CHEMICAL INJURIES
Aetiology
Fig. 21.30 Siderosis oculi. IA) lenticular deposits; {Bl atrophy
of the retina and retinal pigment epithelium (RPE)
associated with an impacted ferrous foreign body
(COurtesy or W USch - Ilg. A; J Donald M Gass, from Stereoscopic Atlas
Macu1ar Diseases, Mosby 1997 - Ilg. BJ
882 Chemical lnJunes
globe or under the upper lid) and related effects such as thermal
damage. Alkalis tend to penetrate more deeply than acids, as the
latter coagulate surface protei ns, forming a protective barrier; the
most commonly involved alkalis are am monia , sodium hydroxide
and lime. Ammonia and sod ium hydroxide cha racteristically
produce severe damage because of rapid penetration. Hydrofluo-
ric acid used in glass etching and cleaning also tends to rapidly
penetrate 1he ocular tissues, whilst sulphuric acid may be compli-
cated by thermal effects and high velocity impacts associated with
car banery explosion.
Pathophysiology
• Damage by severe chemical injuries tends to progress as
below:
O Necrosis of the conjunctiva] and corneal epithelium with
disruption and occlusion of the limbal vasculature. Loss
of limbal stem cells may lead to conjunctivalization and
vasculari7.ation of the corneal su rface, or persistent
corneal epithelial defects with sterile corneal ulceration
and perforation. Longer-term effects include ocular
surface welling disorders, symblepharon fo rmation and
cicatricial entropion.
o Deeper penetration causes the breakdown and
precipitation of glycosaminoglyca ns and stromal corneal
opacification.
o Anterior chamber penetration results in iris and lens
damage.
o Ciliary epithelial damage impairs secretion of ascorbate,
which is required fo r collagen production and corneal
repair.
o Hypolony and phthisis bulbi may ensue in severe
• Healing
o The epithelium heals by migration of epirhe\ial cells
originaling from limbal stem cells.
o Damaged stromal collagen is phagocytosed by keratocytes
and new collagen is synthesized.
Management
Emergency treatment
A chemical burn is the only eye injury that requires emergency
treatment without formal clinical assessment. Immediate treat-
ment is as fo llows:
• Copious irrigation is crucial to minimize duration of
con tact with the chem ical and normali1.e the pH in the
conjunctival sac as soon as possible, and the speed and
efficacy of irrigation is the most importan1 prognost ic facto r
following chemical injury. Topical anaesthetic should be
instilled prior 10 irrigat ion, as this drama1ically improves
comfort and facilitates cooperat ion. A lid speculum may be
helpful. Tap wa ter should be used if necessary to avoid any
delay, but a sterile balanced buffered solution, such as
Chemical injuries range in severity from trivial to potentially
blinding. The majority are accidental, but a few arc due to assault.
Two- 1hirds of accidental burns occur at work and the remainder
at home. Alkali burns are twice as com mon as acid burns, since
alkalis are mo re widely used both at home and in industry. The
severity of a chemical injury is related to the properties of the
or
chemical, the area of affected ocular surface, duration of exposu re
(including retention of particulate chemica l on the surface of the
normal sa line or Ringer laclate, should be used to irrigate
the eye for 15-30 minutes or until the measured pH is
nculral.
• Double-eversion of the upper eyelid shou ld be performed
so that any reta ined particula1e maner !rapped in the
fornices is identified and removed.
• Debridement of necrotic areas of corneal epithelium should
be performed at the slil lamp to promote re-epitheliali1. .1tion
and remove associated chemical residue.
• Admission to hospital will usually be required for severe
injuries (grade 4 ± 3 - see below) in order to ensure
adequate eye drop instillation in the ea rly stages.
Grading of severity
Acute chemical injuries are graded to plan appropriate subsequent
treatment and afford an indication of likely ult imate prognosis.
Grading is performed on the basis of corneal clarity and severity
of limbal ischaemia (Roper-Hall system); the latter is assessed by
observing the patency of the deep and superficial vessels at the
limbus.
• Grade 1 (Fig. 21.31A) is characterized by a dea r cornea
(epithelial damage only) and no limbal ischacmia (excellent
prognosis).
• Grade :2 (Fig. 21.31B ) shows a hazy cornea but with visible
iris detail and less than one-third of the limbus bei ng
ischaemic (good prognosis) .
• Grade 3 (Fig. 21.31C) manifests total loss of corneal
epitheli um , stromal haze obscuring iris detail and between
o ne-third and half limbal ischaemia (guarded prognosis).
