Surendra Prasad Sah Assistant Professor Himalaya Eye Hospital ,Nepal

1. SURENDRA PRASAD SAH
OPTOMETRIST
HIMALAYA EYE HOSPITAL
Ocular surface chemical
injuries

2. Introduction
o A corrosive substance is accidentally introduces to the eye and or
periocular tissues.
o True ophthalmic emergencies that require immediate and intensive
intervention to minimize severe complications and profound
visual loss.
o Most prevalent among young males aged 20-40, can result in
chronic complications and life-long disability.
o 20% - 30% of all ocular injuries.
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Sah Surendra HEH
Eslani M, Baradaran-Rafii A, Movahedan A, Djalilian AR. The ocular
surface chemical burns. J Ophthalmol 2014;2014:196827

3. Introduction
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The severity of chemical injury is determined by several factors
o chemical and physical characteristics of the offending
o agent (particularly the pH),
o specific reactivity with tissues (pK)
o concentration
o volume
o temperature
o impact force.
Wagoner MD. Chemical injuries of the eye: current concepts in pathophysiology
and therapy. Surv Ophthalmol 1997;41:275-313

4. Introduction
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Alkali Vs Acid
Alkaline substances :- due to their lipophilicity, penetrate the
eye more readily and threaten both ocular surface tissues as well
as intraocular structures such as the trabecular meshwork, ciliary
body and lens.
Acid substances :- cause protein clotting in the epithelium, a
process that limits further penetration into the eye
Both alkali and acid can leads to devastating injuries
Schrage NF, Langefeld S, Zschocke J, et al. Eye burns: an emergency
and continuing problem. Burns 2000;26:689-99

5. Epidemiology
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o Chemical injuries to the eye represent between 11.5%-22.1% of
ocular traumas.
o Two thirds of these injuries occur in young men and children age
1-2 years are particularly at risk.
o 2/3rd Workplace &industrial accidents Vs home
o Alkali materials are found more commonly in building materials
and cleaning agents and occur more frequently than acid injuries
o 2/3rd by alkali Vs acid
Clare, G., et al., Amniotic membrane transplantation for acute ocular burns. Cochrane
database of systematic reviews, 2012.

6. Etiology
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Common cause of Alkali injuries (60%)
Colby, K., Chemical injuries of the Cornea. Focal Points in American Academy of
Ophthalmology.2010. 28(1): p. 1-14

7. Etiology
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Common cause of Acid injuries (40%)
Wagoner, M.D., Chemical injuries of the eye: current concepts in pathophysiology and
therapy. Survey of ophthalmology, 1997. 41(4): p. 275-313.

8. Pathophysiology
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Corneal damage bye severe chemical injuries occurs in
the following order:-
Necrosis of the conjunctival and corneal epithelium
Disruption and occlusion of the limbal vasculature
Loss of limbal stem cells
Conjuctivilisation and vascularization of the corneal surface
Persistent corneal epithelial defects with sterile corneal ulceration

9. Classification
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o There are several classification systems of ocular surface injuries
that predict prognosis and clinical outcome by grading the
severity of the injury.
The Roper-Hall (RH) classification
o first introduced by Ballen in the mid-1960s and later modified by
Roper-Hall.
o Base on grades of the severity of injury by the extent of corneal
haze and perilimbal ischemia.
Roper-Hall MJ. Thermal and chemical burns. Trans Ophthalmol Soc U
K 1965;85:631-53

10. Classification
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Roper-Hall MJ. Thermal and chemical burns. Trans Ophthalmol Soc U
K 1965;85:631-53

11. Classification
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Pfister classification
o Based upon the same variables but categorizes the severity of
injury as mild, mild-to-moderate, moderate-to severe, severe, or
very severe based upon photographs.
Dua classification
o based on both clock-hour limbal involvement as determined by
fluorescein staining and percentage of bulbar conjunctival
involvement.
Dua grade has been found to have better prognostic predictive value
in severe ocular injuries than the R-H system.
Dua HS, King AJ, Joseph A. A new classification of ocular surface
burns. Br J Ophthalmol 2001;85:1379-83

