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Emergency Treatment of Eye

Emergency Treatment of Eye

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Published by: Nurrisya Pane on Jun 09, 2014
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Emergency treatment of chemicaland thermal eye burns
Ralf Kuckelkorn, Norbert Schrage, Gabriela Keller andClaudia Redbrake
Department of Ophthalmology, Universitätsklinikum der RWTH Aachen, Aachen,Germany
ABSTRACT.Chemical and thermal eye burns account for a small but significant fraction of ocular trauma. The speed at which initial irrigation of the eye begins, has thegreatest influence on the prognosis and outcome of eye burns. Water is com-monly recommended as an irrigation fluid. However, water is hypotonic to thecorneal stroma. The osmolarity gradient causes an increased water influx intothe cornea and the invasion of the corrosive substance into deeper corneal struc-tures. We therefore recommend higher osmolarities for the initial rinsing tomobilize water and the dissolved corrosives out of the burnt tissue. Universalsystems such as amphoteric solutions, which have an unspecific binding withbases and acids, provide a convenient solution for emergency neutralisation.Both conservative anti-inflammatory therapy and early surgical intervention areimportant to reduce the inflammatory response of the burnt tissue. In mostsevere eye burns, tenonplasty re-establishes the conjunctival surface and limbalvascularity and prevents anterior segment necrosis.
Key words:
 cornea – emergency treatment – eye burns – irrigation fluid – reconstructive surgery.
Acta Ophthalmol. Scand. 2002: 80: 4–10
Copyright 
c
Acta Ophthalmol Scand 2002. ISSN 1395-3907 
R
ecent studies put the incidence of chemical and thermal injuries tothe eye at 7.7%
ª
18% of all ocular trauma(Watz & Reim 1973; Pfister et al. 1984;Liggett 1989; MacEwen 1989; Zagelbaumet al. 1993). Most of these injuries aretrivial and do not cause any lastinglesions, others result in permanent unilat-eral or bilateral visual impairment and alife of dependency (Kuckelkorn et al.1993). The majority of victims are youngand exposure occurs at home, work andin association with criminal assaults(Keeney 1974; Morris et al. 1987; Thi-elsch et al. 1989). Alkali injuries occurmore frequently than acid injuries (Pfister1983; Morgan 1987), eye burns caused bydetergents and thermal agents being lessfrequent again (Kuckelkorn et al. 1995).The most common agents causing alkaliburns are ammonia (NH
3
), lye (NaOH),potassium hydroxide (KOH) and lime(CaOH2). Sulfuric (H2SO
4
), sulfurous(H2SO
3
), hydrofluoric (HF) and hydro-chloric (HCL) acids are the most com-mon causes of acid burns. Table1 lists thedata from 191 patients with 260 severelyburnt eyes who were treated in the eyecenter of the RWTH Aachen between1980 and 1995. There was a high inci-dence of bilateral injuries and most of theinjuries occured at home or during leisureactivities.
Action of alkalis and acids
The severity of ocular injury is related tothe type of chemical, the volume and con-centration (pH) of the solution and theduration of exposure (Hughes 1946). Al-kalis penetrate more rapidly than acids.The hydroxylion (OH) saponifies thefatty acid components of the cell mem-branes with consecutive cell disruptionand cell death, while the cation is respon-sible for the penetration process of thespecific alkali (McCulley 1987). Thepenetration rate increases from calciumhydroxide (slowest), potassium hydroxide(faster), sodium hydroxide (even faster) toammonium hydroxide (fastest; Grant1974). Depending on the degree of pene-tration, there is a loss of corneal and con- junctival epithelium, stromal keratocytesand endothelium. Hydration of the glyco-saminoglycans results in loss of clarity of the stroma (Grant & Kern 1955). Dam-age to the vascular endothelium of con- junctival and episcleral vessels leads tothrombosis of the episleral vessels.The stronger the alkali, the faster itspenetration. Irreversible damage occursat a pH above 11.5 (Friedenwald et al.1944). The pH in the aqueous humourrises within a few seconds of contact withammonium hydroxide (Graupner &Hausmann 1970). Intraocular structuressuch as the iris, lens and ciliary body arerapidly damaged.
Table1.
 Severe chemical and thermal eye burnsin the Department of Ophthalmology of theRWTH Aachen (1985–1995): 191 patients (260eyes).Number of Per centpatientsUnilateral 122 64Bilateral 69 36EyesOccupational injuries 177 68.1Private injuries 63 24.1Others 20 7.8EyesAlkalis 151 58.1Acids 37 14.1Thermal 42 16.2Others 30 11.6
 
