterior segment and limbal stem
cells resulting in permanent unilateral or bilateral
visual impairment.
• The evolution of cicatrisation in severe chemical injuries
especially alkali, takes an unfavourable course.
• The offending chemical may be in the form of a solid,
liquid, powder, mist, or vapor
• The severity of a chemical injury depends on
• pH
• Volume and duration of contact
• Concentration
• Toxicity of the chemical
• Temperature
• Impact force
• The specific reactivity with tissue (pK)
Rafii AB, et al. Current and Upcoming Therapies for Ocular Surface Chemical Injuries. Ocul Surf. 2017 January ; 15(1): 48–64.
doi:10.1016/j.jtos.2016.09.002
 • Chemical injuries to the eye represent between 11.5%-22.1%
of ocular traumas.
• 2/3rd occur in young men and children age 1-2 years
• The vast majority of the injuries occur in the workplace as a
result of industrial accidents.
• A minority of injuries occur in the home or secondary to assault.
• Alkali materials are found more commonly in building materials
and cleaning agents and occur more frequently than acid
injuries.

Wagoner, M.D., Chemical injuries of the eye: current concepts in pathophysiology and
therapy. Survey of ophthalmology, 1997. 41(4): p. 275-313
ALKALIES ACID

IRRITANTS
 ACID
Substance Chemical Composition Found in
Sulfuric acid H2SO4 Car batteries
Sulfurous acid H2SO2 Bleach and refrigerant
Hydrofluoric acid HF Glass polishing and mineral refining
Acetic Acid CH2COOH Vinegar, glacial acetic acid
Hydrochloric acid HCl Swimming pools
 Alkali
Substance Chemical Composition Found in
Ammonia NH2 Cleaning agents, fertilizers,
refrigerants
Potassium Hydroxide KOH Caustic potash
Lye NaOH Drain cleaners, airbags
Magnesium Hydroxide Mg (OH)2 Firework sparklers, flares
Lime Ca(OH)2 Plaster, mortar, cement, white wash
No. Active Ingredients Found in pH
1. Accelerated hydrogen peroxide (0.5%) Vanish 4.5-7
pH 4.5-7
2. Benzalkonium chloride/ quaternary ammonium/ Bebek Kamar Mandi, 2-11
alkyl dimethyl benzyl ammonium chloride Bratacare, Mr. Muscle, (cationic
(0.05%) Disinfectane concentrate surfactant)

3. Chloroxylenol (0.12%) Dettol antiseptic liquid 5

4. Ethyl alcohol atau ethanol (62-71%) Hand sanitizer 7.33
5. Iodine in iodophor (50 ppm) Betadine 6-10
6. Isopropanol atau 2-propanol (50%) Eisco 8
7. Pine oil (0.23%) SOS 5-7
8. Povidone-iodine (1% iodine) Betadine 4.2
9. Sodium hypochlorite (0.05-0.5%) Bayclin , Clorox 11
10. Sodium dichloroisocyanurate (0.1-0.5%) Aqutabs Multipurpose 6.6

Daftar Sementara Bahan Aktif dan Produk Rumah Tangga untuk Disinfeksi Virus Corona Penyebab Covid-19. http://lipi.go.id/berita/Daftar-
Sementara-Bahan-Aktif-dan-Produk-Rumah-Tangga-untuk-Disinfeksi-Virus-Corona-Penyebab-COVID-19/21979
Agent Industry Use Ocular Toxicity
Surfactants, detergents Cleaning Pain; lacrimation; photophobia; anterior
(anionic) segment damage (cationic)
Benzalkonium; chloride
Hydrocarbons, gasoline, Fuel Mild conjunctivitis; usually no corneal
kerosene involvement
Aromatic (hydrocarbons); Solvents used in Mild corneal damage with rapid healing;
benzene, toluene, xylene laboratories damage nerve endings; pain
Hydrogen peroxide Cleaning; Ocular irritation (household strength)
oxidizing agent
Trichloroethane; Dry cleaning Ocular irritation
trichloroethylene
Alcohols antiseptic Mild irritation (dilute), epithelial damage,
toxic keratopathy
Formaldehyde Preservation of Immediate pain and minimal structural
specimen damage; over the next 12 hours, all layers of
cornea and areas of anterior chamber
undergo degeneration
 Raise the pH of ocular tissues

