OPTHALMOLOHY

ASSIGNMENT: CHEMICAL INJURY OF THE EYE

Safia Ahmed-Yassin sh:Ali

Edna Adan University Hospital

July, 2022
 1. Introduction
Chemical injury of the eye is one of the emergencies in ophthalmological field in which

immediate intervention is needed. This accounts about 20-30% of all ocular injuries and is

defined as corrosive substance that is accidently introduced into the ocular tissue or pre-ocular

tissue. It is mostly prevent in young aged males between 20-40 years of age but children are also

at risk.

2. Chemical hazards that may injure the eye

Chemical agents that have potential to cause injury to the ocular or pre-ocular tissue are

either acid or alkali. The normal PH of the eye is 7.4, anything below this is considered acidic

and can damage the eye, whereas alkaline agents causes the most severe effects at PH of 11.0-

11.5. These are found in homes, work places like industries, military training fields and even

battle field. Household cleaners and building material are the most common etiologies in these

days. Some examples of acidic products include automobile batteries (containing sulfuric acid),

refrigerants and vinegar (acetic acid). Examples of alkaline are included fertilizers and building

materials like cement.

3. Pathogenesis

Acid and alkaline chemicals have different mechanism of injuring the ocular tissue. Acid

cause protein participation or protein coagulation in the corneal epithelium creating barrier to

light penetration. However weak acids are protected from the tissue by the corneal epithelium

and these acids causes only temporary loss of the corneal epithelium with minimal damage to the

deeper structures. In addition to that some acids like sulfuric acid causes most devastating

injuries and have great potential for permanent ocular damage. Sulfuric acid reacts with the

water in the tear film and produces significant heat to burn corneal and conjuctival epithelium.
 In contrast alkaline agents can penetrate the tissues rapidly due to their lipophilic nature

allowing it to rapidly reach the cellular lipids to form soap. Saponification of cell membrane

leads to cellular dehydration and destruction of enzymatic and structural protein. This leads to

permanent damage to ocular tissue and also inters into anterior chamber causing further damage,

this shows that alkaline chemicals tends to damage tissue more prolonged then the acids does,

due to it is high penetration ability. However penetration rate differ between different alkalis, for

example ammonium hydroxide is the fastest alkali in penetration followed by sodium hydroxide,

potassium hydroxide and calcium hydroxide respectively.

4. Clinical features

The clinical signs and symptoms include: pre-orbital edema and erythema, cataract:

(indicates deeper penetration), increased intra-ocular pressure: (indicates damage and/or

inflammation of trabecular meshwork), corneal and conjuctival epithelial loss, limbal ischemia:

(prognostic factor), corneal cloudiness.

5. Management

Regardless of underlying chemical involved in the ocular injury, the management and it

is goals remains the same. The management should include removing the offending agent or

irrigation, promoting ocular healing, eliminating inflammation, prevention of infection and

controlling intra-ocular pressure. Surgical intervention can be considered if medical approach

fails or the injury is severe enough to cause limbal ischemia.

A. IRRIGATION: immediate treatment with irrigation proceeds everything even patient

evaluation to decrease further ocular damage and to maximize epithelialization. Tap water can be

used for irrigation if other solution are not available like normal saline (NS) and ringer lactate.
Because tap water are more hypotonic than these solution it may cause slight corneal edema

therefore it is not usually preferred over these solutions. First take the PH of the eye by placing

litmus paper, then apply topical anesthesia because irrigation causes pain, now start irrigating

with normal saline. Continue irrigating and take the PH at interval of 5 minute of irrigating until

the PH is normal which will take normally 20-30 min and 1-2L of normal saline or ringer lactate.

B. PROMOTE OCULAR HEALING: Once inciting chemical is completely eliminated

epithelial healing can begin. Chemically injured eye have poor tendency to produce tear,

therefore artificial tear is applied and play important role in healing. Ascorbate also plays

fundamental role in collagen remodeling which leads to corneal healing. Ascorbate is available

as topical and oral preparation. Also collagenase inhibitors prevent stromal ulceration by

promoting wound healing through inhibition of collagenolytic activities. Placement of

therapeutic bandage contact lens can be used until the epithelium has regenerated.

C. ELIMINATION OF INFLAMMATION: inflammatory mediators released from ocular

surface at the time of injury causes tissue necrosis, neovascularization and scaring. Also

inflammatory response inhibit re-epithelialization and increases corneal ulceration. Controlling

inflammatory damage is done by steroid therefore prednisolone acetate 1% should be used 4

times daily for 1 week in mild chemical burn. Difluprednate and loteprednol etabonate are also

extremely useful topical steroid preparation for chemical ocular injuries. The steroid dose should

be increased hourly in more severe cases. Steroid should also be discontinued or tapered rapidly

by 10-14 days to avoid corneal melting.

D. PREVENTION OF INFECTION: when corneal epithelium is damaged the eye is more

susceptible to infection. Topical moxiflovacin offers broad spectrum coverage and is

preservative free.
 E. DECREASING INTRA-OCULAR PRESSURE: use of aqueous suppressants is

advocated to reduce intra-ocular pressure secondary to chemical injuries, both as initial therapy

and in late recovery phase.

Surgical intervention if medical approach fails is recommended. Limbal stem cell

transplant from the healthy eye or from living relative or even cadaver can be done.

References

1. https://www.youtube.com/watch?v=ebTeCv44v-I medical and surgical

management of ocular chemical injury
2. https://emedicine.medscape.com/article/1215950-overview
ophthalmological approach to chemical burn
3. https://www.researchgate.net/publication/
19652740_Management_of_chemical_injuries_of_the_eye.