Chemical, Thermal and Laser Eye Injuries

Objectives

To identify and manage injuries to the eye resulting from chemical burns/splashes to the eye(s), from exposure to bright ultraviolet sources or from thermal burns.

Scope

This guidance covers the likely mechanism, key findings and immediate management for the above injuries. It is not intended to offer specialist guidance for ophthalmology experts.

Audience

This guideline is intended for the use of registered healthcare professionals fulfilling a role in a forward medical location or in an emergency department in a deployed hospital setting

Initial Assessment & Management

Chemical Injuries

Mechanism

A wide range of chemicals can cause chemical injury to the eyes including alkalis (tend to cause the most damage due to deeper penetration), acids, detergents, solvents, disinfectants, and tear gases.

Symptoms

• Immediate pain and redness
• Visual loss
• In severe chemical trauma, there may be no to minimal pain due to nerve damage

Signs

• Burns to the eyelid and surrounding skin
• Conjunctival blistering (chemosis) and redness
• Limbal and conjunctival blanching (loss of blood flow; indicates poor prognosis)
• Corneal defect
• Corneal sloughing
• Corneal oedema and clouding
• Corneal opacification

Management

1. Ascertain if any immediate actions (i.e. irrigation) have been taken and time of injury
2. IMMEDIATELY IRRIGATE the eye with copious irrigation fluids (i.e. lactated Ringer’s solution, normal saline, or water if other irrigation solutions are not available) for 20- 30 minutes. Copious irrigation to neutralise the ocular surface is essential to limit damage. See note on Diphoterine ® and Hexafluorine ® below.
3. If pH strips are available, aim pH 7.0 – 8.0. Check after stopping irrigation for 1 min. When pH within range, check again in 30 mins. If pH is again out of range after 30 mins, there has been insufficient irrigation and irrigation cycle should be immediately restarted.
4. Local anaesthetic eye drops will aid management and examination
5. Offer oral analgesia and topical cycloplegia
6. Evert upper and lower lids and remove any particulate matter/debris with a moist cotton bud. Adherent matter (e.g. wet plaster, cement) may have to be scraped off with a more firm instrument such as the edge of a blunt needle or closed blunt forceps. To evert the eyelid, gently pull the eyelid out using your thumb and index finger of one hand. With your other hand, use your index finger or a cotton bud to press down gently on the centre of the eyelid and the eyelid should evert.
7. Check visual acuity
8. Wearing sunglasses/avoiding bright light areas may help with light sensitivity.
9. Do not use topical anaesthesia for symptom control, only for examination and procedures (e.g. irrigation).

Photokeratitis (Ultraviolet Corneal Burns)

Mechanism

Photokeratitis is most commonly seen following exposure to bright ultraviolet light such as welding arcs, or sunlight, especially at high altitude. In extreme cases it is possible for damage to the cornea to occur even when the eyelids are closed.Symptoms

Mild

• Irritation
• Foreign body sensation

Severe

• Pain
• Redness
• Photophobia
• Tearing
• Blurred vision

Signs

• Typically bilateral
• Eyelid oedema and redness
• Conjunctival redness
• Transitory reduction in visual acuity
• Associate facial/eyelid redness
• Punctate staining of cornea may be seen with fluorescein staining

Initial Management

1. Offer oral analgesia (NSAIDs are recommended), cold compress, topical lubricants +/- cycloplegia and sunglasses advice for pain management
2. Topical anaesthetic if necessary to aid examination e.g. tetracaine 0.5%
3. If large corneal defect, consider use of topical antibiotics, chloramphenicol 1% QDS
4. Close monitoring (corneal epithelium should largely be healed by the following day)
5. Advise patient to return/seek further help if symptoms persist
6. Advise patient on future eye protection

Thermal Injuries

Mechanism

Thermal injuries may result from a flash burn, direct exposure to flame or pyrotechnics (including flares, phosphorous), or as a result of blast injury.

Management

Use a structured MARCH approach.

Examine the eye to rule out a co-existing open globe injury - if identified then follow guidance in the relevant CGO (link to follow).

If possible - assess visual acuity and lid closure.

Discuss urgently with an opthalmologist if possible, and plan to shield and ship - protect the injured eye(s) and evacuate to a higher level of care at the earliest safe opportunity. 

Advanced Assessment & Management

The principles and available useful equipment in the deployed hospital context will be similar to a forward medical location, so the above guidance can be applied.

Prolonged Casualty Care

If the patient requires evacuation but this is not possible:

Give antibiotic cover: oral doxycycline 100mg bd with topical ointment as often as 2 hourly.

For thermal injury - protection of the ocular surface is paramount.  Use petroleum jelly or Chloramphenicol ointment to keep a protective layer over the cornea and burned lids.

Dress with a paraffin dressing such as Jelonet if available and shield the eye.