What is the management for a child with bleach in their eyes?

Management of Bleach Exposure to the Eye in Children

Immediately irrigate the child's eyes with copious amounts of tap water for at least 15 minutes, and continue until emergency medical services arrive or advanced care is available. 1

Immediate First Aid Actions

Start Irrigation Without Delay

• Begin eye irrigation immediately at the scene—do not wait for medical personnel or specialized equipment. 1
• Use tap water as the preferred irrigation fluid because it is readily available, safe, and effective for chemical eye injuries. 2
• If tap water is unavailable, normal saline or commercially available eye irrigation solutions are reasonable alternatives. 1
• Warmed lactated Ringer's solution is theoretically preferable due to more physiologic pH and osmolarity, but tap water should never be delayed while searching for alternatives. 2

Irrigation Technique and Duration

• Irrigate continuously for a minimum of 15 minutes, and continue up to 30 minutes or even 2 hours in cases of massive exposure. 1, 2
• The length of time the chemical remains in contact with the eye directly determines the severity of injury and risk of vision loss. 3
• Remove any particulate matter or debris during irrigation. 2
• Ensure thorough irrigation of all ocular surfaces, including under the eyelids. 1

Activate Emergency Medical Services

• Call emergency services (EMS) immediately after starting irrigation, especially if the child shows signs of severe injury such as pain, vision changes, or extensive eye involvement. 1
• Contact the Poison Control Center (1-800-222-1222 in the United States) for specific guidance on bleach exposure. 1

Clinical Assessment Priorities

Immediate Ophthalmologic Referral

• All chemical eye burns except the most trivial require immediate ophthalmologic consultation. 2
• Household bleach (sodium hypochlorite) is an alkali that can penetrate ocular tissues within seconds and cause progressive damage. 2, 4
• Alkali injuries generally result in more severe damage than acid injuries because they continue to penetrate deeper tissues. 2

Examination Findings to Document

• Assess the extent of corneal epithelial loss using fluorescein staining when available. 1
• Examine for conjunctival involvement, eyelid burns, and signs of anterior chamber penetration. 1, 4
• Document visual acuity if the child is cooperative and assessment does not delay treatment. 1
• Look for signs of severe injury including corneal opacification, limbal ischemia (whitening of the tissue at the cornea-sclera junction), and increased intraocular pressure. 4

Ongoing Management

Ophthalmology Follow-Up

• Daily ophthalmology review is required during the acute phase for moderate to severe injuries. 1
• Daily ocular hygiene with gentle saline irrigation may be needed to remove mucous or debris. 1
• Monitor for development of complications including corneal ulceration, symblepharon (adhesions between eyelid and eyeball), glaucoma, and cataract formation. 4

Medical Treatment

• Topical antibiotics may be prescribed to prevent secondary infection. 4
• Topical corticosteroids are sometimes used to suppress inflammation, but timing and duration must be carefully controlled by an ophthalmologist. 4
• Ascorbate (vitamin C) and protease inhibitors may be beneficial in severe burns. 4
• Pain control is essential and may require systemic analgesics. 5

Critical Pitfalls to Avoid

• Never delay irrigation to search for a "better" rinsing solution—tap water is excellent and immediately available. 1, 2
• Do not attempt to neutralize the chemical with another substance, as this can generate heat and worsen injury. 2
• Do not underestimate the severity based on initial appearance—alkali burns can progress over hours to days. 4
• Ensure adequate irrigation duration; stopping too early is a common error that allows continued tissue damage. 1, 3

Special Considerations for Children

• Young children may resist irrigation due to fear and discomfort, but it must be performed despite resistance. 3
• Parental involvement and reassurance can help facilitate cooperation. 1
• Consider the child's developmental stage when explaining procedures and providing pain management. 1
• Document circumstances of exposure to assess for potential neglect or abuse, as bleach burns can occur in concerning contexts. 5