A 32-year-old factory worker presents to the emergency department 15 minutes after a splash of concentrated hydrochloric acid to his right eye. He complains of severe pain and blurred vision. On examination, the cornea appears hazy with loss of clarity. What is the most appropriate immediate next step in management?

Explanation

## Immediate Management of Chemical Eye Injury **Key Point:** The golden rule of chemical eye injury is **immediate and copious irrigation** — this is the single most critical intervention that determines visual prognosis. Every minute of delay worsens the outcome. ### Pathophysiology of Acid Injury Acids (like HCl) cause immediate coagulation necrosis of corneal epithelium and stromal collagen. The coagulated protein acts as a barrier, limiting deeper penetration — this is why acid injuries are generally less severe than alkali injuries. However, prolonged contact still causes significant damage. ### Management Algorithm ```mermaid flowchart TD A[Chemical splash to eye]:::outcome --> B[Instil topical anaesthetic]:::action B --> C[Immediate copious irrigation<br/>15-20 min with normal saline]:::action C --> D[Check conjunctival pH<br/>should be 7.0-7.4]:::decision D -->|pH still abnormal| E[Continue irrigation]:::action D -->|pH normal| F[Evert lid, remove particles]:::action F --> G[Topical antibiotics + cycloplegic]:::action G --> H[Urgent ophthalmology referral]:::action ``` **High-Yield:** Irrigation must begin **before** detailed examination. Do not delay for visual acuity testing, slit-lamp examination, or photography — these come *after* irrigation. ### Why Irrigation is Critical 1. **Dilution principle:** Continuous flushing reduces concentration of the chemical 2. **pH normalization:** Restores corneal surface pH to physiological range (7.0–7.4) 3. **Particle removal:** Flushes out solid debris (e.g., lime particles in alkali burns) 4. **Time window:** Damage continues as long as the chemical is in contact; irrigation stops this process **Clinical Pearl:** Use **normal saline or Ringer's lactate** — NOT distilled water (hypotonic, causes cellular swelling) or saline-soaked pads (insufficient flow). A Morgan lens or IV tubing taped to the lid margin allows hands-free continuous irrigation. ### Post-Irrigation Management (After pH Normalized) - Evert upper and lower lids; remove any particulate matter - Instil topical antibiotics (chloramphenicol or gentamicin) to prevent secondary infection - Instil cycloplegic (cyclopentolate 1%) to relieve ciliary spasm and pain - Apply lubricating ointment - Arrange urgent ophthalmology review for assessment of corneal clarity, anterior chamber reaction, and risk of symblepharon formation **Warning:** Do NOT apply pressure bandages immediately — they trap heat and delay cooling of the ocular surface. Bandaging comes *after* irrigation and initial treatment. [cite:Park 26e Ch 10]