Saponification of fatty acids in cell membranes

Cellular disruption

Penetrate the corneal stroma:

Destroy the proteoglycan ground substance and collagen fibers
of stromal matrix

May penetrate the anterior Infiltration of PMN leukocyte : release

chamber, producing severe proteolytic enzymes
tissue damage and intense Dissolving corneal stromal collagen and
inflammation ground substance
Figure 1. Figure 2.

Figure 3.
Decrease the pH of ocular tissue

Denature and precipitate proteins

Incite severe inflammation

Damage to the corneal matrix

Severe chemical injury. (A, B) A 33-year-old patient presenting with severe bilateral
hydrochloric acid injury
Alkali Acid
More Severe Less Severe (except hydrofluoric acid)
Saponify cell membranes and intercellular Quickly denature proteins in the corneal
bridges, which facilitates rapid penetration stroma, forming precipitates that retard
into the deeper layers and into the additional penetration
aqueous and vitreous compartments
Lipophilic : combine with cell membrane Causing localized damage due to its
lipids, mucopolysaccharides and to coagulation effect and protein precipitate
collagen, resulting in disruption of cells and at epithelium level which form a physical
necrosis of the tissue barrier
Necrosis of conjunctival blood vessel
Phase Day Recovery
Initial 0 Clinical findings relate to the severity of injury and can be graded
according to degree of limbal, corneal and conjunctival involvement
Acute 0-7 Epithelial regrowth begins to occur if there is a sufficient amount
undamaged limbal stem cells. Treatment should be directed at encouraging
growth while quelling inflammation
Early 7-21 Corneal/conjunctival epithelium and keratocytes proliferate during this
Repair stage. Mild injuries show complete re-epitheliazation while more severe
injuries can have persistent epithelial defects. Activity of collagenases
peaks by day 14-21 while collagen synthesis continues. Treatment should
attempt to maximize collagen synthesis while minimizing collagenase
activity
Late After In mild injuries, where the limbal stem cell population is intact, repair is
Repair day completed. In grade II injuries, where there is focal stem cell loss, there may
21 be a focal conjunctivalization of the cornea, ultimately leading to either
repopulation by conjunctival epithelium or stromal ulceration and
permanent scarring. In case of severe limbal damage, despite optimal
management, the eye often cannot be salvaged
• HEALING OF THE CORNEAL EPITHELIUM OCCURS WITH
• Centripetal movement of cells from peripheral cornea,
limbus, or conjunctiva
• Limbal stem cells are the cells most qualified to restore the
functional competence of the corneal epithelial surface after
injury
• If healing occur with conjunctival epithelium, it can partial
transdifferentiate to corneal epithelium, but can never fully
expresses corneal epithelial phenotypic features, leads to
delayed reepithelization, superficial and deep stromal
vascularization
• HEALING OF DAMAGED STROMAL COLLAGEN:

• Maintenance and regeneration of the corneal stroma

is done by pluripotent cells- KERATOCYTE
• Phagocytose collagen fibrils
• Synthesis and secrete collagen glycosaminoglycan,
and collagenase inhibitors
• Modulated by cytokines released from the
damaged epithelium, inflammatory cells
 Corneal re-epitheliazation

Limbal stem cells damage results

Epithelialization is complete with in corneal epithelization from
sparing of limbal stem cells conjunctival epithelium

