Ophthalmology

Chemical Injuiries
Mohammad Shahrukh Hassani
SUKD1601033
Aetiology (Trivial to potentially blinding)
● Alkali burns (more common than acid)- e.g ammonia, sodium hydroxide
● Acid burns- eg. Hydrochloric acid, sulphuric acid

The severity of a chemical injury is related to the properties of the chemical, the
area of affected ocular surface, duration of exposure (including retention of
particulate chemical on the surface of the globe or under the upper lid) and related
effects such as thermal damage (eg. hydrochloric acid and sulphuric acid).
Pathophysiology (Damage--->Healing)

Deeper penetration of
Damage: Necrosis chemicals
Anterior Chamber Penetration

Necrosis of conjunctival
Deeper penetration Iris and lens
and corneal epithelium
causes the breakdown damage.
with disruption and
and precipitation of
occlusion of the limbal
glycosaminoglycans and
vasculature with corneal
stromal corneal
ulcerations and
opacification.
perforations
 Hypotony and Phthisis bulbi
Ciliary Epithelial Damage Healing
(Severe Cases)
○

● The epithelium
Hypotony is usually defined as an
Impairs secretion of . pressure (IOP) of 5 mm Hg or
intraocular heals by migration
ascorbate which is less. Low IOP can adversely impact the of epithelial cells
eye in many ways, including corneal originating from
required for collagen decompensation, accelerated cataract
production and corneal formation, maculopathy, and discomfort. limbal stem cells.
repair. ● Damaged stromal
collagen is
Phthisis bulbi is a shrunken, non-
functional eye. It may result from severe phagocytosed by
eye disease, inflammation or injury, or it keratocyte and new
may represent a complication of eye collagen is
surgery.
synthesized.
Emergency treatment
Chemical injuries require immediate emergency treatment before clinical
assessment.
● Copious irrigation (water/normal saline/ringer lactate)with topical anaesthesia crucial to minimize duration
of contact with the chemical and normalize the pH in the conjunctival sac as soon as possible, and the speed
and efficacy of irrigation is the most important prognostic factor following chemical injury.
● Double-eversion of the upper eyelid should be performed so that any retained particulate matter trapped in
the fornices is identified and removed.
● Debridement of necrotic areas of corneal epithelium should be performed at the slit lamp to promote re-
epithelialization and remove associated chemical residue.
● Admission to hospital will usually be required for severe injuries (grade 4 ± 3) in order to ensure adequate
eye drop instillation in the early stages.
Grading Severity
• Grade 1 - is characterized by a clear cornea (epithelial damage only) and no limbal ischaemia (excellent
prognosis).

• Grade 2-shows a hazy cornea but with visible iris detail and less than one-third of the limbus being ischaemic
(good prognosis).

• Grade 3-manifests total loss of corneal epithelium, stromal haze obscuring iris detail and between one-third and
half limbal ischaemia (guarded prognosis).

• Grade 4-manifests with an opaque cornea and more than 50% of the limbus showing ischaemia (poor prognosis).
(A) Limbal ischaemia; (B) grade 2 – corneal 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
Medical treatment
● Steroids reduce inflammation and neutrophil infiltration, and address anterior uveitis. However, they also impair
stromal healing by reducing collagen synthesis and inhibiting fibroblast migration.
● Cycloplegia may improve comfort.
● Topical antibiotic drops are used for prophylaxis of bacterial infection (e.g. four times daily).
● 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 (L-ascorbic acid) four times daily (not in patients with renal disease).
● Citric acid is a powerful inhibitor of neutrophil activity and reduces the intensity of the 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).
● Tetracycline- (tetracycline ointment four times daily) and systemically (doxycycline 100 mg twice daily tapering to
once daily).
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:

● Advancement of Tenon capsule with suturing to the limbus is aimed at re-establishing limbal
vascularity to help to prevent the development of corneal ulceration.
● Limbal stem cell transplantation from the patient’s other eye (autograft) or from a donor (allograft) is
aimed at restoring normal corneal epithelium.
● Amniotic membrane grafting to promote epithelialization and suppression of fibrosis.
● Gluing or keratoplasty may be needed for actual or impending perforation.
• Late surgery may involve:

○ Division of conjunctival bands (Fig.A) and symblephara (Fig B).

○ Conjunctival or other mucous membrane grafting.

○ Correction of eyelid deformities such as cicatricial entropion (Fig.C).

○ Keratoplasty for corneal scarring (Fig.D) should be delayed for at least 6 months and preferably longer to allow maximal
resolution of inflammation.

○ A keratoprosthesis (Fig.E) may be required in a very severely damaged eye.

Late sequelae of chemical injury. (A) Conjunctival bands; (B) symblepharon
(C) cicatricial entropion of the upper eyelid; (D) corneal scarring; (E) keratoprosthesis
References
● Bruce James, Anthony Bron. (2011). Ophthalmology Lecture Notes. 11 th
Edition. Wiley-Blackwell.

● Jack J Kanski & Brad Bowling. (2016). Clinical Ophthalmology: A Systemic

Approach. 8th edition. Elsevier Saunders