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Apart from hydrofluoric acid and, toa lesser extent, sulfurous acid, acidspenetrate the corneal stroma much lessreadily than alkalis (Grant 1974). Thehydrogen ion causes damage due to pHalteration, while the anion producesprotein precipitation and denaturationin the corneal epithelium and superficialstroma (Friedenwald et al. 1946). Pre-cipitation of the epithelial proteins of-fers some protection to the cornealstroma and intraocular structures. How-ever, very strong acids penetrate justquickly as alkalis. No statistical differ-ence between strong alkali and acidsburns was discovered in the clinicalcourse and prognosis of such eyes(Kuckelkorn 1996).
Clinical classification of chemical andthermal burns
Eye burns are classified in 4 grades (Reim1987, 1990). The clinical course and ulti-mate prognosis correlates with the extentof limbal ischemia (Hughes 1946; Ballen1963; Roper-Hall 1965). The prognosisalso depends on the extent of damage toconjunctival and episcleral tissue, severityof lid burn and damage to intraocularstructures (Table2).MildburnsofgradesIandIIareassoci-ated with hyperemia, small conjunctivalecchymosis and chemosis as well as ero-sion of the corneal epithelium (Figs1 and2). In mild acid burns, the coagulated cor-neal epithelium often has a ‘ground-glass’appearance. After removal of the epithel-ium, the clear corneal stroma is visible.Grade III, and especially grade IV,burns are accompanied by extensive anddeep damage to the tissue (Figs3 and 4).Typically, large areas of the conjunctivaland subconjunctival tissue are involved.The visible blood vessels are thrombosedand appear dark. The corneal keratocyt-
Table2.
 Clinical classification and prognosis of eye burnsGrade I II III IVAppearence Erosio Erosio Erosio ErosioLimbal ischemia
3/4 Hyperemia Limbal ischemia
1/3 Limbal ischemia
1/2Chemosis Chemosis ChemosisOpacication Opacication Extensive necrosisClinical outcome Regeneration Recirculation Vascularisation UlcerationRegeneration Ulceration Iris atrophyProliferaton CataractCicatrization GlaucomaPrognosis Complete restitution Complete restitution ScarsPrevention of the globeMultiple operations for Slight scars Multiple operationscosmetic rehabilitation for limited visualrehabilitation
Fig.1.
 Grade I chemical injury: hydrochloric acid (HCl). Burn of the cornea only. Coagulatedcorneal epithelium with ‘ground glass’ appereance. Partial removal of the epithelium, clear corenalstroma.
es are lost and hydration of the denaturedproteins results in corneal opacification.Chemical injury to the iris and crystallinelens may produce mydriasis, a greyish ap-pearance of the iris and the fast develop-ment of a cataract. The lysis of cells of the anterior chamber destroys the bloodaqueous barrier and leads to iridocyclitisand fibrinous exsudation.Toxic substances such as prostagland-ines, superoxide radicals, and presumablyhistamine, angiotensin, leukotriens andothers are released from the burnt cells of the necrotic tissue (Eakins & Bhattach-erjee 1977; Kulkarni & Srinivasan 1993;Rochels et al. 1982). An inflammatory re-sponse is initiated, when they diffuse intosurviving tissues. In mild burns this reac-tion resolves quickly, while in severeburns a severe and long-term inflamma-tory process is initiated, determining theclinical course of the burnt eyes (Reim1982, 1987, 1992; Williams et al. 1983;Struck et al. 1991; Reim & Leber 1993;Reim et al. 1993).
Emergency treatment
Immediate irrigation is of paramount im-portance after chemical or thermal burns(Lubeck & Greene 1988; Cohen & Hynd-iuk1978;Rodeheaveret al.1982).Inmostcases the victims are disabled by severe re-flectory blepharospasm with ensuing dis-orientation. In this situation the victimsare unlikely to be capable of reaching thenearest body or eye shower and need res-
 