Vascularization and scarring, goblet

cell and mucin deficiency, and
recurrent or persistent erosions

Symblepharon formation, cicatricial

entropion, and trichiasis,
fibrovascular pannus
• Severe eye pain
• Epiphora
• Eye Redness
• Blepharospasm
• Reduced visual acuity
• The severity of ocular injury depends on four factors:
• the toxicity of the chemical
• how long the chemical is in contact with the eye
• the depth of penetration
• the area of involvement
• whether they rinsed their eyes afterwards and for how long
• the mechanism of injury (was the chemical under high
pressure)
• whether or not they were wearing eye protection
• Give anesthesia eye drop (Tetracaine 0.5% or Proparacaine
0.5%) 1-2 gtts to both eyes
• The patient should ideally be seated upright with their head
supported and tilted toward the affected side
• Remove the contact lens
• Do the irrigation using sterile saline/ RL/ Balanced Salt Solution
1-3 L through IV tubing
• The irrigating fluid should be administered nasal to lateral,
poured away from the non-affected eye to prevent injury to
that eye
• Particulate chemicals should be removed from the ocular surface
with cotton-​tipped applicators and forceps.
• Eversion of the upper eyelid should be performed to search for
material in the upper fornix
• The fornices should be swept with an applicator to ensure that
no particulate matter remains in
• The physical exam should be used to assess the extent and
depth of injury.
• Specifically, the degree of corneal, conjunctival and limbal
involvement should be documented
• It can be used to predict ultimate visual outcome
 In Emergency setting :
1. Visual Acuity
2. Intraocular pressure
3. Palpebra
4. Conjunctiva Estimation of conjunctival injury
5. Limbal area For example 1/6th +1/6th =
1/3th
6. Cornea (using fluorescein
under cobalt blue light)
7. Anterior segment

Mainster MA. Modification of classification of ocular chemical injuries. doi:

10.1136/bjo.2004.045120
Figure 1. Mild, grade II alkali burn Figure 2. Moderate, grade III alkali burn
Figure 3. Severe, grade IV alkali burn
 ROPER HALL(MODIFIED HUGHES) CLASSIFICATION
GRADE PROGNOSIS CORNEA Conjunctiva/ Limbus
I Good Corneal epithelial No limbal ischemia
no damage
II Good Corneal haze, < 1/3 limbal ischemia
Iris details visible
III Guarded Total epithelial 1/3 – ½ limbal ischemia
loss, stromal haze,
Iris details
obscured
IV Poor Cornea opaque, >1/2 limbal ischemia
iris and pupil
obscured
 DUA CLASSIFICATION FOR OCULAR SURFACE BURNS
GRADE PROGNOSIS CLINICAL FINDINGS CONJUNCTIVAL ANALOGUE
(LIMBAL INVOLVEMENT) INVOLVEMENT SCALE
I Very good 0 clock hours 0% 0/0%
II Good < 3 clock hours < 30% 0.1-3/
1-29.9%
III Good Between 3-6 clock hours 30-50% 3.1-6/
31-50%

IV Good to Between 6-9 clock hours 50-75% 6.1-9/

guarded 51-75
V Good to poor Between 9-12 clock hours 75-100% 9.1-11.9/
75.1-99.9%
VI Very poor Total limbus (12 clock Total conjungtiva 12/100%
hours) (100%) involved
 MEDICAL THERAPY

CHEMICAL EYE INJURY

SURGICAL THERAPY
1. Removing the offending agent
2. Promoting ocular surface
healing
3. Controlling inflammation
4. Preventing infection
5. Controlling IOP
 Antibiotics Cycloplegic Artificial Tears

