Treatment of Chemical Keratitis
Immediate copious irrigation with physiologic saline solution is the cornerstone of chemical keratitis treatment, followed by topical antibiotics to prevent secondary bacterial infection, with corticosteroids and vitamin C as adjunctive therapy to control inflammation and promote healing. 1
Immediate Management
The priority in chemical keratitis is urgent and prolonged irrigation to remove the offending chemical agent. 1 This should be initiated immediately upon presentation, before any other diagnostic or therapeutic interventions.
Initial Therapeutic Approach
Topical prophylactic antibiotics (fluoroquinolones preferred) should be started promptly to prevent progression to bacterial keratitis, ideally within 24 hours of injury. 2
Topical corticosteroids are indicated to control the inflammatory response that characterizes chemical injury, particularly in alkali burns which can cause severe corneal and conjunctival damage. 1
Topical vitamin C supplementation should be considered as part of the adjunctive therapy regimen to support corneal healing. 1
Cycloplegic agents may be used to decrease pain and prevent synechiae formation in cases with significant anterior chamber inflammation. 3
Critical Clinical Distinction
Avoid eye patching or bandage contact lenses in chemical keratitis cases, as these interventions increase the risk of secondary bacterial keratitis. 2 This is a key pitfall that distinguishes chemical keratitis management from other corneal abrasions.
Monitoring and Follow-up
Patients should be instructed to return immediately if symptoms worsen, as this could indicate secondary bacterial infection requiring more aggressive antimicrobial therapy. 2
Daily follow-up is recommended until clinical improvement is documented, particularly for severe chemical injuries. 3
Clinical response is judged by reduced pain and discharge, lessened eyelid edema or conjunctival injection, and initial re-epithelialization. 3
Management of Persistent Epithelial Defects
For persistent epithelial defects after the infection risk is controlled, adjunctive therapies should be instituted:
- Lubrication with preservative-free artificial tears 4, 3
- Antibiotic ointment for overnight protection 4, 3
- Bandage contact lens (only after infection risk is eliminated) 4, 3
- Amniotic membrane coverage for severe cases 4, 3
- Tarsorrhaphy in refractory cases 4, 3
Advanced Interventions for Severe Cases
In cases of corneal thinning or impending perforation:
- Application of tissue adhesive with bandage contact lens for small perforations 4
- Tenon's patch graft with cyanoacrylate glue for larger perforations 4
- Amniotic membrane transplantation to decrease inflammation and stabilize the ocular surface, potentially avoiding urgent keratoplasty 4
- Tectonic keratoplasty (penetrating, lamellar, or Descemet's stripping endothelial keratoplasty) for frank perforation 4
Long-term Considerations
Severe alkali injury of the cornea generally has a good prognosis with immediate and appropriate treatment but can lead to permanent corneal damage and persistent complaints of dry eye. 1 Full restoration of vision is possible with optimal management, though permanent corneal scarring may occur despite aggressive therapy. 1
Underlying ocular surface disease should be treated, including corneal epithelial defects, tear deficiency, entropion, or lagophthalmos, as these conditions can compromise healing. 3