Corneal Burn, Emergency Medicine

Basics

Description

Inappropriate exposure of cornea to chemicals, heat, cold, electrical, or radiant energy causing damage to the cornea and often extending to adjacent structures
Severity of injury related to duration of exposure, type of agent, anion concentration, pH level of solution
Alkalis:
- Cause immediate rise in pH level
- Highly soluble in lipids, so rapidly penetrate the eye, causing severe corneal injury and continue to penetrate over time if no intervention undertaken
- Penetration can occur in <1 min.
- Exception: Calcium alkalis penetrate relatively poorly secondary to soap formation; can cause corneal opacification, so may appear worse but actually have better prognosis than other alkali burns.
Acids:
- Immediately coagulate proteins of corneal epithelium
- Cause opacification
- Coagulation produces barrier to deeper penetration
- Exception: Lipophilicity of hydrofluoric (HF) acid causes it to act similar to a base with more rapid penetration
Thermal burns:
- Affect eyelids more than globe due to reflex blinking and Bell phenomenon (eyes roll up and outward)
- Cause direct injury to cornea
- Damage primarily depends on duration and intensity of heat
Electrical injury:
- Occurs with current flow through head, with input at or near eye
Radiation injury:
- Due to ultraviolet light exposure to cornea

Etiology

Alkalis:
- Ammonia:
  - Fertilizer, refrigerant, household ammonia, cleansing agents
- Potassium hydroxide:
  - Caustic potash
- Magnesium hydroxide:
  - Sparklers, flares, fireworks
- Lye: NaOH:
  - Caustic soda, drain cleaners
- Lime: CaOH2 or MgOH2:
  - Fresh lime, quicklime, calcium hydrate, slaked lime, hydrated lime, plaster, mortar, cement, whitewash
- Nonspecific alkali:
  - Motor vehicle airbag on inflation releases alkali.
Acids:
- Sulfuric acid: H2SO4:
  - Car battery acid, toilet cleaner
- Sulfurous acid: H2SO3:
  - Preservatives (fruit and vegetable)
- Acetic acid: CH3CO2H:
  - Vinegar
Bleach
Refrigerants:
- HF acid:
  - Etching silicon/glass
  - Cleaning brick
  - Electropolishing metals
  - Control of fermentation in breweries
  - Commercial/household rust removal
Thermal:
- Hot liquids, molten metal
- Flames
- Hot smoke/gases
- Flash burn
- Steam
- Cigarette burns
Radiation:
- Sun lamps
- Tanning booths
- High-altitude sunlight
- Reflection off snow/water
- Arc welding

Consider child abuse or neglect.

Diagnosis

Signs and Symptoms

Severe ocular pain
Photophobia
Lacrimation
Foreign body sensation
Conjunctival injection
Corneal edema
Corneal opacification
Impaired visual acuity
Limbal blanching
Lens opacification
Vesicles clear fluid (hypothermal injury)
Vesicles hemorrhagic fluid
Necrosis of iris, ciliary body

History

Type of exposure:
- Inspect any bottles accompanying the patient for active and inactive ingredients
Vehicle of exposure:
- Aerosol: Common
- Propellant: May result in intraocular foreign body/perforation
Duration of exposure
Time of onset
Time irrigation initiated
Pre-existing visual impairment
Protective eyewear
Contact lens use
Treatment before arrival

Physical Exam
Complete eye exam (after irrigation):

Visual acuity
Bright white light for visual inspection of cornea/conjunctivae/limbus
Slit-lamp to evaluate anterior segment inflammation
Fluorescein stain:
- Corneal epithelial damage:
  - Punctate corneal lesions with discrete lower border from inferior lid seen in UV radiation burns
- Perforation (Seidel test)
Check for lenticular clarity
Fundus exam
Measure intraocular pressure (especially in delayed presentation)
Lid/eyelash exam
Check pH with acid/alkali burns with litmus paper or pH indicator on urine dipstick

Diagnosis Tests & Interpretation

Diagnostic Procedures/Surgery

Fluorescein stain
Check pH

Differential Diagnosis

Infection:
- Viral keratitis
- Corneal ulcer
Corneal erosion syndrome:
- Corneal foreign body
- Corneal abrasion
- Hypothermal injury

Handheld slit-lamp and Wood lamp helpful in exam of childs eye

Treatment

Pre-Hospital

Irrigate at scene 15-30 min unless other coexisting life-threatening conditions require immediate transfer
Bring bottle of substance to hospital
Continuous irrigation en route to hospital with NS or water

Initial Stabilization/Therapy

Chemical exposure:
- Suspect acid or alkali in all exposures to unknown substances
- Irrigate with any available diluting substance but preferably water or NS
Thermal exposure:
- Cool-moist dressing with overlying ice packs

