Chemical eye injuryMANAGEMENT

OPHTHALMOLOGIC PRESENTATIONS · 12 SECTIONS

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343 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Acute angle-closure glaucoma Central retinal artery occlusion Central Retinal Vein Occlusion Chemical eye injury Corneal abrasion Corneal ulcer Endophthalmitis Globe rupture Herpes zoster ophthalmicus Hyphema Iritis-Uveitis Ocular foreign body Optic Neuritis Orbital cellulitis Orbital Floor Fracture (Blowout)Posterior vitreous detachment Retinal detachment Retrobulbar hematoma and orbital compartment syndrome Vitreous Hemorrhage

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp40

Immediate priorities

›Time critical stabilization

›Airway compromise from caustic ingestion or inhalation

›If stridor or respiratory distress, airway management

›If altered mental status, resuscitation bay

›Immediate copious irrigation

›Do not delay for history, acuity grading, or visual acuity

›Continue until ocular surface pH normal

›Analgesia and cooperation

›Topical anesthetic to enable irrigation

›Systemic analgesia if severe pain

Decontamination and pH targets

›Irrigation algorithm

›Immediate removal of contact lenses

›Continuous irrigation during removal if needed

›Particulate removal

›Lid eversion

›Fornix sweep with moistened cotton applicator

›Lime or plaster particles removal

›Irrigation fluid selection

›Normal saline

›Lactated Ringer

›Tap water if nothing else immediately available

›Irrigation method

›Morgan lens if tolerated

›Manual irrigation with eyelids held open if not tolerated

›pH monitoring

›Initial pH testing before irrigation if instant and does not delay

02History/hx30

Exposure characterization

›Exposure details

›Substance name and concentration if known

›Alkali

›Acid

›Solvent

›Detergent

›Pepper spray or tear gas

›Liquid versus powder or particulate

›Dry lime cement plaster as retained particulate risk

›Time of exposure

›Minutes since exposure

›Ongoing exposure concern

›Initial first aid prior to arrival

›Irrigation performed

›Duration and fluid type

Risk modifiers

›Patient factors

›Contact lens use

›Prior ocular disease

›Dry eye

›Prior corneal surgery

›Glaucoma

›Immunocompromise

›Anticoagulation and bleeding disorders

Symptom profile

›Symptoms

›Pain severity

03Physical Exam/exam30

Primary assessment

›Vision and basic ocular status

›Visual acuity when feasible after irrigation initiation

›Document best corrected if possible

›Pupils

›Size symmetry

›Afferent pupillary defect

›Extraocular movements

›Pain with movement

›Diplopia

›Periorbital skin involvement

›Chemical burns of eyelids or face

Slit lamp and surface evaluation

›Ocular surface exam

›Conjunctival injection and chemosis

›Corneal clarity and edema

›Epithelial defects with fluorescein

›Limbal ischemia

›Clock hours involved

›Blanching

›Forniceal inspection

›Retained particles

›Necrotic conjunctiva

›Seidel test if concern for perforation

›Intraocular pressure after stabilization

›Elevated IOP after alkali injury risk

PITFALLS

›Common misses

04Differential Diagnosis/ddx14

Vision threatening ocular emergencies

›Alternative diagnoses

›Corneal abrasion

›Corneal ulcer infectious keratitis

›Corneal foreign body

›Penetrating globe injury

›Acute angle closure glaucoma

›Herpetic keratitis

›Severe allergic conjunctivitis

›Thermal burn of ocular surface

Mimics and co-injuries

›Overlapping presentations

›Ultraviolet keratitis

›Chemical conjunctivitis without corneal involvement

›Facial chemical burn with eyelid edema limiting exam

›Inhalation injury with eye irritation

05Laboratory Tests/lt15

When labs are needed

›Systemic assessment triggers

›Large surface area chemical exposure

›Electrolytes and renal function

›Creatine kinase if extensive caustic exposure

›Hydrofluoric acid exposure

›Serum calcium

›Serum magnesium

›Serum potassium

›ECG for dysrhythmia risk

›Ingestion or inhalation co-exposure

›Venous blood gas if respiratory distress

›Lactate if shock concern

Medication safety monitoring

›If high dose topical or systemic therapy planned

›Pregnancy testing when applicable

›Liver function tests for prolonged doxycycline not routine in ED

06Diagnostic Tests/dt33

Scoring Systems

›Burn severity classification

›Roper Hall classification

›Grade I

›Corneal epithelial damage only

›No limbal ischemia

›Grade II

›Corneal haze with visible iris details

›Limbal ischemia less than one third

›Grade III

›Total epithelial loss with stromal haze obscuring iris details

›Limbal ischemia one third to one half

›Grade IV

›Opaque cornea

›Limbal ischemia more than one half

›Dua classification

›Limbal involvement in clock hours

›Conjunctival involvement as percentage

MRI

›Limited indications

›Suspected orbital apex syndrome not typical for isolated chemical burn

›Avoid delay of irrigation for imaging

›CT orbit indications

›Suspected intraorbital foreign body

›High velocity mechanism with unclear exposure history

›Suspected globe rupture with limited exam

›Significant facial burns with concern for orbital compartment syndrome

