Emergency Treatment of Eye

8/12/2019 Emergency Treatment of Eye

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Apart from hydrofluoric acid and, toa lesser extent, sulfurous acid, acidspenetrate the corneal stroma much lessreadily than alkalis (Grant 1974). Thehydrogen ion causes damage due to pHalteration, while the anion producesprotein precipitation and denaturationin the corneal epithelium and superficialstroma (Friedenwald et al. 1946). Pre-cipitation of the epithelial proteins of-fers some protection to the cornealstroma and intraocular structures. How-ever, very strong acids penetrate justquickly as alkalis. No statistical differ-ence between strong alkali and acidsburns was discovered in the clinicalcourse and prognosis of such eyes(Kuckelkorn 1996).

Clinical classification of chemical and

thermal burns

Eye burns are classified in 4 grades (Reim1987, 1990). The clinical course and ulti-mate prognosis correlates with the extent

of limbal ischemia (Hughes 1946; Ballen1963; Roper-Hall 1965). The prognosisalso depends on the extent of damage toconjunctival and episcleral tissue, severityof lid burn and damage to intraocularstructures (Table2).

Mild burns of grades I and II are associ-ated with hyperemia, small conjunctivalecchymosis and chemosis as well as ero-sion of the corneal epithelium (Figs 1 and2). In mild acid burns, the coagulated cor-neal epithelium often has a ground-glassappearance. After removal of the epithel-

ium, the clear corneal stroma is visible.Grade III, and especially grade IV,burns are accompanied by extensive anddeep damage to the tissue (Figs3 and 4).Typically, large areas of the conjunctivaland subconjunctival tissue are involved.The visible blood vessels are thrombosedand appear dark. The corneal keratocyt-

Table 2. Clinical classification and prognosis of eye burns

Grade I II III IV

Appearence Erosio Erosio Erosio Erosio

Limbal ischemia 3/4 Hyperemia Limbal ischemia 1/3 Limbal ischemia 1/2Chemosis Chemosis Chemosis

Opacification Opacification Extensive necrosisClinical outcome Regeneration Recirculation Vascularisation Ulceration

Regeneration Ulceration Iris atrophyProliferaton CataractCicatrization Glaucoma

Prognosis Complete restitution Complete restitution ScarsPrevention of the globeMultiple operations for Slight scars Multiple operationscosmetic rehabilitation for limited visual

rehabilitation

Fig.1. Grade I chemical injury: hydrochloric acid (HCl). Burn of the cornea only. Coagulatedcorneal epithelium with ground glass appereance. Partial removal of the epithelium, clear corenalstroma.

es are lost and hydration of the denaturedproteins results in corneal opacification.Chemical injury to the iris and crystallinelens may produce mydriasis, a greyish ap-pearance of the iris and the fast develop-ment of a cataract. The lysis of cells ofthe anterior chamber destroys the bloodaqueous barrier and leads to iridocyclitisand fibrinous exsudation.

Toxic substances such as prostagland-

ines, superoxide radicals, and presumablyhistamine, angiotensin, leukotriens andothers are released from the burnt cells ofthe necrotic tissue (Eakins & Bhattach-erjee 1977; Kulkarni & Srinivasan 1993;Rochels et al. 1982). An inflammatory re-sponse is initiated, when they diffuse intosurviving tissues. In mild burns this reac-

tion resolves quickly, while in severeburns a severe and long-term inflamma-tory process is initiated, determining theclinical course of the burnt eyes (Reim1982, 1987, 1992; Williams et al. 1983;Struck et al. 1991; Reim & Leber 1993;Reim et al. 1993).

Emergency treatment

Immediate irrigation is of paramount im-

portance after chemical or thermal burns(Lubeck & Greene 1988; Cohen & Hynd-iuk 1978; Rodeheaver et al. 1982). In mostcases the victims are disabled by severe re-flectory blepharospasm with ensuing dis-orientation. In this situation the victimsare unlikely to be capable of reaching thenearest body or eye shower and need res-


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Fig.2. Grade II chemical injury: lime (CaOH). Central epithelial defect, partial limbal ischemiain the nasal inferior quadrant.

cuers who remove them from dangerousareas and apply fast and efficient help totheir eyes and body (Morgan 1987).