12. Classification
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13. Classification
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o Mc Culley has categorized the pathophysiology and course of the
disease process into four distinct clinical phases:
Management
1. Immediate
2. acute (0 to 7 days),
3. early repair (7 to 21 days)
4. late repair (after 21 days) phases.
1. Immediate
2. acute (<6 weeks)
3. chronic (>6 weeks) phases
Singh P, Tyagi M, Kumar Y, et al. Ocular chemical injuries and their
management. Oman J Ophthalmol 2013;6:83-6

14. Acute Clinical finding
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o Periorbital edema & erythema
o De- epithelialized skin
o Loss of eyelashes and eyebrows
o Corneal & conjunctival epithelial defects
o Chemosis
o Conjunctival inflammation
o Limbal ischemia
o Corneal cloudiness
o Edema
o Occasionally perforation

15. Acute Clinical finding
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Figure 1. Eye after combined chemical and thermal injury to the lids
and ocular surface due to an explosion of a pyrotechnic device. There is
total corneal epithelial defect and 360 limbal ischemia (Roper-Hall
grade IV and Dua’s grade VI).

16. Other clinical finding
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o Cataract: indicates deeper penetration – poor prognosis
o High intraocular pressure :Damage & /or inflammation of the
trabecular meshwork- check IOP in acute setting and follow
closely.
o Secondary damage to retina & ON : the most severe cases –
mostly immune mediated.
o One of the most important prognostics factors for visual outcome
is the extent of ocular surface damage – initially reflected by the
amount of Limbal Ischemia – secondary limbal stem cell
deficiency.

17. Management of immediate phase
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 Immediately and thoroughly irrigate the surface to remove the
offending agent- Wagoner MD et al.
 At the site of accident tape water is Ok but ?
 it may promote corneal edema due to its hypotonicity relative to
the corneal stroma.
 However, the choice of aqueous solution is of less prognostic
importance than the timing of treatment and any delay in
irrigation should be avoided.

18. Management of immediate phase
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In Hospital setting
o Most effective choice of irrigation solution remains undetermined
o Use anesthetic drops beforehand
o Can use Morgan lens to facilitate
o Patient comfort was statistically superior with balanced saline
solution plus (BSSP) compared to normal saline
o Use at least 2L of irrigation
o Recheck PH ,continue until pH 7.5-/+0.5
Herr RD, White Jr GL Jr., Bernhisel K, et al. Clinical comparison of
ocular irrigation fluids following chemical injury. Am J Emerg Med
1991;9:228-31

19. Morgan lens
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 An irrigating device, polymethylmethacrylate scleral lens with an
attached perfusion tube .
 The irrigating lens should be inserted into the fornices.
 The Morgan Lens provides continuous lavage to the cornea and
conjunctiva, floating on the irrigating solution and never
physically touching the cornea.
 Delivers a continuous flow of solution to the injured eye within
seconds.

20. Management of Acute Phase
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The main objectives during the acute phase are
o To decrease inflammation
o Avoid further epithelial and stromal breakdown
o Promotions re-epithelialization

21. Management of Acute Phase
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Algorithm for the management of acute phase after chemical burn.

22. Anti-inflammatory Therapy
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o Topical corticosteroids can be critical in controlling acute
inflammation and reducing the resulting inflammatory damage to
the ocular surface after a chemical injury.
o Corticosteroids reduce inflammatory cell infiltration and stabilize
neutrophil cytoplasmic and lysosomal membranes.
o Start immediately after the chemical injury to 7 days.
o regimens including prednisolone 0.5% hourly or fluoromethalone
1% bihourly with subsequent tapering.
o After 7 days stop ?- inhibit epithelialization and collagen synthesis
and potentially increase the risk of corneal perforation
Saud EE, Moraes Jr HV Jr., Marculino LG, et al
Donshik PC, Berman MB, Dohlman CH, et al. Effect of topical corticosteroids
on ulceration in alkali-burned corneas. Arch Ophthalmol
1978;96:2117-20