07Disposition/dispo25

Ophthalmology involvement

›Immediate consultation triggers

›Limbal ischemia

›Corneal haze or opacity

›Large epithelial defect

›Abnormal intraocular pressure

›Persistent abnormal pH after prolonged irrigation

›Suspected penetrating injury

›Hydrofluoric acid exposure

›Pediatric exposure with unreliable exam

Admission and transfer criteria

›Higher level care needs

›Roper Hall grade III or IV

›Dua high limbal involvement

›Inability to perform frequent drops at home

›Severe pain requiring parenteral analgesia

›Poor follow up access

›Need for surgical intervention

›Amniotic membrane

›Debridement

›Limbal stem cell support

Discharge criteria

›Outpatient management profile

›Normalized pH and stable after pause

›No limbal ischemia

›Mild epithelial injury only

›Vision stable and no red flags for open globe

›Reliable next day follow up arranged

08Treatment/t66

Core ED management

›Ocular surface stabilization

›Continue irrigation until pH normal and stable

›Typical volumes 1 to 2 L or more as needed

›Severe alkali injuries may require 10 L or more

›Topical anesthetic for irrigation facilitation

›Proparacaine 0.5 percent 1 to 2 drops

›Tetracaine 0.5 percent 1 to 2 drops

›Particulate removal after initial irrigation

›Repeat fornix sweep until clean

›Pain control

›Acetaminophen oral dosing per weight

›Ibuprofen oral dosing per weight if not contraindicated

›Opioid analgesia if severe pain

Topical medications for mild to moderate injury

›Infection prophylaxis

›Erythromycin ophthalmic ointment 0.5 percent

›Apply 4 times daily

›Use for mild epithelial defects

›Fluoroquinolone ophthalmic drops

›Moxifloxacin 0.5 percent 1 drop 4 times daily

›Ciprofloxacin 0.3 percent 1 drop 4 times daily

›Use for larger epithelial defects or contact lens wearers

›Cycloplegia for pain

›Cyclopentolate 1 percent 1 drop

›Repeat 3 times daily as needed

›Homatropine 5 percent 1 drop

›Repeat 2 times daily as needed

09Special Populations/sp22

Pregnancy

›Medication considerations

›Avoid doxycycline

›Prefer erythromycin ointment for prophylaxis when appropriate

›Cyclopentolate short course generally acceptable with risk benefit discussion

›Disposition considerations

›Lower threshold ophthalmology involvement if severe injury

Geriatric

›Risk modifiers

›Baseline dry eye increasing epithelial vulnerability

›Polypharmacy and anticoagulation affecting periocular skin injury

›Support needs

›Home drop administration reliability

›Earlier admission if poor self care capacity

Pediatrics

›Cooperation and sedation

›Intranasal midazolam for irrigation facilitation if needed

›0.2 mg per kg intranasal

›Maximum 10 mg

›Procedural sedation if irrigation impossible otherwise

›Injury patterns

›Laundry detergent pods as high risk alkali exposure

›Disposition considerations

›Lower threshold admission for frequent drops

›Mandatory ophthalmology follow up arrangement

10Background/b36

Epidemiology

›Exposure settings

›Household cleaners and detergents

›Industrial alkali agents

›Assault exposures pepper spray

›High risk agents

›Ammonia

›Lye sodium hydroxide

›Lime cement plaster

›Hydrofluoric acid

Pathophysiology

›Alkali injury mechanisms

›Saponification of cell membranes

›Deep penetration through stroma

›Limbal stem cell injury and ischemia

›Acid injury mechanisms

›Protein coagulation limiting penetration

›Surface epithelial necrosis

›Complications

›Corneal scarring and neovascularization

›Persistent epithelial defect

›Corneal melt and perforation

›Symblepharon and fornix shortening

›Secondary glaucoma

›Cataract

›Limbal stem cell deficiency

Therapeutic Considerations

›Irrigation as definitive early therapy

11Patient Discharge Instructions/pdi17

copy discharge instructions

›Discharge plan

›Prescribed eye drops and ointment use exactly as directed

›Preservative free artificial tears frequent use

›Avoid rubbing the eye

›No contact lenses until cleared

›Protective eyewear as needed

›Follow up

›Ophthalmology appointment within 24 hours

›Earlier reassessment if worsening symptoms

›Return to ED immediately

›Decreased vision

›Increasing pain

›Increasing redness or swelling

›New photophobia

›Persistent vomiting or severe headache

›Drainage or pus

›Inability to keep drops in due to pain or swelling

12References/r15

Clinical guidelines and key sources

›Core guidance

›American Academy of Ophthalmology guidance on chemical injuries and ocular burns

›Irrigation until physiologic pH

›Particulate removal with lid eversion and fornix sweep

›Roper Hall classification for ocular burns

›Prognosis stratified by corneal haze and limbal ischemia

›Dua classification for ocular burns

›Prognosis stratified by limbal clock hours and conjunctival involvement

›Evidence and consensus

›Emergency medicine consensus for immediate irrigation without delay

›ACEP Level C

›Class I recommendation by expert consensus

›Ophthalmology literature on adjunctive therapy

›Early topical steroids short course for inflammation control

›Doxycycline and ascorbate for stromal melt risk reduction

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.