Effective first aid involves knowing howto overcome blepharospasm by a passiveopening of the lids and how to perform ef-fective irrigation of the eye. All aspects ofthe conjunctiva and cornea should be irri-

Fig.3. Grade III chemical injury: sodium hydroxide (NaOH). Complete corneal and proximalconjunctival epithelial defect with loss of corneal stromal clarity. Limbal ischemia in theinferiorquadrants.

gated, and the patient should be asked tolook in all directions (Tannen & Marsden1991). Topical anesthetic drops may be ap-plied to reduce the pain and to facilitate ir-rigation. According to the American Na-tional Standards Institute (ANSI) stan-dard (Z358.11990) severe eye burns haveto be rinsed for 15 min. At least 5001000

mL of irrigation fluid are thus necessary.Amphotericor buffered solutions can nor-malize the pH of the anterior chamberwithin that time (Schrage et al. 1996). Par-ticles are sometimes trapped in the for-nizes or under the upper lid. Therefore, ec-tropinisation and intensive cleaning of thecul-de-sac are mandatory after everyburn. Materials containing calcium oxid(lime, cement dust) react avidly with waterto produce a calcium hydroxide solutionwith a pH of 12.4 (Moon & Robertson1983). A cotton-tipped applicator soakedin EDTA 1% (EDTA, di-sodium-ethylen-diamintetra-acetat) can be used to facili-tate cleaning of the cul-de-sac from cal-cium hydroxide (Pfister 1983). Immediateirrigation is also important in thermalburns, because this cools the ocular sur-face (Schrage et al. 1997). Continuous ir-rigation also removes inflammatory sub-stances from the ocular surface (Reim1990; Reim & Kuckelkorn 1995).

First aid with intensive irrigation im-

mediately after the injury has a decisiveinfluence on the clinical course and prog-nosis of such eyes (Saari & Parvi 1984;Burns & Paterson 1989). A comparisonbetween visual outcome of better than 1/50 with that of less than 1/50 revealed ahighly significant difference, with signifi-cantly better results after immediate irri-gation. Visual acuity of 1/50 enablesthe patient to move unaided. The numberof operations and the length of stay onthe ward are significantly reduced for eyesthat received prompt irrigation (Table3;

Kuckelkorn et al. 1995).

Choice of irrigation fluid

Burns are accompanied by a loss of thecorneal epithelium within a few seconds.The acutely burnt cornea takes up theburning substance by osmolar forces re-sulting in a high osmolarity. One of theaims of rinsing therapy is to remove thischemical burden.

Water is commonly recommended asan irrigation fluid. It is available almosteverywhere, and copious amounts of

water have a dilutive effect. However,water is hypotonic to the corneal stromaand intraocular milieu. In measurementsof osmolarity, Schrage et al. (unpub-lished) found the corneal stroma to havean osmolarity of 420 mOsm/L. The cor-neal tissue is diluted by rinsing with waterand this is accompanied by an increaseduptake of additional water and diffusionof the corrosive into the deeper layers ofthe cornea. We thus recommend the useof irrigation fluids with higher osmolari-


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Table 3. Value of immediate rinsing therapyversusclinical results in severe eye burns (101 patients,131 eyes).

Rinsing Number Hospitalization Visualof operations (months) acuity

Immediate 6.54.6 4.22.8 45 (76%)Delayed or no 10.410 6.04.5 22 (55%)

Unpaired t-test, P0.05.

ties for initial rinsing in order to preventwater influx into the cornea and to enablethe mobilisation of water and the dis-solved corrosives out of the burnt tissue.

Normal saline (NS), which is often rec-ommended as irrigation fluid, also has alower osmolarity than tear fluid. It failsto normalize the pH of the anteriorchamber even after prolonged irrigation(Table4).

Phosphate buffer is often cited as an

Fig.4. Grade IV chemical injury:sodium hydroxide (NaOH). Loss of corneal transparency, ectro-pion uveae and cataract formation, circular loss of conjunctival and episcleral tissue down to thefornices. The sclera is ischemic.

Table 4. pH on the corneal surface and in the anterior chamber after rinsing with different irrigation fluids (experimental eye burn for 30s/1nNaOH).

pH corneal surface anterior chamber

Directly after burn 130 1005 minutes after rinsing 90 100with 500mL normal saline5 minutes after rinsing 7.50 9.250.44with 500mL phosphat buffer5 minutes after rinsing 7.50 9.340.59with 500mL diphoterine

Concentration of phosphat buffer: 440 mg sodiumdihydrogenphosphat and 4040 mg sodiummonohydrogenphosphat in 100mL H2O.

ideal buffer solution (Thiel 1965; Lauxet al. 1975; Poser 1983; Roth 1993). Forthis reason, there is widespread use ofthis buffer in many factories. However, inan experimental study complete calcifi-cation of the superficial stroma occuredin 100% of all animals after burning with1 n NaOH for 30 s and immediate rinsingwith 500mL phosphate buffer. (Schrageet al., unpublished). We suggest that exo-genously applied phosphate reacts with

endogenous calcium released from rup-tured cells to produce calcium-phophatecomplexes.