Platelet Rich
Steroid eye drop Ascorbic Acid Plasma eye drops
 To prevent infection
GRADE I : a topical antibiotic
ointment (e.g. erythromycin
Antibiotics ointment)
GRADE II ABOVE : stronger
topical antibiotic eye drop
(e.g. fluoroquinolone)
 Recommended for patients with
significant anterior chamber
reaction
Cycloplegic Reduce ciliary spasm and pain
Prevent posterior synechiae
Atropine 0.5% or
Cyclopentolate 1%
 Preferably preservative free q2h
 Reduce the risk of recurrent erosions
 Facilitating corneal epithelial migration
and minimizing conjunctival scarring and
Artificial Tears
symblepharon formation
  Reduce inflammatory cell infiltration and
stabilize neutrophilic cytoplasmic and
lysosomal membranes.
 In MILD INJURIES : topical prednisolone
acetate 1% 4 dd 1 gtt
 In SEVERE INJURIES : topical prednisolone
Steroid eye drop acetate 1% can be used every hour
 Given in the initial phase
 After 1 week, the steroids should be
tapered because the balance of collagen
synthesis vs collagen breakdown may tip
unfavorably toward collagen breakdown
 Promote synthesis of mature collagen by
corneal fibroblasts
 severe alkali burns in rabbit eyes were
associated with reduced ascorbic acid
levels in the aqueous humor Ascorbic Acid
 This reduction correlated with corneal
stromal ulceration and perforation.
 In Adult the dose of oral Vitamin C up to
2 grams/ day
 Contains growth factor and fibronectin
benefit in promoting reepithelialization
 Can lead to faster epithelialization
 The difference between autologous PRP
and autologous serum is the platelets
preserved in the autologous PRP.
 Platelets are great sources of growth Platelet Rich
factors such as platelet-derived growth Plasma eye drops
factors (PDGFs) aa, bb, and ab,
transforming growth factors (TGFs) β1 and
β2, vascular endothelial growth factor, and
epithelial growth factor.
 Keep the bottles in a dark, cool place
under refrigeration at 4°C and prepared
every week
• Doxycycline- acts independently of its antimicrobial properties to reduce the
effects of matrix metalloproteinases (MMPs), which can
• Degrade type I collagen. (caution in children and females of childbearing age)
• Suppression of alpha 1 antitrypsin degradation and scavenging reactive oxygen
species
• Reducing ocular surface inflammation
• Dosis Doxycycline 100 mg BID
• Collagenase inhibitors: Collagenase inhibitors promote wound healing by
inhibiting collagenolytic activity and thus preventing stromal ulceration.
Several collagenase inhibitors including cysteine, acetylcysteine, and citrate
10% have been reported to be efficacious. Only 10-20% acetylcysteine
(mucomist) is available commercially. It is an unstable solution and has to be
refrigerated and used within 1 week of its preparation.
• given 1 week after injury
• Increase IOP : give oral carbonic anhydrase inhibitors (Acetazolamide tab
250 mg 2-4 x 1/ day)
• Bandage soft contact lens
• Hydrophilic high oxygen permeability lenses should be
preferred.
• To promote epithelial migration, helps in the basement
membrane regeneration and enhances epithelial stromal
adhesion
• To protect the migrating epithelium from the ‘windshield-
wiper’ effect of the eyelids

• Temporary tarsorrhaphy : may be beneficial for protecting

ocular surface epithelium
• Done by ophthalmologist
• Option for treatment in severe ocular
chemical injury
• Debridement of necrotic epithelium
• Amniotic Membrane Transplantation
• Tenonplasty
• Limbal Stem Cell Transplant
• Penetrating Keratoplasty
• Boston Keratoprosthesis
• Topical antibiotic ointment (erythromycin ointment or similar) four
times a day
• Prednisolone acetate 1% four times a day
• Preservative free artificial tears as needed
• If there is pain, consider a short acting cycloplegic like
cyclopentolate three times a day

