Chemical Injury of the Eye

Nina Handayani
Ophthalmology Department
Universitas Brawijaya/Saiful Anwar Hospital
Malang
 CHEMICAL INJURIES
• One of the true ophthalmic emergency
• Can cause mild to complete destruction
of the eye.
 Affending agents

• Detergents
• Desinfectans
• Solvent
• Cosmetics
• Bleach
• Fertilizer
• Pesticide,
• caustic chemical.
Affending Agents with Alkali Compound
Affending Agents with Acid Compound

Hydrochloric Acid
Chemical Injury
 ACID BURNS
• Acid dissociate into hydrogen ions and
anions in the cornea e.g. HCL  H+and Cl-
• The hydrogen molecules damages the
ocular surface by altering the Ph.
• Anion causes protein denaturation,
precipitation and coagulation. Less
severe tissue damage than alkali
• Proteins coagulation prevents deeper
penetration of the acid.
 ALKALI BURNS
• Alkaline substance dissociate into a hydroxyl
ion and a cation in the ocular surface, e.g.
NaOH=Na+ + OH-
• The hydroxyl ion saponifies cell membran
fatty acid
• The cation interacts with stromal collagen
and glycosaminoglycans.
• This interaction makes deeper penetration
into and through the cornea and into the
anterior chamber.
The Classification of Ocular Burns
 Grade I
• Corneal epithelial
defect only
• Limbal ischemia (-)
• Cornea remains
clear
 Grade II

• Corneal epithelial
defect
• Stromal haze, but
iris detail still
visible
• Ichemia < 1/3 of
the limbus
 Grade III
• Total corneal epithelial
defect
• Stromal haze obscuring
iris details
• Ischemia 1/3 – ½ of the
limbus
 Grade IV

• Complete loss of corneal

epithelium and limbal stem
cell
• Opaque cornea
• Obscuring view of iris or
pupil.
• Ischemia > ½ of the limbus.
 Management
MINIMALIZED CONTACT WITH THE EYE !
• Immediate and copious irrigation
• Chemical removal
• Decreasing inflammation
• Monitoring IOP
• Limiting matrix degradation
• Promoting reepithelization of the cornea
Immediate Irrigation
 Immediate Irrigation

15-30 Minutes, 500-2000 mL

Normal Saline, Ringer Lactate, BSS
 Examination of the eye in
chemical injuries
• Contact with the chemical agents +
• Check the pH of the eye
• Slit lamp examination : find the eye
abnormality caused by chemical injuries
Acute management
(first 7 days)
Treat Grade I Grade II Grade III Grade IV
ment
a. - Bandage Lens Bandage lens Bandage lens
Auto serum ed 6x/d Auto serum ed/hr
b. (AB+) Steroid steroid ed 6x/d Dexamethason/predni Dexamethason/prednison
ed 4-6x/d Na-EDTA 1% ed 6x/d son ed/hr ed/30mnt
EDTA 1% ed Na-EDTA ed/hr EDTA ed/30mnt
4-6x/d Auto serum ed 6x/d Auto serum ed/hr

c. Antibiotic(+ster Tetrasiklin eo 4x/d Tetrasiklin eo 4x/d Tetrasiklin eo 4x/d

oid) 4-6x/d Doxysiklin 2x/d Doxysiklin 2x/d 100mg Doxysiklin 2x/d 100mg
100mg

d. - Timoptol 0.5% ed Timoptol 0.5% ed 2x/d Timoptol 0.5% ed 2x/d

2x/d Asetazolamide Asetazolamide 2x500mg + ion
2x500mg + kalium kalium substitution
substitution

e. Sulfat Atropin Sulfat Atropin 1% Sulfat Atropin 1% 3x/d Sulfat Atropin 1% 3x/d
1% 3x/d 3x/d Vit C 4x/d 2000mg Vit C 4x/d 2000mg
Vit C 4x/d Vit C 4x/d 2000mg
500mg

