8/28/2017 Ophthalmologic Approach to Chemical Burns: Background, Pathophysiology, Epidemiology

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Ophthalmologic Approach to Chemical Burns

Updated: Apr 11, 2017
Author: Mark Ventocilla, OD, FAAO; Chief Editor: Andrew A Dahl, MD, FACS more...

OVERVIEW

Background
Chemical injuries to the eye represent one of the true ophthalmic emergencies, wherein time is truly
critical. While almost any chemical can cause ocular irritation, serious damage generally results from
either strongly basic (alkaline) compounds or strongly acidic compounds. Alkali injuries are more
common and can be more clinically challenging, with a significant potential for long-term morbidity.
Bilateral chemical exposure is especially devastating, often resulting in complete visual disability.
Immediate, prolonged irrigation, followed by aggressive early management and close long-term
monitoring, is essential to promote ocular surface healing and to provide the best opportunity for visual
rehabilitation. [1, 2, 3] See the image below.

Severe chemical injury with early corneal neovascularization.

View Media Gallery

Pathophysiology
The severity of this injury is related to chemical composition, pH, volume, concentration, duration of
exposure, and degree of penetration of the chemical. The mechanism of injury differs slightly between
acids and alkali. [4]

Acid injury
Acids dissociate into hydrogen ions in the cornea. This usually occurs when a strong acid has a pH of
less than 4. The hydrogen molecule damages the ocular surface by altering the pH, while the anion
causes protein denaturation, precipitation, and coagulation. Protein coagulation creates a barrier and
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8/28/2017 Ophthalmologic Approach to Chemical Burns: Background, Pathophysiology, Epidemiology

thus generally prevents deeper penetration of acids and is responsible for the ground glass
appearance of the corneal stroma following acid injury. Hydrofluoric acid is an exception; it behaves
like an alkaline substance because the fluoride ion has better penetrance through the stroma than
most acids, leading to more extensive anterior segment disruption. [4]

Alkali injury
Alkaline substances are lipophilic and can penetrate cell membranes. They dissociate into a hydroxyl
ion and a cation in the ocular surface. The hydroxyl ion saponifies cell membrane fatty acids, while the
cation interacts with stromal collagen and glycosaminoglycans. This interaction facilitates deeper
penetration into and through the cornea and into the anterior segment. Subsequent hydration of
glycosaminoglycans results in stromal haze. Collagen hydration causes fibril distortion and shortening,
leading to trabecular meshwork alterations that, in turn, result in increased intraocular pressure (IOP),
sometimes permanent. Additionally, the inflammatory mediators released during this process stimulate
the release of prostaglandins, which can further increase IOP. [5] See the image below.

Alkali burn. Note the severe conjunctival reaction and stromal opacification blurring iris details inferiorly.
View Media Gallery

Epidemiology
Frequency

United States

Chemical injuries are responsible for approximately 7% of work-related eye injuries treated at US
hospital emergency departments. [6] More than 60% of chemical injuries occur in workplace accidents,
30% occur at home, and 10% are the result of an assault. [7] Thus, 90% result from accidental
exposures. Safety glasses can help prevent injuries, but industrial accidents often involve chemicals
under high pressure. Safety glasses are not of much defense in this setting.

Mortality/Morbidity
As many as 20% of chemical injuries result in significant visual and cosmetic disability; only 15% of
patients with severe chemical injuries achieve functional visual rehabilitation.

Race

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8/28/2017 Ophthalmologic Approach to Chemical Burns: Background, Pathophysiology, Epidemiology

No overall racial predilection exists; however, young black males are more likely to have high-
concentration, high-impact alkaline chemical injuries secondary to assault. [8]

Sex

Males are 3 times more likely to experience chemical injuries than females. [7]

Age

Chemical injuries can strike any population; however, most injuries occur in patients aged 16-45
years. [6, 7]

Clinical Presentation

References

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3. Spector J, Fernandez WG. Chemical, thermal, and biological ocular exposures. Emerg Med Clin
North Am. 2008 Feb. 26(1):125-36, vii. [Medline].

4. Pfister DA, Pfister RR. Acid injuries of the eye. Fundamentals of Cornea and External Disease.
Cornea. 2005. Vol 2.: 1277-84.

5. Pfister RR, Pfister DA. Alkali injuries of the eye. Fundamentals of Cornea and External Disease.
Cornea. 2005. Vol 2: 1285-93.

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emergency departments in the US. Am J Ind Med. 2005 Jul. 48(1):57-62. [Medline].

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Principles and Practice of Ophthalmology. 2000. Vol 2: 943-59.