Ed Treatment/Procedures

Chemical exposure: Alkalis/acids/mace:
- Continuous irrigation to achieve pH 7.3-7.5 (1-2 L via a Morgan lens >30-60 min):
  - Measure pH every 30 min
  - Dip pH paper in inferior conjunctival fornix
- Topical anesthetic (proparacaine) may be necessary during irrigation
- pH should be evaluated at 5 and 30 min after irrigation to ensure normalization of pH
- Evaluate fornices in detail and eye in full range of motion to ensure removal of all particulate chemical substance
- Antibiotic prophylaxis for Staphylococcus/Pseudomonas until epithelialization is complete:
  - Gentamicin ointment + erythromycin or
  - Bacitracin
- Cycloplegics to minimize posterior synechiae formation:
  - Cyclopentolate 1%
  - Atropine 1%
- Oral analgesics
- If increased intraocular pressure:
  - Immediate ophthalmologic consultation
  - Administer acetazolamide 125 mg PO QID and timolol 0.5% drops BID
Topical steroids to control anterior uveitis (consult ophthalmology)
Eye patch (consult ophthalmology)
May require surgical intervention if frank corneal penetration
Ophthalmologic consultation by phone in mild injuries
Immediate ophthalmologic consultation in all moderate to severe injuries; if unavailable at your hospital, arrange transfer to closest eye center
HF acid:
- Treat as above, + 1% calcium gluconate eyedrops
- Systemic analgesia for 24 hr
Thermal exposure:
- Frequent moist dressing changes
- Antibiotics drop QID
- Generous lubricant application
- Moisture chamber when extensive injury to eyelid
- Steroids (consult ophthalmologist; do not use for >1 wk)
- Ophthalmology consultation for any 2nd- or 3rd-degree burn to eyelids
- Cigarette ash and hot liquid splashes usually result in corneal epithelial injury:
  - Treat as corneal abrasion
Electrical injury:
- Irrigation
- Wound care
- Antibiotic ointment
- Cycloplegic (if anterior uveitis)
- Analgesia
Radiation injury:
- Topical anesthetic
- Short-acting cycloplegic
- Antibiotic ointment
- Consider oral opioids for pan control

Patching poorly tolerated
May require systemic analgesia for complete exam

Medication

Artificial tears
Atropine: 0.5%, 1%, 2% drops (cycloplegia 5-10 days, mydriasis 7-14 days) 1 drop TID
Bacitracin ointment: QID
Ciprofloxacin: 0.35% 1 drop QID
Cyclopentolate: 0.5%, 1%, 2% drops (cycloplegia 1-2 days, mydriasis 1-2 days) 1 drop TID
Erythromycin: 0.5% ointment QID
Gentamicin: 0.3% ointment QID
Gentamicin: 0.3% drops 1 drop q6h
Homatropine: 5% drops 1-2 drop BID-TID
Proparacaine: 0.5% drops 1 drop
Sulfacetamide: 10% ointment QID
Sulfacetamide: 10% drops QID
Tetracaine: 0.5% drops 1-2 drops
Tobramycin: 0.3% ointment q6h
Tobramycin: 0.3% drops q6h
Tropicamide: 0.5%, 1% drops (cycloplegia none; mydriasis 6 hr) 1 drop

Follow-Up

Disposition

Admission Criteria

Intractable pain
Increased intraocular pressure
Corneal penetration requiring immediate surgical intervention
HF acid burn; admit for 24 hr of systemic analgesia
Suspected child abuse

Discharge Criteria
All mild corneal burns

Followup Recommendations

Mandatory follow-up with ophthalmologist in 12-24 hr; arrange before patient discharge

Pearls and Pitfalls

In chemical exposures, delay exam until eye has been irrigated
All patients with epithelial defects need 12-24 hr ophthalmology follow-up
Do not prescribe topical anesthetics for discharged patients

Additional Reading

Dargin JM, Lowenstein RA. The painful eye. Emerg Med Clin North Am. 2008;26(1):199-216.
Khaw PT, Shah P, Elkington AR. Injury to the eye. Br Med J. 2004;328:36-38.
Marx J, Hockberger R, Walls R, eds. Rosens Emergency Medicine. 7th ed. Elsevier, 2009.
Naradzay J, Barish RA. Approach to ophthalmologic emergencies. Med Clin N America. 2006;90:305-328.

Codes

ICD9

940.2 Alkaline chemical burn of cornea and conjunctival sac
940.3 Acid chemical burn of cornea and conjunctival sac
940.4 Other burn of cornea and conjunctival sac
370.24 Photokeratitis

ICD10

H16.139 Photokeratitis, unspecified eye
T26.10XA Burn of cornea and conjunctival sac, unsp eye, init encntr
T26.60XA Corrosion of cornea and conjunctival sac, unsp eye, init
H16.133 Photokeratitis, bilateral
H16.131 Photokeratitis, right eye
H16.132 Photokeratitis, left eye
H16.13 Photokeratitis
T26.11XA Burn of cornea and conjunctival sac, right eye, init encntr
T26.12XA Burn of cornea and conjunctival sac, left eye, init encntr
T26.61XA Corrosion of cornea and conjunctival sac, right eye, init
T26.62XA Corrosion of cornea and conjunctival sac, left eye, init

SNOMED

274204004 Corneal burn (disorder)
447094002 Alkaline chemical burn of cornea (disorder)
446556000 Acid chemical burn of cornea (disorder)
231943000 Thermal and radiation injury to the cornea
287137008 Burn to cornea - blister (disorder)
287138003 Burn to cornea - full thickness (disorder)
3282008 welders keratitis (disorder)
418591009 Corneal wound burn (disorder)

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