Caustic keratoconjunctivitis: Difference between revisions
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==Clinical Features==
==Clinical Features==
{{General approach to caustic burns}}
*Symptoms - Severe pain, blepharospasm, reduced visual acuity
*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>
*Evaluate ocular pH (normal is 7.0-7.2)


==Differential Diagnosis==
==Differential Diagnosis==
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{{Unilateral red eye DDX}}
{{Unilateral red eye DDX}}
==Diagnosis==


==Management==
==Management==
;First prevent personal exposure to the caustic agent by removing all clothing and decontaminating the patient
*Irrigation
 
**Immediate irrigation is the most important treatment for caustic occular injury, and should be started before comprehensive evaluation
#Anesthesia
**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>
#*Apply topical anesthesia (e.g. tetracaine)
**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.
#Irrigation
**Goal is to remove caustic agent and restore normal ocular pH (7.0-7.2)
#*Apply for at least 30min (1-2L) or at least 40min (4L) for alkali exposure
**Use of morgan lens or eyelid speculum will assist with getting more fluid in contact with cornea.
#*Perform immediately and before any examination
*Remove particulate matter
#*NS or LR works best
**Evert both lids, remove any visible particulate matter with cotton-tipped applicator
#*Treat until pH is >7.4 when checked 30min after the last irrigation
*Anesthesia
#**Avoid testing pH of the irrigation fluid (wait few min before checking ocular fluid)
**Apply topical anesthetic (e.g. tetracaine) to help with discomfort.
#Remove particulate matter with cotton applicator
*Further pain control measures
#Measure acuity and IOP (may be increased if trabecular meshwork has been damaged)
**Cycloplegics (e.g. atropine, cyclopentolate) can assist in pain control
#Cycloplegic for pain control
**Encourage generous use of artificial tears, other lubricating drops
#*Avoid phenylephrine
**PO analgesia as needed
#Antibiotics
*Antibiotics
#*Erythromycin ointment QID
**Erythromycin ointment QID for minor burns
#Ophtho consultation for all but minor burns
**For more severe burns, topical fluoroquinolone is warranted.
#*Severe exposures may require anterior chamber irrigation
*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 all pts w/ corneal haziness or opacity or limbal ischemia (paleness at limbus)
*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)
*Discharge w/ 24hr ophthalmology follow-up if pt only has corneal epithelial injury (fluorescein uptake)


==Prognosis==
==Prognosis==

Revision as of 09:48, 21 June 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)
      • 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

Clinical Features

  • Symptoms - Severe pain, blepharospasm, reduced visual acuity
  • Alkali injuries can cause elevated IOP.[3]
  • Evaluate ocular pH (normal is 7.0-7.2)

Differential Diagnosis

Caustic Burns

Conjunctivitis Types

Unilateral red eye

^Emergent diagnoses ^^Critical diagnoses

Management

  • Irrigation
    • 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)[4]
    • NS, LR, or BSS (Buffered Saline Solution) preferred in the hospital setting[5], 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)
    • 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
    • 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 ointment QID for minor burns
    • For more severe burns, topical fluoroquinolone is warranted.
  • Control inflammation
    • Topical steroids - prednisolone 1% QID for 1 week[6]
    • Should not be continued for more than 10 days to avoid corneal breakdown.[7]
  • Ophtho consultation for all but minor burns (Severe exposures may require debridement or other surgical intervention)

Disposition

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

Prognosis

  • Determined by the extent of injury at the limbus and area/depth of injury to cornea

References

  • Brodovsky SC, et al: Management of alkali burns: An 11-year retrospective review. Ophthalmology 2000; 107:1829-1835
  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. ↑ 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.
  5. ↑ 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.
  6. ↑ Dohlman, C.H., F. Cade, and R. Pfister, Chemical burns to the eye: paradigm shifts in treatment. Cornea, 2011. 30(6): p. 613-4.
  7. ↑ Donshik, P.C., et al., Effect of topical corticosteroids on ulceration in alkali-burned corneas. Archives of ophthalmology, 1978. 96(11): p. 2117-20.

See Also

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