Chemical Eye Injuries in the ED

Author: Kishan Indrakumar, Thomas Moore, Mayank Nagar, Preetibah Ratenavelu, Dominique Tiriant / Editor: Charlotte Davies / Codes: EnvC7, OptP3, OptP4, SLO1, SLO4 / Published: 19/08/2025

Why Chemical Eye Injuries Matter

You’re in the middle of your shift when a 30-year-old man arrives in triage, clutching his eye after accidentally splashing a cleaning chemical at work. He’s photophobic, in visible pain, and urgently asking for help.

Chemical eye injuries are true ophthalmic emergencies where every second counts. Prompt recognition and immediate irrigation can mean the difference between full recovery and permanent vision loss.

 Key Actions

• Start irrigation before anything else – even before history or exam.
• Evert the eyelids early and sweep for hidden chemical debris
• Alkali burns are worse than acid: Acids cause coagulation necrosis; alkalis cause liquefaction, penetrating deeper into tissues.
• A painless, white eye is NOT reassuring – it may indicate limbal ischemia.

Clinical Presentation: What to Expect

Patients typically present with:

• Burning eye pain
• Excessive tearing (epiphora)
• Photophobia
• Blepharospasm (eyelid spasm)
• Reduced visual acuity
• Conjunctival redness (may be absent in alkali injuries)

Emergency Management: Step-by-Step Ocular Irrigation

Equipment Checklist

• 0.9% NaCl or Hartmann’s solution (multiple litres)
• Giving set or infusion tubing
• Topical anaesthetic drops (e.g., Proxymetacaine)
• Towels or absorbent pads
• pH indicator paper
• Cotton buds
• Optional: Morgan Lens or nasal cannula

Preparation

• Explain the procedure clearly
• Sit or lie the patient down, supporting the head
• Use towels or drapes to protect clothing and bed
• Consider shielding the unaffected eye

Key Procedural Steps:

Step 1: Immediate Priorities

• Follow ophthalmic ABCs
• Remove contact lenses
• Consider associated inhalation or cutaneous burns

Step 2: Anaesthetise the Eye

• Use Proxymetacaine or tetracaine drops
• Do not delay irrigation if drops are unavailable.

Step 3: Begin Irrigation

• Start with 1L via infusion set or Morgan lens if trained
• Use 0.9% saline or Hartmann’s solution.
• Continue for at least 10–15 minutes, regardless of initial pH.

Step 4: Check Ocular pH

• Use indicator paper in inferior fornix.
• Wait 5–10 minutes post-irrigation before testing.
• Target pH: 7.0–7.2 [1]
• If abnormal, continue irrigation and reassess after every 1L

Step 5: Evert Lids & Remove Debris

• Remove visible particulate matter with moistened cotton bud.
• After 3L, reassess for retained debris.
• Repeat anaesthetic drops if needed.

Step 6: Post-Irrigation Monitoring

• Once pH is neutral (7.0–7.2), recheck every 15 minutes for at least 1 hour.[2]
• Resume irrigation if pH drifts.
• Only instil topical antibiotic/lubricant after stable pH.

Anaesthetise
Begin irrigation
Check pH
Debris removal
Evert lids

Special Irrigation Techniques

Standard Giving Set

Watch demonstration video

1. Anaesthetise the eye
2. Connect and prime a 1L bag of warmed saline
3. Manually open eyelids (assistant may be needed)
4. Irrigate nasal to lateral side
5. Ask patient to look in all directions

Morgan Lens

Watch how-to video

1. Apply topical anaesthetic
2. Connect lens tubing to IV bag and prime
3. Insert under upper then lower lid
4. Secure tubing and adjust flow

Nasal Cannula

Watch setup guide

1. Anaesthetise eye
2. Connect nasal cannula via non-winged cannula to giving set
3. Tape cannula over nasal bridge, angled slightly outward
4. Start gentle flow across both eyes

History and What to Look For

Key History Questions:

• Type of chemical (acid or alkali)
• Duration of exposure & prior irrigation
• Context: workplace, household, assault?
• Call Poisons Information Centre for unknown substances

Key Examination Points:

• Visual acuity (after irrigation if tolerated)
• Start with fluorescein staining, then assess the cornea, conjunctiva, and limbus:
  • Cornea: Look for haze or subtle epithelial loss.
  • Conjunctiva: Check for epithelial damage.
  • Limbus: Assess for ischemia using fluorescein pooling and capillary refill (use cotton bud); record in clock hours. Note: If you see fluorescein pooling over the limbus, it may suggest damage or severe injury.

Grading and What to Do Next

The Roper-Hall classification is a simple and effective tool often used in the ED to guide management.

Use the Roper-Hall Classification to guide management[2]:

Note: The Dua classification is more detailed and preferred by specialists for prognosticating severe burns. [3]

Safe Discharge: What to Tell Them

• No home use of anaesthetic drops – risk of corneal toxicity
• Avoid rubbing the eye until sensation returns
• Eye patch can be used short-term
• Return if pain, vision, or photophobia worsens

Key Points You’ll Remember

• Irrigate first – never delay
• Alkali burns cause deeper, more severe injury
• Check limbal ischemia – it predicts prognosis
• Recheck pH every 5-10 mins post-irrigation
• Grade I = Discuss with Ophthalmology. If discharging, provide safety netting, chloramphenicol eye drops, and follow-up in 1-2 days
• Grade II-IV = Require urgent referral to an Ophthalmologist.

Don’t Irrigate If…

• Suspected globe rupture or perforation: Delay irrigation until assessed by ophthalmology.
• Deep corneal injury or foreign body: Avoid using a Morgan (scleral) lens as it may worsen the injury.

Disclaimer: Selected images in this blog were generated or enhanced using artificial intelligence (ChatGPT-4o, OpenAI). They are illustrative and do not depict real individuals or actual clinical cases. Always refer to clinical guidelines and expert consultation in practice.

References

1. TOXBASE. Chemicals splashed or sprayed into the eyes – features and management [Internet]. UK: TOXBASE; [cited 2025 Apr 29].
2. The Royal College of Ophthalmologists. Chemical injuries of the ocular surface. College News FOCUS. 2018 Apr [Internet]; [cited 2025 Apr 29].
3. Gupta N, Kalaivani M, Tandon R. Comparison of prognostic value of Roper Hall and Dua classification systems in acute ocular burns. Br J Ophthalmol. 2011;95(2):194–8.