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Fig.2.
 Grade II chemical injury: lime (CaOH). Central epithelial defect, partial limbal ischemiain the nasal inferior quadrant.
cuers who remove them from dangerousareas and apply fast and efficient help totheir eyes and body (Morgan 1987).Effective first aid involves knowing howto overcome blepharospasm by a passiveopening of the lids and how to perform ef-fective irrigation of the eye. All aspects of the conjunctiva and cornea should be irri-
Fig.3.
 Grade III chemical injury: sodium hydroxide (NaOH). Complete corneal and proximalconjunctival epithelial defect with loss of corneal stromal clarity. Limbal ischemia in theinferiorquadrants.
gated, and the patient should be asked tolook in all directions (Tannen & Marsden1991).Topicalanestheticdropsmaybeap-pliedtoreducethepainandtofacilitateir-rigation. According to the American Na-tional Standards Institute (ANSI) stan-dard (Z358.1–1990) severe eye burns haveto be rinsed for 15min. At least 500–1000mL of irrigation fluid are thus necessary.Amphotericorbufferedsolutionscannor-malize the pH of the anterior chamberwithinthattime(Schrageet al.1996).Par-ticles are sometimes trapped in the for-nizesorundertheupperlid.Therefore,ec-tropinisation and intensive cleaning of thecul-de-sac are mandatory after everyburn. Materials containing calcium oxid(lime, cement dust) reactavidly with waterto produce a calcium hydroxide solutionwith a pH of 12.4 (Moon & Robertson1983). A cotton-tipped applicator soakedin EDTA 1% (EDTA, di-sodium-ethylen-diamintetra-acetat) can be used to facili-tate cleaning of the cul-de-sac from cal-cium hydroxide (Pfister 1983). Immediateirrigation is also important in thermalburns, because this cools the ocular sur-face (Schrage et al. 1997). Continuous ir-rigation also removes inflammatory sub-stances from the ocular surface (Reim1990; Reim & Kuckelkorn 1995).First aid with intensive irrigation im-mediately after the injury has a decisiveinfluence on the clinical course and prog-nosis of such eyes (Saari & Parvi 1984;Burns & Paterson 1989). A comparisonbetween visual outcome of better than 1/50 with that of less than 1/50 revealed ahighly significant difference, with signifi-cantly better results after immediate irri-gation. Visual acuity of 
 
1/50 enablesthe patient to move unaided. The numberof operations and the length of stay onthe ward are significantly reduced for eyesthat received prompt irrigation (Table3;Kuckelkorn et al. 1995).
Choice of irrigation fluid
Burns are accompanied by a loss of thecorneal epithelium within a few seconds.The acutely burnt cornea takes up theburning substance by osmolar forces re-sulting in a high osmolarity. One of theaims of rinsing therapy is to remove thischemical burden.Water is commonly recommended asan irrigation fluid. It is available almosteverywhere, and copious amounts of water have a dilutive effect. However,water is hypotonic to the corneal stromaand intraocular milieu. In measurementsof osmolarity, Schrage et al. (unpub-lished) found the corneal stroma to havean osmolarity of 420 mOsm/L. The cor-neal tissue is diluted by rinsing with waterand this is accompanied by an increaseduptake of additional water and diffusionof the corrosive into the deeper layers of the cornea. We thus recommend the useof irrigation fluids with higher osmolari-

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