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ARTICLE
Year : 1968  |  Volume : 16  |  Issue : 4  |  Page : 228-231

Chemical burns of the conjunctiva and cornea


Ophthalmic Dept. King Edward VII Memorial Hospital, Parel, Bombay, India

Date of Web Publication24-Dec-2007

Correspondence Address:
B T Maskati
Ophthalmic Dept. King Edward VII Memorial Hospital, Parel, Bombay
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Maskati B T, Adrianwala S D. Chemical burns of the conjunctiva and cornea. Indian J Ophthalmol 1968;16:228-31

How to cite this URL:
Maskati B T, Adrianwala S D. Chemical burns of the conjunctiva and cornea. Indian J Ophthalmol [serial online] 1968 [cited 2020 Aug 9];16:228-31. Available from: http://www.ijo.in/text.asp?1968/16/4/228/37561

Table 1

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Table 1

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Injuries due to chemicals are some of the most treacherous injuries of the eyes. Whereas the natural pro­tective mechanism offered by the pe­culiar bony anatomy of the orbit offers protection against injuries caus­ed by larger sized lethal objects, and the brisk movement of the lids and a quick secretion of tears against small­er sized ones, the fluid nature of most of the chemicals that get splashed on to the eyes and face know no anato­mical or physiological bounds. They cause chemical burns not only of the eyes but of the protective mechanisms themselves and sometimes end in the most ugly and debilitating scarring of the face, lids and conjunctiva which tax the ingenuity of a plastic surgeon later. The ultimate damage is greater than the immediate reaction may suggest. It will depend on a) concentration of chemical b) dura­tion of contact is ocular bisues c) chemical reaction which can take place c the bissue components and d) diffusibility of the agents.

Of the two, alkaline burns are more vicious, for if not washed away early, mild at first the), enter the stroma to set up an inflammatory process which penetrates deeper and progresses from day to day as we look helplessly on. Chemicals are used often to settle private scores and eke vengeance out of frustration. Fortunately for these homicidal attempts, almost always, acids are chosen.

Secondly such wounds easily get infected, adding to the product of destruction, so that in all chemical burns it is not possible to predict the eventual outcome, the end result. That is why they are treacherous.

Great progress has been made since the last war in the treatment of che­mical burns and although the event­ual results may be better, chemical burns of the eyes and face need more than the usual respect and attention, that thermal burns and injuries of the eyes from other causes, receive.


  Materials and methods Top


This paper is an analysis of cases of chemical burns treated as inpa­tients in the K.E.M. Hospital, Bom­bay during the last five years. Special emphasis has been laid on the man­agement of these cases.

Thirty seven cases of corneal burns were admitted to the ophthal­mic ward of the K.E.M. Hospital, during the last five years. The cases have been analysed according to

1) Nature of injury, viz. which chemical was responsible

2) Intention of injury, viz. suicidal, homicidal or accidental

3) Age and Sex

4) Unilateral or Bilateral

5) Modes of Treatment (First-aid, local and systemic)

(1) Nature of Injury:

1) Acid burns - 11 cases

2) Alkaline burns - 23, cases. Of these, 13 were clue to lime, 6 due to caustic soda, 3 due to ammonia and one due to an adhesive paste.

3) Miscellaneous 3 cases. Of these one was due to silica, one due to potasium permanganate, and one due to lysol (the patient was a doctor).

(2) Intention of Injury: The majo­rity of these cases, (33) were acciden­tal, three were homicidal (all acid in nature) and one was suicidal (also acid in nature).

(3) Age and Sex: Only three cases out of 37 were below the age of 12 years (8.1%). The remaining 34 cases were above the age of 12 years (91.9%).

Only five cases were females (13.5%). The remaining 32 cases were males (86.5%). The sex distri­bution is rather overwhelmingly male, because in this series accidental cases predominated, where the majority of workers were male.

(4) Whether unilateral or bilaeral: In 18 cases, both eyes were involved, whereas in 19 cases only one eye was involved.


  Treatment Top


Treatment can be divided into first-aid, local and systemic.

First-Aid: This forms an essential part of the treatment. Chemicals, since they set up a progressive reac­tion of destruction when in contact with the tissues, must be removed as soon as possible. This can be done by removing all pieces of garment soaked in the chemical and washing the eyes and face with copious quan­tities of water to dilute the chemical if not actually to wash it away. A proper first aid of this nature can make all the difference between a good and a bad end result. However, in the case of lime burns, it is im­portant not to apply any water, other­wise slaked lime that is produced on mixing with water adds to the destruction from the intense heat liberat­ed. It is best to pick out the lime pieces, preferably under intravenous anesthesia as soon as possible. Lime can also be washed away by a con­tinuous stream of cold water on boric lotion as the cold wash will neutra­lise the effect of liberated heat. The stream, however, must be continuous, and continued for 15 to 20 minutes. The use of EDTA (ethylenediamine­tetra acetate) has been recommended in cases of lime burns to prevent the formation of slaked lime. Moreover the lime particles become less adhe­rent after the use of EDTA.

