Caustic keratoconjunctivitis: Difference between revisions
 
(23 intermediate revisions by 7 users not shown)
Line 1: Line 1:
==Background==
==Background==
*Chemical burn to eye
*Chemical burn to eye
*Alkali injuries are more severe than acidic injuries
*Alkali injuries are more severe than acidic injuries, and are considered an '''ophthalmologic emergency'''
*'''Ocular alkali exposures are an ophthalmologic emergencies'''
*Prognosis is determined by the extent of injury at the limbus and area/depth of injury to cornea


{{Caustics background}}
{{Caustics background}}
{{Keratoconjunctivitis Types}}


==Clinical Features==
==Clinical Features==
*Symptoms - Severe pain, blepharospasm, reduced visual acuity
[[File:Chemical burn injury..jpg|thumb|Complication of an alkali corneal burn causing ocular surface failure with neovascularisation, opacificatio,n and blindness.]]
*Alkali injuries can cause elevated IOP.<ref>Lin, M.P., et al., Glaucoma in patients with ocular chemical burns. American journal of ophthalmology, 2012. 154(3): p. 481-485 e1.</ref>
*Severe [[eye pain|ocular pain]], blepharospasm, reduced [[vision loss|visual acuity]]
*Evaluate ocular pH (normal is 7.0-7.2)
*Altered ocular pH (normal = 7.0-7.2)
*Appearance
**[[red eye|Conjunctival injection]] '''OR''' blnnching
**Chemosis, hemorrhage, epithelial defects
**Corneal loss '''OR''' edema
*Perilimbal ischemia (white ring around iris)
**Concerning due to co-location of corneal stem cell layer (re-epitheliazation relies on migration of limbal stem cells)
===[[Caustic burns|Alkali Burns]]===
*Rapid penetration through cornea and anterior chamber
*Causes liquefaction necrosis from hydroxyl ions combining with fatty acids
*Elevated [[IOP]] may be seen in alkali injury<ref>Lin, M.P., et al., Glaucoma in patients with ocular chemical burns. American journal of ophthalmology, 2012. 154(3): p. 481-485 e1.</ref>
*Acute injury liquefaction necrosis and ischemia which can be graded on degree of limbal and corneal involvement
*Early sequelae corneal edema and elevated IOP
*Later injury after one week - corneal breakdown, [[corneal ulcer|ulceration]], perforation because of collagenase activity exceeds synthesis
 
===[[Caustic burns|Acid Exposure]]===
*Injury related to length of exposure and concentration of chemical
*Causes coagulation necrosis and protein precipitation thus limits depth of penetration
*Delayed complications corneal and conjunctival scarring, vascularization, [[glaucoma]], [[uveitis]]
 
===Other Chemicals===
*Most exposures produce only simple irritation
 
===Roper-Hall classification<ref>Gupta N et al. Comparison of Prognostic Value of Roper Hall and Dua Classification Systems in Acute Ocular Burns. Br J Ophthalmol. 2011;95(2):194-198. http://www.medscape.com/viewarticle/739100.</ref>===
{| {{table}}
| align="center" style="background:#f0f0f0;"|'''Grade'''
| align="center" style="background:#f0f0f0;"|'''Cornea Appearance'''
| align="center" style="background:#f0f0f0;"|'''Limbal Ischemia'''
| align="center" style="background:#f0f0f0;"|'''Prognosis'''
|-
| I||Clear||None||Good
|-
| II||Hazy/iris details visible||<1/3||Good
|-
| III||Opaque/iris details obscured||1/3-1/2||Guarded
|-
| IV||Opaque/iris details obscured||>1/2||Poor
|-
|}


==Differential Diagnosis==
==Differential Diagnosis==
Line 17: Line 57:


{{Unilateral red eye DDX}}
{{Unilateral red eye DDX}}
==Evaluation==
*Generally a clinical diagnosis