• Grade4 (Fig. 21.31D) manifests with an opaque cornea and
more 1han 50% of the limbus showing ischaemia (poor
prognosis).
Other features that should be noted at the initial assessment arc
the extent of corneal and conjunctiva] epithelial loss, iris changes,
the status of the lens and the !OP.
Medical treatment
Most milder (grade 1 and 2) injuries are treated with topical ant i-
biotic ointment for about a week, with topical steroids and
cycloplegics if necessary. The main aims of treatment of more
severe burns are to reduce inflammation, promote epithelial
regeneration and prevent corneal ulceration. For moderate to
severe inj uries, preservative-free drops should be used.
• Steroids reduce inflammation and ncutrophil infiltration,
and address anterior uveitis. However, they also impair
stromal healing by reduci ng collagen synthesis and inhibiting
fibroblast migration. For this reason topical steroids may be
used initially (usually 4-8 times daily, strength depending on
injury severit y) but must be tailed off aft er 7-10 days when
sterile corneal ulceration is mos1 likely to occur. Steroids
may be replaced by topical non-steroidal ant i-i nflammatory
drugs, which do 001 affec1 keratocyte fun cl'ion.
• Cycloplegia may improve comfort.
• Topical antibiotic drops are used for prophylaxis of
bacterial infection (e.g. four times daily).
Fig. 21.31 Chemical burns. (A) Limbal ischaemia; (Bl grade 2 - cornea l haze but visible iris detail - the white area at left is
the reflected slit beam rather than haze alone; (C) grade 3 - corneal haze obscuring iris details; (D) grade 4 - opaque
cornea

• Ascorbic acid reverses a localized tissue scorbutic state and
improves wound healing, promoting the synthesis of mature
collagen by corneal fibroblasts. Topical sodium ascorbate
10% can be given 2-hourly in addition to a systemic dose of
1-2 g vitamin C CL-ascorbic acid) four times daily (not in
patients with renal disease).
• Citric acid is a powerful inhibitor of neutrophil activity and
reduces th e intensity of th e inflammatory response.
Chelation of extracellular calcium by citrate also appears to
inhibit collagenase. Topical sodium citrate 10% is given
2-hourly for about 10 days, and may also be given orally (2 g
four times daily). The aim is to eliminate the second wave of
phagocytes, which normally occurs about 7 days after the
injury. Ascorbate and citrate can be tapered as the
epithelium heals.
• Tetracyclines are effective collagenase inhibitors and also
inhibit neutrophil activity and reduce ulceration. They
should be considered if there is significant corneal melting
and can be administered both topically (tetracycline
ointment four times daily) and systemically (doxycycline
100 mg twice daily tapering to once daily). Acetylcysteine
10% six times daily is an alternative anticollagenase agent
given topically.
• Symblepharon formation should be prevented as necessary
by lysis of developing adhesions with a sterile glass rod or
damp cotton bud.
• IOP should be monitored, with treatment if necessary; oral
acetazolamide is recommended to avoid adding further to
the ocular surface burden. ..
• Periocular skin injury may require a dermatology opini~
Fig. 21.32 Late sequelae of chemical injury. (A) Conjunctiva I
bands ; (B) symblepharon; (C) cicatricial entropion of the
upper eyelid; (D) cornea l scarring; (E) keratoprosthesis -
(Courtesy of C Barry - fig. D; R Bates - fig. E)

Surgery
• Early surgery may be necessary to promote revascularization
of the limbus, restore the limbal cell population and
re-establish the fornices. One or more of the following
procedures may be used:
o Advancement of Tenon capsule with suturing to the
lin1bus is aimed at re-establishing limbal vascularity to
help to prevent the development of corneal ulceration.
o Limbal stem cell transplantation from the patient's other
eye (autograft) or from a donor (allograft) is aimed at
restoring normal corneal epithelium.
o Amniotic membrane grafting to promote epithelialization
and suppression of fibrosis .
o Gluing or keratoplasty may be needed for actual or
impending perforation.
• Late surgery may involve:
O Division of conjunctiva! bands (Fig. 21.32A) and
symblephara (Fig. 21.32B).
o Conjunctival or other mucous membrane
grafting.
o Correction of eyelid deformities such as cicatricial
entropion (Fig. 21.32C).
o Keratoplasty for corneal scarring (Fig. 21.32D) should be
delayed for at least 6 months and preferably longer to
allow maximal resolution of inflammation.
o A keratoprosthesis (Fig. 21.32E) may be required in a very
severely damaged eye.