A chemical splash is one of the very few situations in ophthalmology where the outcome is decided before the patient reaches a doctor. What happens in the first ten minutes, at the kitchen sink or on the factory floor, matters more than anything I can do afterwards. This article sets out what to do immediately, how long to irrigate and with what, what must never be done, and how acid and alkali injuries differ.
Irrigate. Immediately, with whatever clean water is within reach. Do not read the label, do not phone anyone, do not set off for hospital first. Every second before irrigation begins is a second in which the chemical penetrates further.
Technique matters as much as speed. The eye closes reflexively and rinsing a closed eye achieves nothing, so hold the lids apart with your fingers. Direct the flow from the nose side outward so the chemical is not carried into the other eye, and move the eye up, down and sideways to flush the recesses beneath the lids. If a contact lens comes out easily, remove it; if not, keep irrigating.
Sterile saline is ideal, but its absence is not a reason to wait. Clean tap or bottled drinking water is perfectly acceptable. Standing under a shower, pouring from a jug or using a workplace eyewash station are all reasonable. Sterility is secondary; speed and volume are not.
Irrigate for at least fifteen minutes. For alkalis that is not enough: thirty minutes or more is advised, and irrigation should continue during transport where possible. Solid particles such as lime, cement or plaster lodge under the lids and keep releasing alkali long after the surface looks clean. Irrigation alone does not deal with them and examination is mandatory.
Both are emergencies and the first aid is identical, but they behave differently.
Acids such as battery acid, descalers and some toilet cleaners coagulate proteins on contact. That layer acts as a partial barrier and limits how deep the substance travels, so acid injuries are often, though not always, more superficial. Hydrofluoric acid is the exception: it penetrates readily and causes damage comparable to an alkali.
Alkalis such as sodium hydroxide drain cleaners, oven cleaners, ammonia, lime, cement and plaster dissolve the lipid components of cell membranes and keep advancing through tissue. This is why alkali injuries are the ones ophthalmologists fear most: a contact that looks minor can reach the deeper structures at the front of the eye. Household bleach is mildly alkaline and most domestic splashes cause superficial irritation, but that is no reason to skip irrigation.
One deceptive feature deserves emphasis. After a serious alkali burn the eye may look white and quiet. Blanching of the vessels around the coloured part of the eye means the blood supply there has been compromised, and it is among the most serious findings there is. Pain may also be milder than expected because surface nerves are damaged. I have written about the management of these injuries on my page on chemical injuries of the eye surface.
The first thing that usually happens is more irrigation. The pH of the tear film is measured from the recess beneath the lower lid and irrigation continues until that reading returns to normal, which often takes longer and uses far more fluid than patients expect.
Once the pH has settled, a topical anaesthetic allows proper examination. The lids are everted to remove retained particles, the cornea is stained to map tissue loss, blanching around the limbus is graded and intraocular pressure measured. Treatment depends on severity and may include lubrication, agents to prevent infection, drugs to control inflammation and drops to rest the pupil. In severe injuries, amniotic membrane grafting protects the surface while it heals.
Dust, sand and eyelashes are usually cleared by blinking and tearing. Do not rub. Pulling the upper lid over the lower one, or rinsing with clean water, is usually enough. A particle trapped under the upper lid can only be found by everting it, which is best done by someone trained to do so.
Some features change the picture entirely. If the object arrived at speed during grinding, hammering metal or drilling, assume the globe may have been penetrated. The same applies if vision has dropped, the pupil is no longer round, fluid appears to leak from the eye, or there is severe pain and light sensitivity. Do not press on the eye, do not attempt removal, shield it loosely with something rigid, avoid food and drink in case surgery is needed, and attend an emergency department at once.
Minor splashes usually heal within days without consequence. Serious burns are different: the injury does not end when the chemical is washed away. Corneal scarring with reduced vision, persistent dryness, damage to the stem cells that renew the surface, raised intraocular pressure and cataract are all recognised outcomes.
Another late problem is scarring between the inner lid surface and the globe, which restricts eye movement and distorts lid position; I discuss it on my page about eye surface and lid adhesions. Follow-up after a significant chemical injury therefore continues for weeks, sometimes months.
After any chemical contact, be examined once you have irrigated, however the eye looks or feels. This is not a situation for waiting overnight.
For foreign bodies, seek help urgently if vision is reduced, if a scratching sensation persists after rinsing, if pain, redness, discharge or light sensitivity worsen, or if the pupil looks abnormal. One final point, because it is the easiest: most of these injuries happen to people who were not wearing eye protection. Safety glasses during cleaning, renovation, grinding and garden work make everything else in this article unnecessary.
Start irrigating immediately with whatever clean water is nearest. Hold the lids apart, let the water run from the nose side outward and move the eye in every direction. Continue for at least fifteen minutes, then have the eye examined even if it feels better.
Fifteen minutes is the minimum. For alkalis such as drain cleaner, oven cleaner, ammonia, lime, cement or plaster, irrigate considerably longer, thirty minutes or more, and continue on the way to hospital if you can.
No. The reaction generates heat and worsens the injury, and looking for the neutralising substance wastes the minutes that actually matter. Water is the only fluid to use.
Sterile saline is ideal, but do not spend time searching for it. Clean tap or bottled drinking water is entirely acceptable. Starting quickly matters far more than the fluid being sterile.
Yes. A severe alkali burn can leave the eye looking white and quiet, and pain may be misleadingly mild because surface nerves have been damaged. Blanching of the vessels around the coloured part of the eye is a serious sign, not a reassuring one.
Treat it as a possible penetrating injury. Do not press on the eye, do not try to remove anything and do not put drops in. Cover it loosely with a rigid shield, avoid eating or drinking in case surgery is needed, and go to an emergency department without delay.
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