Local treatment can be further subdivided into medical and surgi­cal.

Medical treatment locally includes the use of 1% atropine drops twice a day, corticosteriod drops two hourly round the clock (preferably betame­thasone or dexamethasone). CORVA­SYMTON (p-Methylamino ethanol­phenol-tartrate) or oxedrine tartrate drops two hourly have proved very useful. The last named drug is ac­tually an analeptic or a cardiac sti­mulant, but it was accidentally dis­covered to be useful in alkaline burns of the cornea. It prevents the delay­ed penetrating damage caused by the alkali. Locally any antibiotic may be used to prevent infection.

Surgical treatment of chemical burns:

Particles of Lime should be remov­ed from the fornices with a pair of forceps, prior to washing the eye, so that no dissolution of the lime parti­cles occurs. If necessary a double eversion of the lid may be done to remove particles from the upper for­nix.

In cases of severe conjunctivo­corneal burns where one expects symblepharon formation, it is most essential to keep the palpebral and bulbar conjunctiva apart. This can be clone either by passing a glass rod in the fornices twice a day or better still by leaving an inert tissue bet­ween the two. Sorsby recommends an amniotic membrane and he des­cribes a method of preparing and pre­serving amniotic membrane to be available for immediate application. It mixes with the conjunctiva and needs no removal. A fresh piece of amnio­tic membrane can also be used for the purpose, but it should be removed aseptically and kept in a penicillin solution for an hour before use. Be­fore use all fatty matter should be removed gently with a piece of gauze clipped in a 2% caustic potash solu­tion. A piece 5 cm x 5 cm should be sufficient and stitched from fornix to fornix without stretching. A window is cut over the healthy cornea to pro­mote corneal respiration.

An egg membrane can also be used for the same purpose. In our series, egg-membrane grafting was done in 4 cases.

A hard boiled egg is peeled with aseptic precautions and the mem­brane over the egg is then slit and peeled off. A square of this mem­brane is sutured to the conjunctiva both superiorly and inferiorly, nasal­ly and temporally. A small window is cut open in the membrane over the cornea to promote corneal oxygena­tion. The membrane prevents adhe­sions between the palpebral and bul­bar conjunctiva.

Superficial keratectomy was per­formed in two cases, one of severe acid burns and one case of lime burns. This was done to remove and debride the cornea of the superficial eschar, so that corneal healing would be pro­moted. Therapeutic lamellar grafting can also be clone instead of simple keratectomy.

Horwitz strongly advocates surgi­cal debridement daily of the necrotic conjunctival tissues, plus superfical debridement of necrotic corneal tissue, for the first five to seven clays. In his opinion, this helps the return of visual acuity to normal.

Systemic Treatment:

The use of systemic antibiotics, preferably broad-spectrum, helps to prevent secondary infection.

Systemic corticosteroids, ACTH and other anti inflammatory agents of the butazolidine group (e.g. oxy­phenylbutozone or Tanderil) help in minimizing the inflammatory reac­tion.

In obviously malnourished pati­ents, vitamin C and high proteins in the diet promote healing.

In cases where permanent corneal damage remains, keratoplasty (either lamellar or penetrating as required) may be clone to improve visual acuity.


  Prognosis Top


It depends on the degree of con­junctical and corneal necrosis that has taken place by the time treat­ment is commenced, the rapidity with which treatment can be institu­ted, the degree of secondary infec­tion and the general condition of the patient.


  Results Top


Visual improvement following che­mical injuries depends on the Seve­rity of the burns of the cornea, interval between injury and treatment and the nature of the irritant.

In our series, we have found that acid burns on the whole have a com­paratively better prognosis than alkaline burns. Of the alkaline series, lime burps have the worst prognosis while all cases of ammonio burns re­covered completely.


  Summary Top


Thirty seven cases of chemical injuries of the eye have been analy­sed as regards nature of injury, type of injury age and sex incidence.

Special discussion about treatment has been elaborated.[2]

 
  References Top

1.
Horwitz, I: Management of Alkali Burns of the Cornea Amer. J. Ophth. 61, 340-1 (1966).  Back to cited text no. 1
    
2.
Sorshy, A: Chapter 44 "Amniotic Membrane Crafts in Burns" in Sorsby's Modern Trends in Ophthalmology. Vol. II. p. 503 Butterworth, London (1948).  Back to cited text no. 2
    



 
 
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