A 32-year-old male factory worker presents to the emergency department 15 minutes after a splash of concentrated hydrochloric acid in both eyes. He complains of severe pain, photophobia, and blurred vision. On examination, the cornea appears hazy with visible epithelial sloughing, and the conjunctiva is chemosed. What is the most appropriate immediate next step in management?

Explanation

## Immediate Management of Chemical Eye Injury **Key Point:** Chemical eye injuries are true ocular emergencies requiring immediate copious irrigation — delay in irrigation increases tissue damage and worsens prognosis. ### Pathophysiology of Chemical Injury Chemical burns cause: 1. **Immediate epithelial and stromal damage** — acid denatures proteins; alkali saponifies lipids and penetrates deeper 2. **Progressive inflammation** — continued tissue injury occurs over hours even after chemical removal 3. **Limbal stem cell destruction** — in severe injuries, leads to cicatricial changes and visual loss **High-Yield:** Alkali burns are MORE SEVERE than acid burns because alkali penetrates deeper into the stroma and anterior chamber, causing progressive damage. Acid causes coagulation necrosis that limits penetration. ### Immediate Management Protocol **Step 1: Irrigation (FIRST priority)** - Instill topical anaesthetic (proparacaine or tetracaine) to allow patient cooperation - Irrigate with normal saline or Ringer's lactate for **15–20 minutes minimum** (some guidelines recommend up to 30 minutes for alkali) - Use Morgan's lens or IV tubing for continuous irrigation - Evert lids and sweep fornices to remove particulate matter **Step 2: Assessment of pH** - Use pH paper on conjunctiva after irrigation - Target: neutral pH (6.8–7.4) - If pH > 7.4, continue irrigation **Step 3: Examination** - Assess corneal clarity, conjunctival injection, limbal ischemia - Document Roper Hall classification (grades I–IV) - Visual acuity (if patient can cooperate) ### Roper Hall Classification (Prognostic Grading) | Grade | Cornea | Conjunctival Ischemia | Prognosis | |-------|--------|----------------------|----------| | I | Clear | None | Excellent | | II | Hazy | < 1/3 limbus | Good | | III | Opaque, iris details lost | 1/3–1/2 limbus | Guarded | | IV | Opaque, iris not visible | > 1/2 limbus | Poor | **Clinical Pearl:** Limbal ischemia (whitening of limbus) is the single most important prognostic indicator — it reflects severity of vascular injury and predicts cicatricial sequelae. ### Post-Irrigation Management 1. **Topical medications:** - Broad-spectrum antibiotic (moxifloxacin or gentamicin) - Lubricating drops (preservative-free) - Cycloplegic agent (cyclopentolate 1%) to reduce ciliary spasm - Topical corticosteroid (prednisolone acetate 1%) — reduces inflammation and cicatrization (controversial in first 24 hours; some prefer delayed use) 2. **Systemic support:** - Oral analgesics (paracetamol, NSAIDs) - Tetanus prophylaxis if indicated - Vitamin C supplementation (500 mg QID) — may reduce scarring 3. **Follow-up:** Urgent ophthalmology review within 24 hours; daily monitoring for first week **Warning:** Do NOT delay irrigation to perform slit-lamp examination or visual acuity testing. Time is tissue — every minute of delay increases irreversible damage. Examination comes AFTER irrigation. **Mnemonic:** **CRIB** — **C**lean (irrigate), **R**emove particulates, **I**nstill medications, **B**ring to ophthalmology. [cite:Khurana 7e Ch 10]