23. Prevention of Stromal Breakdown
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o Corneal ulceration and melting occur relatively frequently after
severe chemical injuries.
o Reactive inflammatory cells release enzymes such as
collagenases and matrix metalloproteinases (MMPs), which
potentiate corneal thinning.
o Prevent corneal thinning experimentally & or clinically-
collagenase inhibitors and proteinase inhibitors.
Tetracycline
Ascorbic acid( Vit-C) Aprotinin
Citrate
cysteine

24. Promotion of Re-epithelialization and Repair
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o Frequent preservative – free lubricants.
o Prophylactic antibiotic drops which avoids medications with
toxicity( Gentamycin)

25. Bandage Contact Lens
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o Therapeutic bandage contact lenses protect a compromised ocular
surface and promote epithelialization through improvement in the
spreading of tear fluid over the ocular surface.
o Silicone hydrogel contact lenses have been found to confer
improved corneal health and patient satisfaction among frequent
lens wearers
o In patients with relatively severe pain and photophobia, large
diameter gas-permeable scleral contact lenses can establish a
fluid-filled pre-corneal vault, providing even greater protection to
the cornea from desiccation and friction from the eyelids during
blinking.
Rosenthal P, Cotter J. The Boston Scleral Lens in the management of
severe ocular surface disease. Ophthalmol Clin North Am 2003;16:
89-93

26. Amniotic Membrane Transplantation
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o Permanent surgical graft to provide a basement membrane for
epithelialization or as a patch where it acts as a biological
bandage contact lens.
o to promote epithelialization and to reduce inflammation, scarring,
and neovascularization.
o In patients with mild to moderate grade injuries ( up to grade III)
is offer better acute pain reduction and earlier epithealization.
o Probably no significant differences in long –term outcomes.
Dua HS, Gomes JA, King AJ, Maharajan VS. The amniotic membrane
in ophthalmology. Surv Ophthalmol 2004;49:51-77

27. Autologous Serum
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o Human serum contains many soluble factors that promote healing
in various tissues including the cornea.
o Autologous serum has been shown to be effective in promoting
wound healing in patients with persistent epithelial defects due to
a variety of etiologies, including chemical injury.
Jeng BH, Dupps Jr WJ Jr.. Autologous serum 50% eyedrops in the
treatment of persistent corneal epithelial defects. Cornea 2009;28:
1104-8

28. Platelet rich plasma
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 More recent studies have reported the use of platelet rich plasma
(PRP) as a variation of autologous serum in patients with ocular
chemical injuries.
 Topical and subconjunctival injection of PRP and it is a safe and
effective adjunct to standard medical treatments.
 The mechanism of action the same as autologous serum.
However, it has a higher concentration of growth factors and
platelets, which may lead to faster healing.
Panda A, Jain M, Vanathi M, et al. Topical autologous platelet-rich
plasma eyedrops for acute corneal chemical injury. Cornea 2012;31:
989-93

29. Tenonplasty
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 Tenonplasty is an intervention that may be utilized in severe
injuries that cause loss of limbal vascularity and subsequent
anterior segment necrosis.
 To re-establish the limbal blood supply and to promote ocular
surface repair.
 Tenonplasty may be combined with AMT with or without
lamellar corneal patch grafting
 prevents anterior segment necrosis, scleral ischemia, melting, and
sterile ulceration.
Kuckelkorn R, Schrage N, Reim M. Treatment of severe eye burns by
tenonplasty. Lancet 1995;345(8950):657-8

30. Management of Acute Phase
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o Requires a multi-disciplinary approach involving cornea
,oculoplastics & Glaucoma specialists.
o The goal of these surgical interventions is to restore normal
ocular surface anatomy & visual function.
The typical order for surgical intervention is:
1. Correction of eyelid abnormalities
2. Management of glaucoma
3. Ocular surface reconstruction
4. keratoplasty
Symblepharon: Severe symblepharon
formation.

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Algorithm for the management of chronic phase after chemical burn.