Pediatric emergency medicine trisk 4053 4053
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penetration. Alkaline substances tend to cause more damage as they cause
saponification of fatty acids and can essentially “melt” the cornea and gain access
to the internal structures of the eye.
Goals of Treatment
Chemical injury to the eyeball is a true ocular emergency requiring immediate
assessment and intervention by ED personnel. Copious irrigation, even prior to
ocular examination in many cases, is necessary to minimize damage to the ocular
surface and is the mainstay of treatment if exposure is suspected. Emergency
management may be the most important factor in determining long-term visual
outcome.
Clinical Considerations
Clinical Recognition. Often, there is a clear history of a noxious substance
coming in contact with the ocular surface. It may also be that the event is not
witnessed and a parent may not be certain of the caustic exposure. Thus, the ED
clinician must maintain a high index of suspicion in children presenting with
photophobia or an irritated, red or painful eye of acute onset. A prompt pH test
done by touching a litmus strip to the eye can be useful in detecting acidic or
alkaline conditions. It is also important to determine whether particulate matter
may have been deposited on the ocular surface. Smoke can cause chemical
conjunctivitis, particularly in housefires when chemicals are liberated into the air
from burning plastics and other substances. Foreign bodies such as ashes and
other particulate matter in smoke are not uncommon. The examiner must also
assess the degree of exposure. If a child has no symptoms (e.g., pain,
photophobia) or signs (e.g., red eye, epiphora, conjunctival swelling) and a weak
history of actual chemical exposure to the eye it may be acceptable to avoid
lavage.
Clinical Assessment. A thorough clinical examination of the eye is often deferred
until after irrigation if there is confirmation, or strong suspicion of, chemical
exposure. Immediate intervention is essential to improving the patient’s
prognosis.
Management. Any patient with sufficient history should be immediately placed in
the supine position so ocular lavage may be started. This procedure can often be
frightening and anxiety provoking for a child, and some level of restraint is often
needed. Sedation and topical anesthetic may be helpful, but the physician should