At present, there is ongoing experimen-tal research to find irrigation fluids withan osmolarity similar to the cornealstroma. Currently available fluids whichare suitable for irrigation are sterile, lac-tated Ringers (LR) and balanced salinesolution (BSS; Herr et al. 1991). LactatedRinger is a buffered solution and may bemore effective than normal saline. Theosmolarity of BSS is similar to that ofaqueous humour; its pH is neutral and itcontains sodium acetat and citrat(McDermott et al. 1988). According toPfister, isotonic citrate buffer initiateschelat-complexes and binds unspecificmetal-ions derived from the corrosive(Pfister et al. 1981; Pfister et al. 1984).Balanced saline solution has an enhancedbuffering capacity; it prevents the corneafrom swelling and preserves the cornealendothelium (McNamara et al. 1987).

The pH, osmolarity and buffer ca-pacity of the aqueous humour, cornealstroma and some irrigations fluids arelisted in Table5.

A new amphoteric solution which issuitable for irrigation is Diphoterine(PrevinA, Fa. Prevor). This newly syn-thetisized fluid is able to bind both alkalisand acids. 0.4% Diphoterinehas a pH of7.4 and an osmolarity of 820 mosml/L.The pH in the conjunctival sac and in thecorneal stroma is reduced as rapidly asafter irrigation with phosphate buffer.

The constituents of Diphoterine are listedin Table6.

Transport problems

As strong acids and alkalis penetratewithin seconds or minutes and remain forhours (Grant & Kern 1955), irrigationshould not be interrupted during trans-port to a professional eye-care unit. Therecommendations for minimum irri-gation times range from 15min (ANSIstandard; Lubeck & Greene 1988) to 24


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Table 5.pH, osmolarity, constituents and buffer capacity of the aqueous humour, corneal stromaand different irrigation fluids.

pH osmolarity constituents buffer capacity

Aqueous humour 7.4 304 Na, K, Cl, Ca, PO4, 0.0008proteins

Stroma 7.4 420 Na, K, Cl, Ca, S, SO4, 0.0004PO4,proteins, lipids,glycosaminoglycans

Normal saline 7.0 290 Na, Cl 0.0002Phosphate buffer 7.4 260 Na, K, PO4 0.00625Lactated Ringers 5.07.5 280309 Na, K, Ca, Cl, lactat 0.00069

BSS 7.2 310 Na, K, Ca, Cl, citrat, acetat 0.001Diphoterine 7.4 820 Diphoterine, Na, Cl, glycin 0.02

h (Pfister 1983; Saari et al. 1984). We rec-ommend the use of an intravenous in-fusion set to supply at least 5001000mLof irrigation fluid. As described above,one of the rescuers should hold the eye-lids open while a second rescuer flushesthe eye with a mild, directable and con-

trollable stream of fluid. Local anestheticdrops should be administered repeatedlyif necessary to relieve the patient frompain and to facilitate irrigation.

Some authors favor the use of speciallydesigned irrigation systems (Naumann1964; Girard & Soper 1966; Schulze &Tost 1967; Tan 1970; Morgan 1971; Lau1979). Whereas these systems providecontinuous irrigation of the eye, they failto flush the ocular surface homogenouslyand appropiately, especially the cul-de-sac. A further risk with lime or cement

burnsis that particles retained under theeye lids are not detected and removedonce the loop or lens has been applied.Moreover, rescuers unfamiliar with thehandling of these systems will lose pre-cious time when installing the slings orlenses, which may cause additional dam-age to the eye.

The effectiveness of rinsing therapy canbe assessed by using universal indicatorpaper to determine the pH of the externaleye. Irrigation must be continued as longas the pH remains outside the normal

range. If prolonged irrigation does notachieve normalization of the pH, one

Table 6.

Constituents of diphoterine.

Amphoter: Diphoterine 3.8/100mLNaCl: 1.8/100 mLGlycin: 0.75/100 mLPreservative: 0.05/100 mLAqua destillata: ad 100 mL

must consider the possibility that thereare still particles in the superior or in-ferior cul-de-sac.

Subsequent care

The subsequent care of eye burns is de-pendent on the severity of the injury.

Further therapeutical procedures are ap-plied according to the extent of the dam-age. If the injury is mild (grades I and II)and irrigation began immediately, mosteyes will heal without permanent damagewithin a few days (Moon & Robertson1983; Morgan 1987; Beare 1990; Kuckel-korn et al. 1993). Topical steroid/anti-biotic drops and ointment plus paddingmay suffice for the treatment of thesemild burns. Follow-up treatment within24h is mandatory.