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13. Jafarinasab MR, Feizi S, Javadi MA, Karimian F, Soroush MR. Lamellar keratoplasty and
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Media Gallery

Alkali burn. Note the severe conjunctival reaction and stromal opacification blurring iris details
inferiorly.
Severe chemical injury with early corneal neovascularization.
Complete cicatrization of the corneal surface following chemical injury.

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Contributor Information and Disclosures

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8/28/2017 Ophthalmologic Approach to Chemical Burns: Background, Pathophysiology, Epidemiology

Author

Mark Ventocilla, OD, FAAO Adjunct Clinical Professor, Michigan College of Optometry; Editor,
American Optometric Association Ocular Surface Society Newsletter; Chief Executive Officer, Elder
Eye Care Group, PLC; Chief Executive Officer, Mark Ventocilla, OD, Inc; President, California Eye
Wear, Oakwood Optical

Mark Ventocilla, OD, FAAO is a member of the following medical societies: American Academy of
Optometry, American Optometric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Simon K Law, MD, PharmD Clinical Professor of Health Sciences, Department of Ophthalmology,
Jules Stein Eye Institute, University of California, Los Angeles, David Geffen School of Medicine

Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of
Ophthalmology, Association for Research in Vision and Ophthalmology, American Glaucoma Society

Disclosure: Nothing to disclose.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Jefferson Medical College of

Thomas Jefferson University; Director of the Cornea Service, Co-Director of Refractive Surgery
Department, Wills Eye Hospital

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of

Ophthalmology, American Ophthalmological Society, American Society of Cataract and Refractive
Surgery, Cornea Society, Contact Lens Association of Ophthalmologists, Eye Bank Association of
America, International Society of Refractive Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cornea
Society, AAO, OMIC, Aerie, Bausch & Lomb, Bio-Tissue, Shire, TearLab<br/>Serve(d) as a speaker or
a member of a speakers bureau for: Allergan, Bausch & Lomb, Bio-Tissue.

Chief Editor

Andrew A Dahl, MD, FACS Assistant Professor of Surgery (Ophthalmology), New York College of
Medicine (NYCOM); Director of Residency Ophthalmology Training, The Institute for Family Health
and Mid-Hudson Family Practice Residency Program; Staff Ophthalmologist, Telluride Medical Center

Andrew A Dahl, MD, FACS is a member of the following medical societies: American Academy of
Ophthalmology, American College of Surgeons, American Intraocular Lens Society, American Medical
Association, American Society of Cataract and Refractive Surgery, Contact Lens Association of
Ophthalmologists, Medical Society of the State of New York, New York State Ophthalmological
Society, Outpatient Ophthalmic Surgery Society

Disclosure: Nothing to disclose.

Additional Contributors

Fernando H Murillo-Lopez, MD Senior Surgeon, Unidad Privada de Oftalmologia CEMES

Fernando H Murillo-Lopez, MD is a member of the following medical societies: American Academy of

Ophthalmology
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8/28/2017 Ophthalmologic Approach to Chemical Burns: Background, Pathophysiology, Epidemiology

Disclosure: Nothing to disclose.

Acknowledgements

Alok S Bansal, MD Fellow, Vitreoretinal Surgery, Wills Eye Hospital

Alok S Bansal, MD is a member of the following medical societies: American Academy of

Ophthalmology, American Society of Cataract and Refractive Surgery, Association for Research in
Vision and Ophthalmology, and International Society of Refractive Surgery

Disclosure: Nothing to disclose.

Geoffrey Broocker, MD, FACS Walthour-DeLaPerriere Professor of Ophthalmology, Department of

Ophthalmology, Emory University School of Medicine; Former Chief of Service, Ophthalmology, Grady
Memorial Hospital

Geoffrey Broocker, MD, FACS is a member of the following medical societies: American College of
Surgeons

Disclosure: Nothing to disclose.

Evan S Loft, MD Clinical Assistant Professor, Department of Ophthalmology, Emory University

Evan S Loft is a member of the following medical societies: American Academy of Ophthalmology,
American Medical Association, American Society of Cataract and Refractive Surgery, Association for
Research in Vision and Ophthalmology, and Phi Beta Kappa

Disclosure: Nothing to disclose.

J Bradley Randleman, MD Associate Professor, Department of Ophthalmology, Section of Cornea,

External Disease and Refractive Surgery, Emory University School of Medicine; Director of Cornea,
External Disease and Refractive Surgery Fellowship, Emory University; Physician Member, Section of
Ophthalmology, The Emory Clinic

J Bradley Randleman, MD is a member of the following medical societies: Alpha Omega Alpha,
American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery, Cornea
Society, and International Society of Refractive Surgery

Disclosure: Nothing to disclose.

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