Chemical Injury Protocol

ST.
JOHN EYE HOSPITAL

JERUSALEM
Certificate No.MEA2105257
Title: Managing Chemical Injury Guidelines

Effective Date: January 2017
Department: Cornea and Anterior Segment
Issue Number: 1
Next Revision Date: 2020
1. Policy:
Ophthalmic Chemical injury is an ophthalmic EMERGENCY.
Almost any chemical can cause ocular irritation; serious damage generally results
from either strongly basic (alkaline) compounds or acidic compounds.
Chemical injuries produce extensive damage to the ocular surface epithelium, cornea,
and anterior segment, resulting in permanent unilateral or bilateral visual impairment.
Immediate management
a. Copious prolonged irrigation of the eyes with sterile normal saline; if not
immediately available, use tap water
b. Irrigate for 15-30 min (with intermittent topical anesthetic if required) or until
pH between 7 and 8 (normal value 7.4, range 7.3 7.7).
c. To measure PH, cease irrigation, wait for 1 min, apply universal indicator
paper to fornix
d. When pH normal, check again after additional 30 min
e. Remove any particulate matter
History: Must record name of substance, whether particulate or liquid, if workrelated, the time of injury, the time of attendance to eye hospital, and if irrigated
before attendance.
2. Purpose:
2.1.
To quickly judge the nature and extent of the injury and then treat according
to grade of severity
2.2.
Initial medical therapy is directed toward promoting re-epithelialization and
transdifferentiation of the ocular surface, augmenting corneal repair by supporting
keratocyte collagen production and minimizing ulceration related to collagenase
activity, and controlling inflammation.
2.3.
Early surgical therapy, if indicated, is directed toward removal of necrotic
corneal epithelium and conjunctiva, prompt re-establishment of an adequate limbal
vascularity, and re-establishment of limbal stem cell populations early in the clinical
course
3. Definition:
A wide variety of chemicals can be responsible for ocular injury, including:
3.1. Alkalis, such as:
Ammonia compounds (household cleaners, fertilizer)
Sodium hydroxide (drain and oven cleaners)
Lime, i.e. calcium hydroxide (cement, plaster)
(NB alkalis cause liquefactive necrosis and readily penetrate the eye, damaging the
corneal stroma and endothelium, as well as other anterior segment structures such as
the iris, lens, and ciliary body)
3.2. Acids, such as:
Sulphuric (car batteries)
Hydrofluoric (glass etching)
ST. JOHN EYE HOSPITAL

JERUSALEM

Issue Number: 1
Hydrochloric (>25% is corrosive)
Glacial acetic (wart, verruca treatment)
Citric (lime scale removal)
(NB acids cause coagulative necrosis, which impedes penetration of the eye, where they
may threaten vision by producing profound disturbances of the ocular surface. Strong
acids, such as hydrofluoric acid, may readily penetrate as quickly as alkalis)
3.3. Detergents, such as:
Free chlorine liberating compounds including sodium hypochlorite (bleach)
3.4. Solvents, such as:
Paint thinners
Petrol
Nail varnish remover
Fixatives, such as:
Formaldehyde
Glutaraldehyde
3.5. Contact lens solutions, including hydrogen peroxide; in clinics, tonometer
disinfection fluids
3.6. Pepper spray, tear gases (CS, CN, CR)
3.7. Cyano-acrylate adhesive (superglue) tube can be confused with eye ointment
4. Procedure:
4.1.
Irrigation and best-corrected visual acuity should be done for every patient.
4.2.
Treat each patient according to attached pathway (according to grade severity)
4.3.
Grades II, III, and IV should be followed up by the cornea specialist.
5. Attachments:
Pathway for Chemical Injury Management
6. References:
6.1. Survey of Ophthalmology; Michael D. Wagoner; Chemical Injuries of the Eye:
Current Concepts in Pathophysiology and Therapy; 1997
6.2. Ehlers, Justis P.; Shah, Chirag P.; Wills Eye Manual, The: Office and Emergency
Room Diagnosis and Treatment of Eye Disease, 5th Edition; 2008
6.3. Yanoff & Duker: Ophthalmology, 3rd ed.; 2008
6.4. Pavan-Langston, Deborah; Manual of Ocular Diagnosis and Therapy, 6th Edition;
2008
6.5. AAO; External disease and cornea; 2014-2015
6.6. Kanski; Clinical Ophthalmology; 2016
6.7. The College of Optometrists, Clinical management guidelines -Trauma (chemical),
version 9.
ST. JOHN EYE HOSPITAL

JERUSALEM

Issue Number: 1
6.8. Bagley DM, Casterton PL, Dressler WE, Edelhauser HF, Kruszewski FH, McCulley
JP, Nussenblatt RB, Osborne R, Rothenstein A, Stitzel KA, Thomas K, Ward SL.
Proposed new classification scheme for chemical injury to the human eye. Regul Toxicol
Pharmacol. 2006;45(2):206-13

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ST.

JOHN EYE HOSPITAL

Title: Managing Chemical Injury Guidelines

ST. JOHN EYE HOSPITAL

Title: Managing Chemical Injury Guidelines

Pathway for Chemical Injury Management

ST. JOHN EYE HOSPITAL

Title: Managing Chemical Injury Guidelines

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