f. - - Necrotomy+ Necrotomy+ conjunctival limbal

conjunctival limbal Graft
Early repair management
(7-21 days)
Treat Grade I Grade II Grade III Grade IV
ment
a. - Bandage Lens Bandage lens Bandage lens
Auto serum ed 6x/d Auto serum ed/hr
b. (AB+) Steroid steroid edtapp off Dexamethason/predni Dexamethason/prednison ed
ed tapp.off Na-EDTA 1% ed tapp son ed stop  change stop  change with NSAID ed
off with NSAID ed 6x/d 6x/d
Na-EDTA ed/hr EDTA ed/30mnt
Auto serum ed 6x/d Auto serum ed/hr

c. Antibiotic(+ster Tetrasiklin eo 2x/d Tetrasiklin eo 2x/d Tetrasiklin eo 4x/d

oid) ed tapp offf Doxysiklin 2x/d Doxysiklin 2x/d 100mg Doxysiklin 2x/d 100mg
100mg

d. - IOP normal : IOP normal ; Timoptol Timoptol 0.5% ed 2x/d

Timoptol 0.5% ed Asetazolamide+ Asetazolamide 2x500mg + ion
stop kalium substitution kalium substitution
stop

e. Uveitis -:Sulfat Uveitis - : Sulfat Sulfat Atropin 1% 3x/d Sulfat Atropin 1% 3x/d
Atropin 1% stop Atropin 1%stop Vit C 4x/d 2000mg Vit C 4x/d 2000mg
Vit C 2x/d 2000mg Retinoic acid eo 2x Vitamin A and E

f. - - Necrotomy+ Necrotomy+ conjunctival limbal

conjunctival limbal Graft or amnion graft
Graft Keratoplasty
Management of Late repair
(>21 days)
Action Grade I Grade II Grade III Grade IV
a. Solcosery Epiteliopathy Epiteliopathy(±) Re-piteliopati (±):
3x/d (±) : : Bandage lens continued
Solcoseryl Solcoseryl 4x/d
4x/d Retinoic Ac 1%
1x/d
b. NSAID ed NSAID ed 40x/d NSAID ed 4-6x/d
40x/d Medroxy- Medroxy-progesteron 4-6x/d
progesteron 1% Na-EDTA 4-6x/d
4x/d Auto serum 4-6x/d
c. Tetrasiklin eo 4x/d
Doxysiklin 2x100mg
d. Increasing IOP (-) :
Timoptol 0.5% tapp.off
Acetazolamid + ion kaliom
stop
e. Uveitis (-) : SA stop
Vit C 2x2000mg
Vit A and E
f. Conjunctival limbal
Graft/Therapeutic
keratoplasty/Keratoprosthes
• The corneal transplant procedure in which
diseased host corneal tissue is excised and
replaced with healthy donor cornea.
Am J Emerg Med. 1991 May;9(3):228-31.
Clinical comparison of ocular irrigation fluids following chemical injury.
Herr RD1, White GL Jr, Bernhisel K, Mamalis N, Swanson E.
Department of Surgery, University of Utah Medical School, Salt Lake City.

Abstract
This study tested the hypothesis that four ocular irrigating solutions were
equally irritating during copious irrigation. We conducted a prospective,
double-blind study of patients with chemical exposure to the eye. Each
underwent cross-over irrigation with all of the following in random order:
normal saline (NS), lactated Ringer's (LR), normal saline adjusted to pH 7.4
with sodium bicarbonate (NS + Bicarb), and Balanced Saline Solution Plus (BSS
Plus, Alcon Laboratories, Fort Worth, TX). Compared with traditional NS and
LR, NS + Bicarb tended to be more comfortable. BSS Plus was statistically
superior (P less than .05) to NS and preferred over LR and NS + Bicarb. Three
patients demanded discontinuance of NS or NS + Bicarb infusions. All
solutions had comparable normalization of conjunctival pH and degree of
injection. Alternate solutions including BSS Plus should be considered for use
in those patients whose poor tolerance to normal saline threatens to delay or
interrupt eye irrigation following a chemical injury.