==Management==
==Management==
#Irrigation
{{Caustic ocular exposure managment}}
#*Immediate irrigation is the most important treatment for caustic occular injury, and should be started before comprehensive evaluation
#*Irrigate affected eye(s) with copious amounts of fluid (no consensus on volume or length of time)<ref>Chau JP, Lee DT, Lo SH. A systematic review of methods of eye irrigation for adults and children with ocular chemical burns. Worldviews Evid Based Nurs. 2012 Aug;9(3):129-38.</ref>
#*NS, LR, or BSS (Buffered Saline Solution) preferred in the hospital setting<ref>Herr RD, White GL Jr, Bernhisel K, Mamalis N, Swanson E. Clinical comparison of ocular irrigation fluids following chemical injury. Am J Emerg Med. 1991 May;9(3):228-31.</ref>, but tap water is acceptable, esp in pre-hospital setting.
#*Goal is to remove caustic agent and restore normal ocular pH (7.0-7.2)
#*Do NOT attempt to neutralize pH by adding base to an acidic burn or visa versa
#*Use of morgan lens or eyelid speculum will assist with getting more fluid in contact with cornea.
#**Apply anesthesia to eye, place lens under upper eyelid, followed by lower eyelid
#Remove particulate matter
#*Evert both lids, remove any visible particulate matter with cotton-tipped applicator
#Anesthesia
#*Apply topical anesthetic (e.g. tetracaine) to help with discomfort.
#*Further pain control measures
#**Cycloplegics (e.g. atropine, cyclopentolate) can assist in pain control
#**Encourage generous use of artificial tears, other lubricating drops
#**PO analgesia as needed
#[[Antibiotics]]
#*Erythromycin ophthalmic ointment QID for minor burns
#*For more severe burns, topical fluoroquinolone is warranted.
#Control inflammation
#*Topical steroids - prednisolone 1% QID for 1 week<ref>Dohlman, C.H., F. Cade, and R. Pfister, Chemical burns to the eye: paradigm shifts in treatment. Cornea, 2011. 30(6): p. 613-4.</ref>
#*Should not be continued for more than 10 days to avoid corneal breakdown.<ref>Donshik, P.C., et al., Effect of topical corticosteroids on ulceration in alkali-burned corneas. Archives of ophthalmology, 1978. 96(11): p. 2117-20.</ref>
#Ophtho consultation for all but minor burns (Severe exposures may require debridement or other surgical intervention)


==Disposition==
==Disposition==
*Admit all pediatric patients.
===Admit===
*Admit all pts w/ corneal haziness or opacity or limbal ischemia (paleness at limbus)
*Pediatric patient
*Discharge w/ 24hr ophthalmology follow-up if pt only has corneal epithelial injury (fluorescein uptake)
*Corneal haziness, opacity, or limbal ischemia (paleness at limbus)


==Prognosis==
===Discharge===
*Determined by the extent of injury at the limbus and area/depth of injury to cornea
''With 24hr ophthalmology follow-up''
*If only has corneal epithelial injury
**Encourage use of artificial tears and other lubricating eyedrops


==See Also==
==See Also==
*[[Eye Algorithm (Main)]]
*[[Eye Algorithms (Main)]]
*[[Caustic burns]]
*[[Caustic burns]]
*[[Keratoconjunctivitis]]


==References==
==References==
<references/>
<references/>


[[Category:Ophtho]]
[[Category:Ophthalmology]]
[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Tox]]
[[Category:Toxicology]]

Latest revision as of 23:08, 28 February 2024

Background

  • Chemical burn to eye
  • Alkali injuries are more severe than acidic injuries, and are considered an ophthalmologic emergency
  • Prognosis is determined by the extent of injury at the limbus and area/depth of injury to cornea

Caustics

  • Substances that cause damage on contact with body surfaces
  • Degree of injury determined by pH, concentration, volume, duration of contact
  • Acidic agents cause coagulative necrosis
  • Alkaline agents cause liquefactive necrosis (considered more damaging to most tissues)
  • Corrosive agents have reducing, oxidising, denaturing or defatting potential

Alkalis

  • Accepts protons → free hydroxide ion, which easily penetrates tissue → cellular destruction
    • Liquefactive necrosis and protein disruption may allow for deep penetration into surrounding tissues
  • Examples
    • Sodium hydroxide (NaOH), potassium hydroxide (KOH)
      • Lye present in drain cleaners, hair relaxers, grease remover
    • Bleach (sodium hypochlorite) and Ammonia (NH3)
      • Cleaning products such as oven cleaners, swimming pool chlorinator
      • Household bleach ingestion (4-6% sodium hypochlorite) rarely causes significant esophageal injury[1][2]

Acids

  • Proton donor → free hydrogen ion → cell death via denatured protein → coagulation necrosis and eschar formation, which limits deeper involvement
    • However, due to pylorospasm and pooling of acid, high-grade gastric injuries are common
      • Mortality rate is higher compared to strong alkali ingestions
  • Can be systemically absorbed and → metabolic acidosis, hemolysis, AKI
  • Examples
    • Hydrochloric acid (HCl), hydrofluoric acid (HF), Sulfuric acid (H2SO4), Phosphoric acid, Oxalic Acid, Acetic acid
      • Found in: auto batteries, drain openers, toilet bowl, metal cleaners, swimming pool cleaners, rust remover, nail primer

