Ocular Alkali Burns: Treatment Algorithm Improves Care

Marlene Busko

August 04, 2015

A treatment algorithm for managing patients who presented to an emergency department with mild ocular alkali burns led to standardized care and better outcomes in a small, single-center, retrospective study.

Specifically, after in-house treatment guidelines were implemented, more patients who presented to the Massachusetts Eye and Ear Infirmary emergency department with mild ocular alkali burns (eg, from lime [plaster, mortar, cement], lye [drain cleaners], ammonia [fertilizer, cleaning products], magnesium hydroxide [firework sparkers], and potassium hydroxide [potash]) had recovered visual acuity of 20/30 or better within 2 weeks.

"Despite the weaknesses and limitations of our small retrospective study, the results suggest that application of an evidence-based clinical algorithm in the acute phase of injury can improve outcomes in mild alkali burns, potentially reducing injury-related costs and recovery time," Ahmad Al-Moujahed, MD, and James Chodosh, MD, both from the Massachusetts Eye and Ear Infirmary, Department of Ophthalmology, Harvard Medical School, Boston, write in a research letter published online July 30 in JAMA Ophthalmology.

Guillermo Amescua, MD, from the Bascom Palmer Eye Institute, University of Miami, Florida, told Medscape Medical News that they use a very similar algorithm for patients with mild chemical burns. Although there are a few differences in the two protocols, he told Medscape Medical News that the general approach was the right one. "I agree that having a standardized protocol will speed the care that patients will receive as soon as they arrive to the emergency room," he said.

Alkali Eye Burns Need Prompt Attention

Optimal treatment of alkali burns is critical to reduce visual loss, but there is a lack of evidence-based guidelines, Dr Al-Moujahed and Dr Chodosh write. "Our algorithm was intended for our very specific environment: we treat mild and occasionally moderate ocular burns," Dr Chodosh told Medscape Medical News. Severe ocular burns are treated at Massachusetts General.

The algorithm, which was published 2 years ago, is based on published evidence and "supports the use of frequent topical corticosteroids, oral doxycycline, oral vitamin C, along with amniotic membrane grafting if there is a significant area of burn," Dr Chodosh said.

The authors report on a comparison of outcomes in 28 patients (35 eyes) seen in the 2 years before the guidelines were introduced and 15 patients (17 eyes) seen in the year after introduction of the guidelines.

The patients in the earlier group had a mean age of 45 years (range, 21 - 82 years), and 61% were men. Just less than half had work-related accidents, just more than half had non-work-related accidents, and one patient had been assaulted with alkali. The patients in the latter group had a mean age of 39 years (range, 14 - 70 years), 73% were men, and the circumstances surrounding the eye injuries were similar.

All patients had normal vision before the eye injury. Classification of the eye injury severity was available for patients seen under the new protocol, and these patients all had grade 1 burns, based on the Roper-Hall classification system for ocular surface burns (ie, corneal epithelial damage and no limbal ischemia).

The relative risk of not reaching a visual acuity of 20/30 or better was 0.54 (95% confidence interval, 0.17 - 1.67; P = .29) in patients who were treated under the new protocol compared with patients treated earlier.

Similarly, in patients who were treated under the new protocol, the relative risk of not reaching a visual acuity of 20/30 or better within 2 weeks was 0.42 (95% confidence interval, 0.20 - 0.87; P = .005) compared with patients treated earlier.

Similar Algorithm, Severe Burns, and Call for More Trials

"Emergency room physicians need to understand that a chemical burn to the ocular surface can potentially cause corneal blindness and needs to be addressed as soon as possible," Dr Amescua stressed. It is also important to know how to evaluate the severity of the injury, as a patient with significant ischemia of the limbal area (blanching around the cornea) has a worse prognosis and needs to be evaluated by an ophthalmologist and, if possible, by a corneal specialist, he added.

Most corneal chemical burns that they see at their eye emergency room "are mild and can be treated with simple topical medications, and patients have a good prognosis," he said.

"We recently started to use the Dua classification [system for ocular surface burns more often, to grade the chemical burn severity,] instead of the Roper-Hall [criteria]," he added. Also, unlike in the protocol in use at the Massachusetts Eye and Ear Infirmary emergency department, "we only use contact lenses when we know patients are [likely to be] [compliant] with treatment and follow-up," he said. "Otherwise, we follow a very similar algorithm."

Their algorithm does not cover patients with more severe chemical burns, Dr Chodosh explained. "In severe cases, we have a low threshold to admit a patient to our hospital; we give systemic steroids to quiet inflammation, and we encourage early use of amniotic membrane to cover all the ocular surface (cornea, conjunctiva)," he said.

Similarly, Dr Amescua said that at their parent hospital with a level 1 trauma center, they see about one case a month of severe chemical/thermal burn of the ocular surface and face caused by an explosion or car accident. "These patients are usually admitted to the burn trauma [intensive care unit] due to the severity of the burn, and we encourage the early use of amniotic membrane to protect the ocular surface," he said.

Dr Al-Moujahed and Dr Chodosh call for more research to evaluate the merits of having a protocol for treating mild alkali ocular burns. "A prospective randomized clinical trial is needed to properly evaluate the benefits of any treatment protocol" they conclude.

The authors have disclosed no relevant financial relationships.

JAMA Ophthalmol. Published online July 30, 2015. Abstract

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