Elsevier

The Ocular Surface

Volume 15, Issue 1, January 2017, Pages 48-64
The Ocular Surface

Clinical Science
Current and Upcoming Therapies for Ocular Surface Chemical Injuries

https://doi.org/10.1016/j.jtos.2016.09.002Get rights and content

Abstract

Chemical injuries frequently result in vision loss, disfigurement, and challenging ocular surface complications. Acute interventions are directed at decreasing the extent of the injury, suppressing inflammation, and promoting ocular surface re-epithelialization. Chronically, management involves controlling inflammation along with rehabilitation and reconstruction of the ocular surface. Future therapies aimed at inhibiting neovascularization and promoting ocular surface regeneration should provide more effective treatment options for the management of ocular 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.

References (228)

  • R.D. Herr et al.

    Clinical comparison of ocular irrigation fluids following chemical injury

    Am J Emerg Med

    (1991)
  • H. Merle et al.

    Alkali ocular burns in Martinique (French West Indies) Evaluation of the use of an amphoteric solution as the rinsing product

    Burns

    (2005)
  • S.C. Brodovsky et al.

    Management of alkali burns: an 11-year retrospective review

    Ophthalmology

    (2000)
  • R. Beams et al.

    Effect of topical corticosteroids on corneal wound strength

    Am J Ophthalmol

    (1968)
  • H.D. Perry et al.

    Systemic tetracycline hydrochloride as adjunctive therapy in the treatment of persistent epithelial defects

    Ophthalmology

    (1986)
  • R.R. Pfister et al.

    Ascorbic acid in the treatment of alkali burns of the eye

    Ophthalmology

    (1980)
  • J. Imanishi et al.

    Growth factors: importance in wound healing and maintenance of transparency of the cornea

    Prog Retin Eye Res

    (2000)
  • K. Kalwerisky et al.

    Use of the Boston Ocular Surface Prosthesis in the management of severe periorbital thermal injuries: a case series of 10 patients

    Ophthalmology

    (2012)
  • H.S. Dua et al.

    The amniotic membrane in ophthalmology

    Surv Ophthalmol

    (2004)
  • C.S. Bouchard et al.

    Amniotic membrane transplantation in the management of severe ocular surface disease: indications and outcomes

    Ocul Surf

    (2004)
  • S.C. Tseng et al.

    How does amniotic membrane work?

    Ocul Surf

    (2004)
  • D. Meller et al.

    Amniotic membrane transplantation for acute chemical or thermal burns

    Ophthalmology

    (2000)
  • J.A. Gomes et al.

    Amniotic membrane transplantation for partial and total limbal stem cell deficiency secondary to chemical burn

    Ophthalmology

    (2003)
  • A. Tamhane et al.

    Evaluation of amniotic membrane transplantation as an adjunct to medical therapy as compared with medical therapy alone in acute ocular burns

    Ophthalmology

    (2005)
  • A. Baradaran-Rafii et al.

    Limbal stem cell deficiency in chronic and delayed-onset mustard gas keratopathy

    Ophthalmology

    (2010)
  • R. Kuckelkorn et al.

    Treatment of severe eye burns by tenonplasty

    Lancet

    (1995)
  • M.P. Lin et al.

    Glaucoma in patients with ocular chemical burns

    Am J Ophthalmol

    (2012)
  • K. Takeda et al.

    Ocular surface reconstruction using the combination of autologous cultivated oral mucosal epithelial transplantation and eyelid surgery for severe ocular surface disease

    Am J Ophthalmol

    (2011)
  • J.W. Shore et al.

    Results of buccal mucosal grafting for patients with medically controlled ocular cicatricial pemphigoid

    Ophthalmology

    (1992)
  • M. Eslani et al.

    The ocular surface chemical burns

    J Ophthalmol

    (2014)
  • R. Pfister

    Chemical injuries of the eye

    Ophthalmology

    (1983)
  • J.P. McCulley

    Ocular hydrofluoric acid burns: animal model, mechanism of injury and therapy

    Trans Am Ophthalmol Soc

    (1990)
  • H.S. Dua et al.

    A new classification of ocular surface burns

    Br J Ophthalmol

    (2001)
  • M.J. Roper-Hall

    Thermal and chemical burns

    Trans Ophthalmol Soc U K

    (1965)
  • P.H. Ballen

    Treatment of chemical burns of the eye

    Eye Ear Nose Throat Mon

    (1964)
  • P. Singh et al.

    Ocular chemical injuries and their management

    Oman J Ophthalmol

    (2013)
  • A. Lin et al.

    Management of ocular conditions in the burn unit: thermal and chemical burns and Stevens-Johnson syndrome/toxic epidermal necrolysis

    J Burn Care Res

    (2011)
  • R. Fish et al.

    Management of ocular thermal and chemical injuries, including amniotic membrane therapy

    Curr Opin Ophthalmol

    (2010)
  • A. Kosoko et al.

    Chemical ocular burns: a case review

    Am J Clin Med

    (2009)
  • N. Gupta et al.

    Comparison of prognostic value of Roper Hall and Dua classification systems in acute ocular burns

    Br J Ophthalmol

    (2011)
  • J.P. McCulley

    Chemical injuries

  • Z. Rodrigues

    Irrigation of the eye after alkaline and acidic burns

    Emerg Nurse

    (2009)
  • J.P. Chau et al.

    A systematic review of methods of eye irrigation for adults and children with ocular chemical burns

    Worldviews Evid Based Nurs

    (2012)
  • N. Ikeda et al.

    Alkali burns of the eye: effect of immediate copious irrigation with tap water on their severity

    Ophthalmologica

    (2006)
  • D.M. Maurice

    The permeability to sodium ions of the living rabbit's cornea

    J Physiol

    (1951)
  • E. Shirzadeh

    Bilateral chemical burns of the cornea due to limewater: a specific case

    Iran Red Crescent Med J

    (2013)
  • A. Al-Moujahed et al.

    Outcomes of an algorithmic approach to treating mild ocular alkali burns

    JAMA Ophthalmol

    (2015)
  • C.E. Hamill et al.

    Corneal alkali burns: a review of the literature and proposed protocol for evaluation and treatment

    Int Ophthalmol Clin

    (2013)
  • E.E. Saud et al.

    Clinical and histopathological outcomes of subconjunctival triamcinolone injection for the treatment of acute ocular alkali burn in rabbits

    Cornea

    (2012)
  • A.R. Davis et al.

    Topical steroid use in the treatment of ocular alkali burns

    Br J Ophthalmol

    (1997)
  • Cited by (125)

    View all citing articles on Scopus

    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).

    Drs. Baradaran-Rafii and Eslani contributed equally to this paper.

    View full text