II. Definitions
- Chemical Eye Injury
- Eye Injury via strong acids or bases in liquid, powder or gas form
III. Epidemiology
- Common Work-Related Eye Injury
- Also occurs with home cleaning products (e.g. bleach)
IV. Risk Factors
- Strong acids or bases
- Alkali are more common in home cleansers
- Alkali penetrate the eye surface rapidly
- Longer duration of exposure
- Most eye damaging agents
- Strong bases/alkali such as bleach (pH > 10, associated with worse outcomes)
- Hydrofluoric Acid (semiconductor production)
V. Pathophysiology
- Damage to Conjunctiva and Cornea
- Ischemia may result from adjacent injury to Conjunctival or Scleral vessels
- May cause Corneal scarring and opacification
VI. Symptoms
- Severe Eye Pain
- Photophobia
- Blurred Vision
- Eye Foreign Body Sensation
VII. Signs
-
Eyelid burn
- Reflex blepharospasm may interfere with exam
-
Conjunctival or Corneal color
- Red Eye with Conjunctival injection (most common)
- Corneal Epithelium disruption (Fluorescein stain uptake)
- White eye (Corneal clouding) suggests severe Eye Injury with ischemia
VIII. Exam
- Litmus paper (acid-base pH paper) applied to Conjunctival fornix (where bulbar and palpebral Conjunctiva meet)
- Visual Acuity
- Observe eye appearance for injury
- Corneal Opacification or clouding
- Conjunctival injection
- Observe for Eyelid Swelling or Burn Injury
- Fluorescein stain for Corneal epithelial defect
IX. Grading: Roper-Hall Classification
- Grade 1: Mild Corneal epithelial damage
- Grade 2: Corneal Stromal haze but maintained visible iris details
- Grade 3: Corneal Stromal haze obscures iris details
- Grade 4: Cornea completely Opaque, completely blocking any view of iris
- Roper-Hall (1965) Trans Ophthalmol Soc 85:631-53 [PubMed]
X. Management: Immediate Eye Irrigation to Neutral pH (7.0 to 7.5)
- See Eye Irrigation
- Ocular Emergency requiring immediate management
- Apply Topical Anesthetic to eye or add Lidocaine to saline irrigation bag (see Eye Irrigation)
- Immediate and Copious Eye Irrigation for at least 2 liters irrigant over 30 minutes
- See Eye Irrigation
- Do not delay irrigation for exam, contact removal, or sterile fluid
- Measure pH of ocular surface 5 minutes after initial irrigation
- Further irrigation until pH neutralized to 7.0 to 7.5
- Recheck pH to confirm stability at 30 minutes
- Sweep upper and lower lids with a moist cotton swab
- Removes any retained crystallized chemical particles
XI. Management: Following Irrigation to neutral pH
- Precautions
- Do not patch eye (increased risk of infection)
- Topical agents: All chemical eye burns with any Corneal Epithelial Disruption, Fluorescein uptake
- Antibiotic eye drops (e.g. Erythromycin, Ciprofloxacin, Gentamycin, Tobramycin)
- Preservative-free artificial tears
- Topical agents: Grade 3-4 Chemical Burns
- Add in combination with Topical Antibiotics and artificial tears described above
- Topical Corticosteroids (e.g. Prednisolone) or in combination with Antibiotic (e.g. Tobradex)
- Consider Cycloplegic agent (e.g. Cyclopentolate or Cyclogyl, Scopolamine 0.25%)
- Disposition
- Recheck within 24 hours
- Recheck Intraocular Pressure, Corneal surface, lid injury
- Indications for emergent or urgent ophthalmology referral
- Strong alkali or acid burn
- Abnormal Visual Acuity
- Severe Eye Pain
- Marked Conjunctival swelling or Chemosis
- Corneal epithelial defect (Fluorescein uptake)
- Cloudy Cornea (Corneal Opacification, Roper-Hall Grades 2-4)
XII. Prognosis
- Best prognosis with early copious irrigation and Grade 1-2 injuries
- Corneal Opacity or ischemia is associated with worse prognosis and longterm Decreased Visual Acuity
XIII. Resources
- Toxic Substances and Disease Registry
XIV. References
- Trobe (2013) Physicians Guide to Eye Care, p. 89-92
- Gelston (2020) Am Fam Physician 102(9):539-45 [PubMed]
- Gelston (2013) Am Fam Physician 88(8): 515-9 [PubMed]
- Lusk (1996) AAOHN J 47:80-7 [PubMed]
- Pokhrel (2007) Am Fam Physician 76:829-36 [PubMed]