Hemmati HD, Colby KA. Treating Acute Chemical Injuries of the Cornea.2012. https://www.aao.org/eyenet/article/treating-acute-
chemical-injuries-of-cornea
• Topical antibiotic drop like fluoroquinolone four times daily
• Prednisolone acetate 1% hourly while awake for the first 7-10
days. Consider tapering the steroid if the epithelium has not
healed by day 10-14
• Long acting cycloplegic like atropine
• Preservative free artificial tears as needed
• Oral Vitamin C, 2 grams in four times a day
• Doxycycline, 100 mg twice a day (avoid in children)
• Debridement of necrotic epithelium
 • Medical Therapy
• Topical antibiotics, cycloplegics, ascorbate, tetracycline should be continued.
• Topical steroids should be discontinued or tappered off unless the patient is
observed daily.
• Ocular hypotensives should be continued if the intraocular pressure remains high.
• A glued-on contact lens may be considered in severe burns with complete
denudation of the cornea and no corneal melting.
• N-acetylcysteine (Mucomyst) 10% solution every hour
• Autologous or homologous serum can be applied dropwise
• Lysis of adhesions to prevent symblepharon.
• Bandage Contact Lens
• Surgical Therapy
• Tarsorraphy
• Consider Amniotic Membrane Transplant in grade III-IV

Singh P, Tyagi M, Kumar Y, Gupta KK, Sharma PD. Ocular Chemical Injuries and Their management. Oman J Ophthalmol. 2013 May-Aug; 6(2): 83–
86.
Ralph RA. Chemical Injuries of the Eye. Duane’s Ophthalmology. 2006. New York: Lippincott Williams & Wilkins
• Medical Therapy
• Surgical Therapy
•Amniotic membrane transplantation
•Conjunctival/tenons advancement
•Tissue adhesives
•Therapeutic penetrating keratoplasty
Singh P, Tyagi M, Kumar Y, Gupta KK, Sharma PD. Ocular Chemical Injuries and Their management.
Oman J Ophthalmol. 2013 May-Aug; 6(2): 83–86.
Ralph RA. Chemical Injuries of the Eye. Duane’s Ophthalmology. 2006. New York: Lippincott Williams
& Wilkins
 • The tear film should be augmented when
necessary with preservative-free artificial tears. Heavily vascularized cornea with
symblepharon several years after
• Lysis of symblephara and reconstruction of the severe chemical burn.
fornices, possibly with mucosal grafts, may be
performed. Silicone rubber sheets and an acrylic
conformer are useful.
• Correction of cicatricial entropion and trichiasis is
necessary if keratoplasty is anticipated.
Opacification of keratoplasty in
• Penetrating keratoplasty heavily vascularized cornea

• If there is perforation :conjunctival/tenons

advancement, tissue adhesives, therapeutic
penetrating keratoplasty
• Keratoprosthesis
Singh P, Tyagi M, Kumar Y, Gupta KK, Sharma PD. Ocular Chemical Injuries and Their management.
Oman J Ophthalmol. 2013 May-Aug; 6(2): 83–86. Keratoprosthesis in chemical injury.
Ralph RA. Chemical Injuries of the Eye. Duane’s Ophthalmology. 2006. New York: Lippincott Williams Collagenolytic lysis occurs around
& Wilkins the central optical post.
PRIMARY COMPLICATIONS

 Conjunctival inflammation
 Corneal abrasions
 Corneal haze and edema
 Iritis
 Acute rise in IOP
 Corneal melting and
perforations
 EYELID
 Trichiasis
 Madarosis
 Ankyloblepharon
 CONJUNCTIVA
 Scarring (destruction of goblet cells &
accessory lacrimal glands
 Severe dryness
 Symblepharon
 Pseudopterygium
 CORNEA
 Corneal ulceration
 Recurrent corneal erosions
 Corneal opcification
 Vascularization thinning & perforation
 SECONDARY GLAUCOMA
 ATROPHIC BULBI
• Chemical eye injury is a true ocular emergency
• Requiring immediate assessment and initiation of treatment.
• The goals in treatment of chemcal eye injury are
1. Removing the offending agent
2. Promoting ocular surface healing
3. Controlling inflammation
4. Preventing infection
5. Controlling IOP
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_note-Wagoner-2
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