Clinical ScienceCurrent and Upcoming Therapies for Ocular Surface Chemical Injuries
Introduction
Ocular chemical injuries are true ophthalmic emergencies that require immediate and intensive intervention to minimize severe complications and profound visual loss.1 Such injuries, which are most prevalent among young males aged 20-40, can result in chronic complications and life-long disability. The severity of chemical injury is determined by several factors, including the chemical and physical characteristics of the offending agent (particularly the pH), the specific reactivity with tissues (pK), concentration, volume, temperature, and impact force.2, 3 It is well known that alkaline substances, due to their lipophilicity, penetrate the eye more readily and therefore threaten both ocular surface tissues as well as intraocular structures such as the trabecular meshwork, ciliary body, and lens. In contrast, acidic substances cause protein coagulation in the epithelium, a process that limits further penetration into the eye.4, 5, 6 Nonetheless, acids may severely damage the ocular surface. With all ocular chemical injuries, swift intervention is crucial to improving the outcome and prognosis.
The purpose of this review is to provide an update on the current medical and surgical management of ocular chemical injuries and to describe future potential therapies.
Section snippets
Classification of Ocular Surface Injuries
There are several classification systems of ocular surface injuries that predict prognosis and clinical outcome by grading the severity of the injury.3, 7, 8 The Roper-Hall (R-H) classification, first introduced by Ballen9 in the mid-1960s and later modified by Roper-Hall,8 grades the severity of injury by the extent of corneal haze and perilimbal ischemia (Table 1). A similar classification proposed by Pfister is based upon the same variables but categorizes the severity of injury as mild,
Management of Immediate Phase
The obvious first step in treating an ocular chemical injury is to immediately and thoroughly irrigate the surface to remove the offending agent.2, 14, 17, 18, 19, 20, 21 Given the correlation between time to irrigation and outcomes, swift irrigation is usually performed at the site of the accident and prior to completion of a thorough assessment of the injury.22 Accordingly, tap water is appropriately employed as the aqueous solution for irrigation in most pre-hospital settings due to its
Management of Acute Phase
The main objectives during the acute phase are to decrease inflammation, avoid further epithelial and stromal breakdown, and foster re-epithelialization (Figure 2, Table 4).31
Management of Chronic Phase
Management of chronic ocular disease after a chemical injury can pose major therapeutic challenges and requires a multidisciplinary approach involving cornea, oculoplastic, and glaucoma specialists. Much effort has been made to develop more effective surgical interventions for the ocular surface disorders in these patients. The goal of these surgical interventions is to restore normal ocular surface anatomy and visual function. The typical order for surgical intervention is: correction of
Future Horizons
Most patients with mild-to-moderate chemical injuries can achieve a stable ocular surface and functional visual acuity with current management strategies. However, most severe chemical injuries have an unfavorable prognosis. A substantial number of patients with severe injuries go on to develop significant corneal and limbal stem cell disease, often complicated by neovascularization, melts, and perforations. Furthermore, extensive conjunctival scarring and symblepharon formation often progress
Summary
Chemical injuries can have devastating consequences for the ocular surface and periocular structures. The overall goal of treatment is restoration of normal ocular surface anatomy, a process that begins with immediate treatment, followed by measures to control inflammation, and ultimately reconstructive procedures to restore a normal ocular surface environment. With advancements in regenerative medicine, the clinical outcomes are expected to further improve.
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Supported in part by Clinical Scientist Development Program Award K12EY021475 (ME), R01 EY024349-01A1 (ARD) and Core grant EY01792 from NEI/NIH; MR130543 (ARD) from DoD; and unrestricted grant to the department from RPB.
The authors have no commercial or proprietary interest in any concept or product discussed in this article.
Single-copy reprint requests to Ali R. Djalilian, MD (address below).
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Drs. Baradaran-Rafii and Eslani contributed equally to this paper.