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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

- Potassium hydroxide: - Magnesium hydroxide: - Sparklers, flares, fireworks

- Vehicle of exposure: - Aerosol: Common - Propellant: May result in intraocular foreign body/perforation

- Oral analgesics - If increased intraocular pressure: - Immediate ophthalmologic consultation - Administer acetazolamide 125 mg PO QID and timolol 0.5% drops BID

- 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

- Radiation injury: - Topical anesthetic - Short-acting cycloplegic - Antibiotic ointment - Consider oral opioids for pan control

  • 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 levelHighly soluble in lipids, so rapidly penetrate the eye, causing severe corneal injury and continue to penetrate over time if no intervention undertakenPenetration 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 epitheliumCause opacificationCoagulation produces barrier to deeper penetrationException: 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 corneaDamage 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 agentsPotassium hydroxide:Magnesium hydroxide:Sparklers, flares, fireworksLye: NaOH:Caustic soda, drain cleanersLime: CaOH2 or MgOH2:Fresh lime, quicklime, calcium hydrate, slaked lime, hydrated lime, plaster, mortar, cement, whitewashNonspecific alkali:Motor vehicle airbag on inflation releases alkali.
  • Acids:Sulfuric acid: H2SO4:Car battery acid, toilet cleanerSulfurous acid: H2SO3:Preservatives (fruit and vegetable)Acetic acid: CH3CO2H:
  • Bleach
  • Refrigerants:HF acid:Etching silicon/glassCleaning brickElectropolishing metalsControl of fermentation in breweriesCommercial/household rust removal
  • Thermal:Hot liquids, molten metalFlamesHot smoke/gasesFlash burnSteamCigarette burns
  • Radiation:Sun lampsTanning boothsHigh-altitude sunlightReflection off snow/waterArc 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: CommonPropellant: 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 burnsPerforation (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 keratitisCorneal ulcer
  • Corneal erosion syndrome:Corneal foreign bodyCorneal abrasionHypothermal 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 substancesIrrigate 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 minDip pH paper in inferior conjunctival fornixTopical anesthetic (proparacaine) may be necessary during irrigationpH should be evaluated at 5 and 30 min after irrigation to ensure normalization of pHEvaluate fornices in detail and eye in full range of motion to ensure removal of all particulate chemical substanceAntibiotic prophylaxis for Staphylococcus/Pseudomonas until epithelialization is complete:Gentamicin ointment + erythromycin orBacitracinCycloplegics to minimize posterior synechiae formation:Cyclopentolate 1%Atropine 1%Oral analgesicsIf increased intraocular pressure:Immediate ophthalmologic consultationAdminister 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 eyedropsSystemic analgesia for 24 hr
  • Thermal exposure:Frequent moist dressing changesAntibiotics drop QIDGenerous lubricant applicationMoisture chamber when extensive injury to eyelidSteroids (consult ophthalmologist; do not use for >1 wk)Ophthalmology consultation for any 2nd- or 3rd-degree burn to eyelidsCigarette ash and hot liquid splashes usually result in corneal epithelial injury:Treat as corneal abrasion
  • Electrical injury:IrrigationWound careAntibiotic ointmentCycloplegic (if anterior uveitis)Analgesia
  • Radiation injury:Topical anestheticShort-acting cycloplegicAntibiotic ointmentConsider 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.

See Also (Topic, Algorithm, Electronic Media Element)

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)