Caustic keratoconjunctivitis: Difference between revisions
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{{Unilateral red eye DDX}} | {{Unilateral red eye DDX}} | ||
==Diagnosis== | |||
==Management== | ==Management== | ||
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#Anesthesia | #Anesthesia | ||
# | #*Apply topical anesthesia (e.g. tetracaine) | ||
#Irrigation | #Irrigation | ||
# | #*Apply for at least 30min (1-2L) or at least 40min (4L) for alkali exposure | ||
# | #*Perform immediately and before any examination | ||
# | #*NS or LR works best | ||
# | #*Treat until pH is >7.4 when checked 30min after the last irrigation | ||
# | #**Avoid testing pH of the irrigation fluid (wait few min before checking ocular fluid) | ||
#Remove particulate matter with cotton applicator | #Remove particulate matter with cotton applicator | ||
#Measure acuity and IOP (may be increased if trabecular meshwork has been damaged) | #Measure acuity and IOP (may be increased if trabecular meshwork has been damaged) | ||
#Cycloplegic for pain control | #Cycloplegic for pain control | ||
# | #*Avoid phenylephrine | ||
# | #Antibiotics | ||
# | #*Erythromycin ointment QID | ||
#Ophtho consultation for all but minor burns | #Ophtho consultation for all but minor burns | ||
# | #*Severe exposures may require anterior chamber irrigation | ||
==Disposition== | ==Disposition== | ||
Revision as of 13:47, 24 May 2015
Background
- Chemical burn to eye
- Alkali injuries are more severe than acidic injuries
- Ocular alkali exposures are an ophthalmologic emergencies
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)
- Sodium hydroxide (NaOH), potassium hydroxide (KOH)
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
- However, due to pylorospasm and pooling of acid, high-grade gastric injuries are common
- 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
- Hydrochloric acid (HCl), hydrofluoric acid (HF), Sulfuric acid (H2SO4), Phosphoric acid, Oxalic Acid, Acetic acid
Clinical Features
- All pts w/ serious esophageal injuries have some initial sign or symptom
- E.g. stridor, drooling, vomiting
- Exam eyes and skin (splash and dribble injuries may easily be missed)
- GI tract injury
- Dysphagia, odynophagia, epigastric pain, vomiting
- Laryngotracheal injury
- Dysphonia, stridor, respiratory distress
- Occurs via aspiration of caustic or vomitus or inhalation of acidic fumes
Differential Diagnosis
Caustic Burns
- Caustic ingestion
- Caustic eye exposure (Caustic keratoconjunctivitis)
- Caustic dermal burn
- Airbag-related burns
- Hydrofluoric acid
- Tar burn
- Cement burn
Conjunctivitis Types
Unilateral red eye
- Nontraumatic
- Acute angle-closure glaucoma^
- Anterior uveitis
- Conjunctivitis
- Corneal erosion
- Corneal ulcer^
- Endophthalmitis^
- Episcleritis
- Herpes zoster ophthalmicus
- Inflamed pinguecula
- Inflamed pterygium
- Keratoconjunctivitis
- Keratoconus
- Nontraumatic iritis
- Scleritis^
- Subconjunctival hemorrhage
- Orbital trauma
- Caustic keratoconjunctivitis^^
- Corneal abrasion, Corneal laceration
- Conjunctival hemorrhage
- Conjunctival laceration
- Globe rupture^
- Hemorrhagic chemosis
- Lens dislocation
- Ocular foreign body
- Posterior vitreous detachment
- Retinal detachment
- Retrobulbar hemorrhage
- Traumatic hyphema
- Traumatic iritis
- Traumatic mydriasis
- Traumatic optic neuropathy
- Vitreous detachment
- Vitreous hemorrhage
- Ultraviolet keratitis
^Emergent diagnoses ^^Critical diagnoses
Diagnosis
Management
- First prevent personal exposure to the caustic agent by removing all clothing and decontaminating the patient
- Anesthesia
- Apply topical anesthesia (e.g. tetracaine)
- Irrigation
- Apply for at least 30min (1-2L) or at least 40min (4L) for alkali exposure
- Perform immediately and before any examination
- NS or LR works best
- Treat until pH is >7.4 when checked 30min after the last irrigation
- Avoid testing pH of the irrigation fluid (wait few min before checking ocular fluid)
- Remove particulate matter with cotton applicator
- Measure acuity and IOP (may be increased if trabecular meshwork has been damaged)
- Cycloplegic for pain control
- Avoid phenylephrine
- Antibiotics
- Erythromycin ointment QID
- Ophtho consultation for all but minor burns
- Severe exposures may require anterior chamber irrigation
Disposition
- Admit all pts w/ corneal haziness or opacity or limbal ischemia (paleness at limbus)
- Discharge w/ 24hr f/u if pt only has corneal epithelial injury (fluorescein uptake)
Prognosis
After irrigation perform complete eye exam. The prognosis is determined by the extent of injury at the limbus and area/depth of injury to cornea.
Sources
- Brodovsky SC, et al: Management of alkali burns: An 11-year retrospective review. Ophthalmology 2000; 107:1829-1835