Keratoconjunctivitis Types

Clinical Features

Complication of an alkali corneal burn causing ocular surface failure with neovascularisation, opacificatio,n and blindness.
  • Severe ocular pain, blepharospasm, reduced visual acuity
  • Altered ocular pH (normal = 7.0-7.2)
  • Appearance
  • Perilimbal ischemia (white ring around iris)
    • Concerning due to co-location of corneal stem cell layer (re-epitheliazation relies on migration of limbal stem cells)

Alkali Burns

  • Rapid penetration through cornea and anterior chamber
  • Causes liquefaction necrosis from hydroxyl ions combining with fatty acids
  • Elevated IOP may be seen in alkali injury[3]
  • Acute injury liquefaction necrosis and ischemia which can be graded on degree of limbal and corneal involvement
  • Early sequelae corneal edema and elevated IOP
  • Later injury after one week - corneal breakdown, ulceration, perforation because of collagenase activity exceeds synthesis

Acid Exposure

  • Injury related to length of exposure and concentration of chemical
  • Causes coagulation necrosis and protein precipitation thus limits depth of penetration
  • Delayed complications corneal and conjunctival scarring, vascularization, glaucoma, uveitis

Other Chemicals

  • Most exposures produce only simple irritation

Roper-Hall classification[4]

Grade Cornea Appearance Limbal Ischemia Prognosis
I Clear None Good
II Hazy/iris details visible <1/3 Good
III Opaque/iris details obscured 1/3-1/2 Guarded
IV Opaque/iris details obscured >1/2 Poor

Differential Diagnosis

Caustic Burns

Conjunctivitis Types

Unilateral red eye

^Emergent diagnoses ^^Critical diagnoses

Evaluation

  • Generally a clinical diagnosis

Management

Caustic Ocular Exposure Management

  • Eye irrigation
    • Immediate irrigation is the most important treatment for caustic ocular injury, and should be started before comprehensive evaluation
    • Irrigate affected eye(s) with copious amounts of fluid (no consensus on volume or length of time)[5]
    • NS, LR, or BSS (Buffered Saline Solution) preferred in the hospital setting[6], but tap water is acceptable, especially in pre-hospital setting.
    • Goal is to remove caustic agent and restore normal ocular pH (7.0-7.2)
    • Do NOT attempt to neutralize pH by adding base to an acidic burn or acid to an alkali burn
    • Use of morgan lens or eyelid speculum will assist with getting more fluid in contact with cornea
  • Remove particulate matter
    • Evert both lids, remove any visible particulate matter with cotton-tipped applicator
  • Anesthesia
  • Antibiotics
  • Control inflammation
  • Ophthalmology consultation for all but minor burns (Severe exposures may require debridement or other surgical intervention)

Disposition

Admit

  • Pediatric patient
  • Corneal haziness, opacity, or limbal ischemia (paleness at limbus)

Discharge

With 24hr ophthalmology follow-up

  • If only has corneal epithelial injury
    • Encourage use of artificial tears and other lubricating eyedrops

See Also

References

  1. ↑ Wasserman RL, Ginsburg CM. Caustic substance injuries. J Pediatr. 1985;107(2):169-174. doi:10.1016/s0022-3476(85)80119-0
  2. ↑ Harley EH, Collins MD. Liquid household bleach ingestion in children: a retrospective review. Laryngoscope. 1997;107(1):122-125. doi:10.1097/00005537-199701000-00023
  3. ↑ Lin, M.P., et al., Glaucoma in patients with ocular chemical burns. American journal of ophthalmology, 2012. 154(3): p. 481-485 e1.
  4. ↑ Gupta N et al. Comparison of Prognostic Value of Roper Hall and Dua Classification Systems in Acute Ocular Burns. Br J Ophthalmol. 2011;95(2):194-198. http://www.medscape.com/viewarticle/739100.
  5. ↑ Chau JP, Lee DT, Lo SH. A systematic review of methods of eye irrigation for adults and children with ocular chemical burns. Worldviews Evid Based Nurs. 2012 Aug;9(3):129-38.
  6. ↑ Herr RD, White GL Jr, Bernhisel K, Mamalis N, Swanson E. Clinical comparison of ocular irrigation fluids following chemical injury. Am J Emerg Med. 1991 May;9(3):228-31.
  7. ↑ Dohlman, C.H., F. Cade, and R. Pfister, Chemical burns to the eye: paradigm shifts in treatment. Cornea, 2011. 30(6): p. 613-4.
  8. ↑ Donshik, P.C., et al., Effect of topical corticosteroids on ulceration in alkali-burned corneas. Archives of ophthalmology, 1978. 96(11): p. 2117-20.
Retrieved from "https://www.wikem.org/w/index.php?title=Caustic_keratoconjunctivitis&oldid=372830"