In a chemical eye injury the outcome is decided by what happens in the first minutes, not by how quickly the patient reaches hospital. The most common mistake I see is that people set off for the emergency room without rinsing the eye at all. As long as the chemical stays on the ocular surface it keeps working its way into the tissue, and irrigation is the only thing that stops it.
This is the order I give my patients:
Three things determine severity: whether the substance is an acid or an alkali, how concentrated it is, and how long it stays on the eye. Only the last one is in your hands, which is why I insist so strongly on irrigation.
Bleach, ammonia-based cleaners, drain openers, lime, quicklime, cement, oven cleaners and dishwasher tablets belong to this group. Alkalis dissolve the fats in cell membranes and travel inwards; they do not stay on the surface and, if contact continues, they can pass through the cornea into the eye. This is the most dangerous group and the one that needs the longest irrigation.
A question I am asked often: household diluted bleach splashed into the eye usually causes superficial irritation and settles within a few days once the eye has been rinsed promptly. That is not a reason to skip rinsing. With concentrated products, or when irrigation is delayed, the same substance can leave permanent corneal scarring.
Hydrochloric acid, battery acid and some toilet and limescale removers fall here. Acids coagulate the proteins on the surface they touch, and that coagulated layer acts as a partial barrier against deeper penetration. For this reason acid injuries usually stay more superficial than an alkali of comparable strength. This does not make acids harmless: highly concentrated acids and hydrofluoric acid penetrate as deeply as alkalis do.
Thinner, alcohol, spray detergents and insecticides mostly produce a superficial chemical irritation with severe pain, redness, light sensitivity and heavy tearing, while permanent damage is far less common than with alkalis. If a pesticide gets into the eye, two things matter: rinse thoroughly, and bring the product label, because some agricultural chemicals also have effects beyond the eye and the doctor needs to know the compound.
The aims are to restore the surface, control inflammation and prevent infection. Preservative-free artificial tears and lubricating gels, antibiotic drops against infection, short courses of anti-inflammatory drops under supervision, and drops that rest the eye and ease pain are used together. In the first days the regimen is revised almost daily, so keeping the follow-up appointments matters as much as the treatment itself.
When epithelial loss is extensive I place an amniotic membrane on the ocular surface. Prepared from the innermost layer of the placenta, it covers the surface, speeds healing, reduces inflammation and helps prevent adhesions between the lid and the globe. Where the risk of adhesion is high, a ring or conformer may also be placed in the fornices.
When the stem cell reserve at the limbus is severely lost, the cornea can no longer renew itself: the surface becomes vascularised, hazy and repeatedly breaks down. This is called limbal stem cell deficiency. If only one eye is affected, a small piece of limbal tissue from the healthy eye can be transplanted to the injured one. A corneal graft placed before the surface is healthy will fail, so the order matters: the ocular surface is restored first and corneal transplantation, if needed, comes later. Lid margin deformity, misdirected lashes or adhesions are corrected in a separate procedure, which I describe on the eye surface and lid adhesions (symblepharon) page.
In mild injuries the corneal surface closes within a few days and vision returns to normal. In moderate and severe injuries healing stretches over weeks and sometimes months, and during that time dryness, light sensitivity and fluctuating vision are expected. Longer-term problems include permanent corneal haze, chronic dry eye disease, lid adhesions, raised intraocular pressure and cataract. Most of these can be treated once they are identified, which is why regular review in the first months is essential.
After irrigation, seek care the same day if you notice reduced vision, severe persistent pain, blanching of the white of the eye, inability to open the eye, a particle sensation under the lid that will not clear, or if the substance was a drain opener, lime, cement, caustic soda or a concentrated acid. With those agents an examination is needed even when symptoms seem mild.
Chemical injuries are the most preventable of the ocular surface diseases. Wearing goggles or a face shield with side protection, never mixing cleaning products in a closed room, and keeping bottles below eye level prevent the majority of them. You can find the related conditions under ocular surface diseases.
Ayşe Dolar Bilge MD, FEBOphth.
Ophthalmologist, Oculoplastic Surgery
As an Ophthalmologist, Dr. Ayşe Dolar Bilge, I provide diagnosis and treatment services with my experienced team.
Household diluted bleach usually causes intense burning, redness and heavy tearing, and the damage is generally limited to the outermost layer of the ocular surface. If you rinse the eye with plenty of water for 20 minutes straight away, the symptoms usually settle within a few days. Because bleach is an alkali, delayed rinsing or a concentrated product can leave deeper corneal damage, so I still want the eye examined after irrigation.
At least 15 to 20 minutes of continuous irrigation. With alkalis such as bleach, lime, cement or drain openers I advise extending this to 30 minutes. You must hold the lids open with your fingers while rinsing, otherwise the water never reaches the surface. In hospital, irrigation is continued until the pH of the ocular surface returns to normal.
Insecticides usually cause a superficial chemical irritation with severe stinging, redness, light sensitivity and tearing; permanent damage is far less common than with alkalis. Rinse the eye with plenty of water for at least 15 minutes and bring the product label with you. Some agricultural chemicals also have effects beyond the eye, so it matters that the doctor knows which compound was involved.
No. Adding baking soda to an acid, or vinegar and lemon to an alkali, releases heat during the reaction and adds a burn on top of the chemical injury. The only correct way to clear a chemical from the ocular surface is dilution with plenty of clean water. This is the most harmful piece of first-aid folklore I encounter.
Yes. Rinsing stops the chemical from acting, but it does not show you the damage that has already occurred. At the examination the surface pH is measured, fluorescein staining maps the epithelial loss, and the blood supply at the limbus is assessed. Even if the symptoms have eased, the severity of the injury cannot be known without this assessment.
In mild and moderate injuries the ocular surface heals and vision usually returns to its previous level. Permanent loss occurs in severe alkali burns where the limbal stem cells that renew the cornea are extensively destroyed; the cornea then loses its clarity and becomes vascularised. The two factors that decide the outcome are the nature of the substance and how long it remained on the eye.
In severe injuries adhesions called symblepharon can form between the ocular surface and the inner surface of the lid. They develop when two raw surfaces heal against each other and they can restrict eye movement. Early amniotic membrane placement and a conformer ring in the fornices reduce this risk. Established adhesions are corrected with symblepharon surgery.
When the stem cells at the limbus, where cornea meets sclera, are extensively lost, the corneal surface cannot renew itself: it breaks down repeatedly and becomes vascularised. If only one eye is affected, a small piece of limbal tissue from the healthy eye is transplanted to the injured one. A corneal graft performed before the surface is healthy will not succeed, so the surface is restored first.
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