Severe ocular eye burns (grades III and

IV) are difficult to treat and the courseof healing often takes several months. Inthese cases, accurate classification withregard to the extend of (limbal) ischemiaand depth of tissue destruction is essen-tial. An examination with the operatingmicroscope is thus mandatory. Parabul-bar or general anesthesia are sometimesneeded if the patient suffers pain and lo-cal anesthetic drops are not sufficient.

Less severe eye burns (grade III) arecharacterized by superficial ischemia ofthe conjunctival tissue. In these cases

where regular anterior chamber struc-tures are preserved and there is no dam-age to the iris, ectropium uveae or fibri-nous exsudation, subsequent manage-ment takes the for m of a moreconservative therapy. Admission to andtreatment in a local eye clinic are thussufficient (Reim & Kuckelkorn 1995).

Most severe eye burns (grade IV) leadto significant limbal ischemia and ne-crosis of the bulbar and tarsal conjunc-tiva as well as of the episcleral tissue

down to the fornices. In cases with super-ficial necrosis, the deep episcleral vesselsare still perfused while necrosis of thedeeper episcleral tissue is associated withthrombosis of the episcleral vessels. Inthese severe cases, opacification of thecornea is common and the anteriorchamber structures are obscured. A grey-ish aspect of the iris, ectropium uveaeand the breakdown of the blood aqueousbarrier with fibrinous exsudation into theanterior chamber confirm the destructionof the deep anterior segment. The lidsand aspects of the tarsal conjunctiva areoften involved. Many problems arise inthe acute phase of the burn. The mostdelicate problem is preventing the eyefrom early melting.

Necrosis of the conjunctiva and sub-conjunctival tissue is accompanied by aconsiderable exsudation of leucozytes(PMNs). These leucozytes release largeamounts of lysosomal enzymes. The ma-trix metalloproteinases (MMP), collagen-

ase (MMP-1 and MMP-8; Itoi et al.1969; Hook et al. 1971; Newsome &Gross 1977; Johnson-Muller & Gross1978; Kuter et al. 1989; Fini & Girard1990), gelatinase (MMP-2, MMP-9)(Collier et al. 1988; Fini & Girard 1990;Huhtala et al. 1990), and stromelysin(MMP-3; Collier et al. 1988; Chin et al.1995) in particular are responsible for thesplitting of the collagen molecules andthe development of corneoscleral andcorneal ulceration, characteristically 46weeks after the accident.

The basic principle in the treatment ofthese eyes is to reduce the inflammatoryresponse caused by the necrotic tissue.The traditional mainstay of therapy is theearly and intensive application of cortico-steroids (Donshik et al. 1978; Leibowitz1980; Reim & Schmidt-Martens 1982;Kenyon 1985; Reim 1987). Additionally,local antibiotics are necessary to preventmicrobiobal infections until the ocularsurface has reepithelialized (Girard et al.1970; Kuckelkorn et al. 1987; Beare1990). Tetracycline derivates play an im-

portant role because they have beenshown to inhibit metallo-proteinases(Brion et al. 1985; Golup et al. 1987;Seedor et al. 1987; Burns et al. 1989;Perry et al. 1993) independently of theiranti-microbial properties.

Besides conservative therapy, activesurgical intervention with the debride-ment of necrotic conjunctival and sub-conjunctival tissue is necessary in orderto remove a nidus of continued inflam-mation from retained caustic materials,


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although also any accumulation of PMNand to prevent the sustained release oftheir destructive enzymes. Special recon-structive approaches such as tenonplastyallow the denuded avascular sclera to becovered with vital connective tissue pre-pared from the equator of the globe(Reim & Teping 1989; Reim 1992; Reim &Kuckelkorn 1992, 1995; Kuckelkorn &Reim 1993; Reim & Leber 1993; Kuckel-korn et al. 1995). The main advantage ofthis tissue is that it enables the recon-struction of the conjunctival matrix andof limbal vascularity. These interventionsprevent anterior segment necrosis and/orsterile ulceration and the eye is preserved.It is advisable to admit these cases to aneye clinic specialized in the treatment ofthese eyes and familiar with specializedprocedures in plastic reconstruction.

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Received on April 9th, 2001.Accepted on September 9th, 2001.

Correspondence:

Ralf Kuckelkorn, MDWilhelmstrasse 852070 AachenGermany

Emergency Treatment of Eye

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