What is the treatment for an alkaline burn to the eye with a corneal defect, chemosis, and hyperemia?

Treatment of Alkaline Eye Burns with Corneal Defect, Chemosis, and Hyperemia

Immediate copious irrigation with large volumes of clean water is the single most critical intervention and must begin at the scene of injury without delay, continuing until pH normalization is confirmed by a healthcare professional. 1

Immediate Emergency Management (First 15-30 Minutes)

Irrigation Protocol

• Begin continuous irrigation immediately with tap water or any available clean water source for at least 15 minutes minimum. 1
• Use large, continuous volumes—the endpoint is pH normalization (normal ocular pH ~7.4), not a fixed time duration. 2, 1
• If immediately available, normal saline or Ringer's lactate may be used, but do not delay irrigation to obtain these solutions. 1
• Continue irrigation during transport to medical facility—delays worsen outcomes significantly. 3, 4

Critical Initial Actions

• Remove any particulate matter from the ocular surface to prevent ongoing chemical exposure. 3
• Avoid contaminating the unaffected eye during irrigation. 1
• The definitive endpoint for irrigation is when a healthcare professional confirms the pH of the eye has returned to normal (pH ~7.4). 1

Ophthalmologic Assessment and Ongoing Management

Immediate Ophthalmology Consultation

• All alkaline burns require immediate ophthalmologic evaluation—these are sight-threatening emergencies. 5, 6
• Examine with fluorescein staining using cobalt blue light to assess corneal epithelial defects. 2
• Daily ophthalmologic review is mandatory during the acute phase. 2

Topical Therapy Regimen

Lubrication (Essential for all cases):

• Apply preservative-free artificial tears (hyaluronate or carmellose) every 2 hours throughout the acute illness. 2
• For severe corneal epithelial defects, use only preservative-free formulations. 2
• Consider overnight ointment or moisture chamber devices. 2

Antibiotic Prophylaxis:

• Broad-spectrum topical antibiotics are mandatory when corneal epithelial defects are present (as in your case with corneal defect). 2
• In the UK, moxifloxacin or levofloxacin (quinolones) four times daily is recommended for broad Gram-positive and Gram-negative coverage. 2
• Continue until epithelial defect heals. 2

Anti-inflammatory Therapy:

• Topical corticosteroids (e.g., preservative-free dexamethasone 0.1%) supervised by ophthalmology may reduce ocular surface damage in acute phase. 2
• Important caveat: Corticosteroids can mask signs of corneal infection and should be used with extreme caution in the presence of corneal epithelial defects. 2
• Monitor closely for infection if steroids are used. 2

Cycloplegics:

• Cycloplegic agents (e.g., cyclopentolate or atropine) for pain relief and to prevent posterior synechiae formation. 7

Daily Ocular Hygiene

• Daily removal of inflammatory debris and lysis of conjunctival adhesions by ophthalmologist or trained nurse using saline irrigation, squint hook, and forceps. 2
• Apply topical anesthetic (proparacaine or tetracaine) before this procedure. 2
• Avoid blind sweeping of fornices with cotton swabs—this causes additional damage. 2

Corneal Exposure Prevention

• If patient has significant chemosis or lid involvement preventing complete closure, establish moisture chamber with polyethylene film to prevent corneal exposure and ulceration. 2

Adjunctive Therapy

Oral Vitamin C

• Oral vitamin C (ascorbic acid) was used in 50% of cases in one successful case series to promote collagen synthesis and wound healing. 7

Monitoring for Complications

• Watch for signs of infection: increased pain, purulent discharge, worsening infiltrate, stromal loss. 2
• If infection suspected, obtain cultures (bacterial and fungal—Candida keratitis is common in surface disease) and initiate hourly broad-spectrum antibiotics. 2
• Monitor for symblepharon formation, corneal ulceration, and perforation risk. 7, 6

Common Pitfalls to Avoid

1. Delaying irrigation to seek "better" solutions—tap water immediately is superior to delayed saline. 1, 3
2. Stopping irrigation too early—continue until pH confirmed normal, not just for 15 minutes. 1
3. Using preserved artificial tears with severe epithelial defects—these worsen surface damage. 2
4. Aggressive fornix sweeping without proper technique—causes additional trauma. 2
5. Using topical steroids without close monitoring—can mask infection in compromised corneas. 2

Prognosis

With appropriate immediate irrigation and aggressive acute management, 83% of patients in one case series returned to premorbid visual acuity. 7 However, alkali burns have high pathological potential due to their ability to penetrate intraocular structures, making immediate treatment the single most important prognostic factor. 7, 6