RISK FACTORS: Construction work (plaster, cement, whitewash), Use of cleaning agents (drain cleaners, ammonia), Automobile battery explosions (sulfuric acid), Industrial work (many possible agents), Alcoholism
GENERAL MEASURES Copious irrigation and removal of corneal or conjunctival foreign bodies are always the initial treatment. Continue irrigation until the tear fi lm is of neutral pH and pH is stable. Sweep the conjunctival fornices every 12-24 hours to prevent adhesions.
SURGICAL MEASURES
β’ Punctal occlusion for tear fi lm preservation and corneal epitheliopathy
β’ Tarsorrhaphy for persistent epithelial defects
β’ Tissue adhesive (e.g., isobutyl cyanoacrylate) for impending or actual corneal perforation
β’ Conjunctival or limbal autograft transplantation for epithelial stem cell restoration
β’ Lamellar or penetrating keratoplasty for tectonic stabilization or visual rehabilitation
β’ Amniotic membrane transplantation, if no autogenous mucus membrane available
ACTIVITY Ambulatory
DIET Usual for patient
PATIENT EDUCATION
β’ Safety glasses
β’ Need for immediate ocular irrigation with any available water following chemical exposure to the eyes
DRUG(S) OF CHOICE
. Immediate treatment (any non-toxic irrigant):
. In hospital setting, sterile water, normal saline, lactated Ringers solution are effective
. In the field, use what is available (tap water). Rapidity of irrigation is critical.
. Irrigation is continued until pH of superior/inferior cul-de-sac is neutral
. It is impossible to over-irrigate
. Further treatment: (depending on severity and associated conditions)
. Topical prophylactic antibiotics: Any broad spectrum agent, e.g., bacitracin-polymyxin B (Polysporin) ointment q2-4h, ciprofl oxacin (Ciloxan) drops q 2-4h, chloramphenicol (Chloroptic) ointment q2-4h
. Tear substitutes: hydroxypropyl methylcellulose (Hypotears PF, Refresh Plus) drops q4h, Carboxymethylcellulose (Refresh P.M.) ointment qhs
. Cycloplegics for photophobia and/or uveitis: Cyclopentolate 1% tid, or scopolamine 1/4% bid
. Anti-glaucoma for elevated intraocular pressure (IOP): latanoprost (Xalatan) 0.005% q24h or timolol (Timoptic) 0.5% bid or levobunolol (Betagan) 0.5% bid and/or acetazolamide (Diamox) 125-250 mg po q6h or methazolamide (Neptazane) 25-50 mg po bid and/or mannitol 20% 1-2 g/kg IV prn
. Corticosteroids for intraocular infl ammation: Prednisolone (Pred-Forte) 1% or equivalent q1-4h for 10-14 days; if severe, prednisone 20-60 mg po qd for 5-7 days. Taper rapidly if epithelium intact by this time.
. Consider vitamin C (ascorbic acid) 500 mg po qid and/or acetylcysteine (Mucomyst) 10-20% top q4 h if
corneal melting occurs
ALTERNATIVE DRUGS Where available
- topical fi bronectin, epidermal growth factor, prokinase inhibitors
PATIENT MONITORING
β’ Depending on severity of ocular injury, from daily to weekly visits initially
β’ May be inpatient
β’ If on mannitol or prednisone, consider frequent serum electrolytes
PREVENTION/AVOIDANCE Safety glasses to safeguard uninvolved eye
POSSIBLE COMPLICATIONS
β’ Persistent epitheliopathy
β’ Fibrovascular pannus
β’ Corneal ulcer/perforation
β’ Progressive symblepharon and entropion
β’ Neurotrophic keratitis
β’ Glaucoma
β’ Cataract
β’ Hypotony
β’ Phthisis bulbi
EXPECTED COURSE/PROGNOSIS
β’ Depends on severity of initial injury
β’ Increasing amounts of limbal ischemia and corneal opacification correlate with poorer prognosis
β’ For severely injured eyes, permanent loss of vision is not uncommon
β’ Autologous cultivated corneal epithelium has been used for long term restoration of vision.
β’ Autologous nasal mucosal transplantation has also been successfully employed
β’ Use of amniotic membrane transplantation is being evaluated in clinical trials