Caustic keratoconjunctivitis: Difference between revisions

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==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}}


==Clinical Features==
==Clinical Features==
*Symptoms - Severe pain, blepharospasm, reduced visual acuity
*Severe ocular 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>
*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>
*Evaluate ocular pH (normal is 7.0-7.2)
*Altered ocular pH (normal = 7.0-7.2)
*Appearance
*Appearance
**Conjunctival injection OR blannching
**Conjunctival injection '''OR''' blannching
**Chemosis, hemorrhage, epithelial defects
**Chemosis, hemorrhage, epithelial defects
**Corneal loss OR edema
**Corneal loss '''OR''' edema
*Perilimbal ischemia = white ring around iris
*Perilimbal ischemia (white ring around iris)
**Concerning due to co-location of corneal stem cell layer
**Concerning due to co-location of corneal stem cell layer (re-epitheliazation relies on migration of limbal stem cells)
**Re-epitheliazation relies on migration of limbal stem cells
 
*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>
===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>===
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| align="center" style="background:#f0f0f0;"|'''Grade'''
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{{Unilateral red eye DDX}}
{{Unilateral red eye DDX}}
==Diagnosis==
*Generally a clinical diagnosis


==Management==
==Management==
#Irrigation
*Irrigation
#*Immediate irrigation is the most important treatment for caustic occular injury, and should be started before comprehensive evaluation
**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>
**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.
**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, especially in pre-hospital setting.
#*Goal is to remove caustic agent and restore normal ocular pH (7.0-7.2)
**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
**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.
**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
#Remove particulate matter
**Evert both lids, remove any visible particulate matter with cotton-tipped applicator
#*Evert both lids, remove any visible particulate matter with cotton-tipped applicator
*Anesthesia
#Anesthesia
**Topical anesthetic (e.g. tetracaine) to help with discomfort.
#*Apply topical anesthetic (e.g. tetracaine) to help with discomfort.
**Other options include cycloplegics (e.g. atropine, cyclopentolate), IV/IM/PO analgesics
#*Further pain control measures
*[[Antibiotics]]
#**Cycloplegics (e.g. atropine, cyclopentolate) can assist in pain control
**Erythromycin ophthalmic ointment QID for minor burns
#**Encourage generous use of artificial tears, other lubricating drops
**Topical fluoroquinolone for more severe burns
#**PO analgesia as needed
*Control inflammation
#[[Antibiotics]]
**Topical steroids - prednisolone 1% ophthalmic 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>
#*Erythromycin ophthalmic ointment QID for minor burns
**Limit topical steroid use to 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>
#*For more severe burns, topical fluoroquinolone is warranted.
*Ophtho consultation for all but minor burns (Severe exposures may require debridement or other surgical intervention)
#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 for:
*Admit all patients with corneal haziness or opacity or limbal ischemia (paleness at limbus)
**Pediatric patient
*Discharge with 24hr ophthalmology follow-up if only has corneal epithelial injury (fluorescein uptake)
**Corneal haziness, opacity, or limbal ischemia (paleness at limbus)
 
*Discharge with 24hr ophthalmology follow-up if only has corneal epithelial injury
==Prognosis==
**Encourage use of artificial tears and other lubricating eyedrops
*Determined by the extent of injury at the limbus and area/depth of injury to cornea


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


Revision as of 23:42, 3 April 2016

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

Clinical Features

  • Severe ocular pain, blepharospasm, reduced visual acuity
  • Elevated IOP may be seen in alkali injury[3]
  • Altered ocular pH (normal = 7.0-7.2)
  • Appearance
    • Conjunctival injection OR blannching
    • 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)

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

Diagnosis

  • Generally a clinical diagnosis

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)[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
    • Topical anesthetic (e.g. tetracaine) to help with discomfort.
    • Other options include cycloplegics (e.g. atropine, cyclopentolate), IV/IM/PO analgesics
  • Antibiotics
    • Erythromycin ophthalmic ointment QID for minor burns
    • Topical fluoroquinolone for more severe burns
  • Control inflammation
    • Topical steroids - prednisolone 1% ophthalmic QID for 1 week[7]
    • Limit topical steroid use to 10 days to avoid corneal breakdown.[8]
  • Ophtho consultation for all but minor burns (Severe exposures may require debridement or other surgical intervention)

Disposition

  • Admit for:
    • 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.
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